FORESTS AND TREES FOR HUMAN HEALTH: PATHWAYS, IMPACTS, CHALLENGES AND RESPONSE OPTIONS

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FORESTS AND TREES
FOR HUMAN HEALTH:
PATHWAYS, IMPACTS, CHALLENGES
AND RESPONSE OPTIONS
A Global Assessment Report
Editors: Cecil Konijnendijk, Dikshya Devkota,
Stephanie Mansourian and Christoph Wildburger
IUFRO World Series Vol. 41

Funding support for this publication was provided by the German Federal Ministry for Economic Cooperation and
Development, the Ministry for Foreign Affairs of Finland, the United States Forest Service and the Austrian Federal
Ministry of Agriculture, Forestry, Regions and Water Management. The views expressed within this publication
do not necessarily reect the ofcial policy of the governments represented by these institutions/agencies or the
institutions to whom the authors are afliated.
Publisher:
International Union of Forest Research Organizations (IUFRO)
IUFRO World Series Vol. 41
Forests and Trees
for Human Health:
Pathways, Impacts, Challenges
and Response Options
A Global Assessment Report
Editors: Cecil Konijnendijk, Dikshya Devkota,
Stephanie Mansourian and Christoph Wildburger

Recommended catalogue entry:
Cecil Konijnendijk, Dikshya Devkota, Stephanie Mansourian & Christoph Wildburger (eds.), 2023.
Forests and Trees for Human Health: Pathways, Impacts, Challenges and Response Options.
A Global Assessment Report.
IUFRO World Series Volume 41. Vienna. 232p.
ISBN 978-3-903345-20-1
Published by:
International Union of Forest Research Organizations (IUFRO)
Available from:
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Cover photographs: Olya Humeniuk, John Parrotta, Sital Uprety
Printed in Austria by Eigner Druck, Tullner Straße 311, 3040 Neulengbach, Austria

5
Preface
Since its establishment in 2007, the Global Forest Expert Panels (GFEP) initiative of the Collaborative Part-
nership on Forests (CPF) has been effectively linking scientic knowledge with political decision-making
on forests. GFEP responds to critical forest-related policy concerns by consolidating available scientic
knowledge and expertise on these issues at the global level. It provides decision-makers with the most
relevant, objective and accurate information and thus makes essential contributions to increasing the
quality and effectiveness of international forest governance.
This report titled, “Forests and Trees for Human Health: Pathways, Impacts, Challenges and Re-
sponse Options”, presents the results of the eighth global scientific assessment undertaken within
the framework of GFEP. All GFEP assessments are prepared by internationally recognized scientists
from varied professional backgrounds and geographical contexts. The publications are presented to
stakeholders across relevant international policy fora to support more coherent policies on the role
of forests in addressing the environmental, social and economic challenges reflected in the United
Nations Sustainable Development Goals (SDGs).
In recent years, global public health challenges have taken centre stage. The COVID-19 pandemic
has created severe healthcare disruptions and reversed decades of health and economic improve-
ments. In addition to infectious diseases, the surge of non-communicable diseases has also become
a major public health threat. Global factors, including urbanisation and climate change, further
exacerbate such adverse effects on human health.
Forests have immense potential to contribute to the mental, physical and social health and well-
being of humans. Forests, trees and green spaces can provide nutritious food and medicines, sup-
port climate change mitigation and adaptation, filter air and water pollutants and offer areas of
recreation. At the same time, poor practices of conservation and management of forests can result
in adverse effects on human health with the emergence of zoonotic diseases, forest fires and aller-
gic outcomes. This report consolidates available scientific evidence on the interlinkages between
forests and human health and identifies trade-offs, synergies, and opportunities for strengthening
policies, programmes and activities to enhance the positive health impacts of forests in diverse
populations and settings.
The vast potential of forests, and nature, to contribute to positive health outcomes is increasingly
recognised and promoted by policy processes at the international level. For example, the recently
agreed Kunming-Montreal Biodiversity Framework calls for the adoption of integrative approaches
such as One Health and ‘Good health and wellbeing for all’ is the third goal of the 2030 Agenda for
Sustainable Development. Scientific reports like this are important tools for supporting policymak-
ers and stakeholders in their ambition to ensure sustainable development that takes into consider-
ation the health of humans, other species and the planet as a whole.
I would like to thank the Chair of the Global Forest Expert Panel on Forests and Human Health
Cecil Konijnendijk, GFEP Coordinator Christoph Wildburger, GFEP Editor Stephanie Mansourian, and
GFEP Project Manager Dikshya Devkota for their excellent work in guiding the assessment process
and in leading the development of this publication. It is my sincere hope that those with a respon-
sibility for implementing the SDGs at all levels will find this report a useful source of information
and inspiration.
Alexander Buck
IUFRO Executive Director
5

7
Acknowledgements
This publication is the product of the collaborative work of scientic experts within the framework of
the Global Forest Expert Panel (GFEP) on Forests and Human Health, who served in different capacities
as panel members and authors. We express our sincere gratitude to all of them:
Thomas Astell-Burt, Nicole Bauer, Agnes van den Berg, Gregory N. Bratman, Matthew H.M.E. Browning,
Matilda van den Bosch, Victoria Bugni, Payam Dadvand, Djibril S. Dayamba, Geoffrey Donovan, Xiaoqi
Feng, Elaine Fuertes, Emma Gibbs, Nelson Grima, Sarah Laird, Serge Morand, Cristina O’Callaghan-Gordo,
Unnikrishnan Payyappallimana, Ranaivo Rasolofoson, Roseline Remans, David Rojas-Rueda, Giovanni
Sanesi, Joshitha Sankam, Charlie Shackleton, Patricia Shanley, Shureen Faris Abdul Shukor, Giuseppina
Spano, Margarita Triguero-Mas, Liisa Tyrväinen, Sjerp de Vries and Bo-Yi Yang.
Without their continued efforts and commitments, the preparation of this publication would not have
been possible. We are also grateful to the institutions and organisations to which the authors are afliated
for enabling them to contribute their expertise to this assessment. At the same time, we wish to note
that the views expressed within this publication do not necessarily reect the ofcial policy of these
institutions and organisations.
We acknowledge and sincerely thank the reviewers of the report, whose valuable comments have
greatly improved this publication: Christos Gallis, Christopher Golden, Qing Li, Michelle Kondo, Kjell
Nilsson, Abi Tamim Vanak, Benedict Wheeler, Maxine Whittaker, Kathleen Wolf and the Food and
Agriculture Organization of the United Nations (FAO).
We also gratefully acknowledge the generous nancial and in-kind support provided by the German
Federal Ministry for Economic Cooperation and Development, the Ministry for Foreign Affairs of Finland,
the United States Forest Service and the Austrian Federal Ministry of Agriculture, Forestry, Regions and
Water Management.
Our special thanks go to the IUFRO Secretariat for providing indispensable administrative and technical
support. Furthermore, we would like to thank the member organisations of the Collaborative Partnership
on Forests (CPF) for their in-kind contributions and overall guidance to the assessment.
Stephanie Mansourian
Content Editor
Christoph Wildburger
GFEP Programme Coordinator
Dikshya Devkota
GFEP Project Manager
Cecil Konijnendijk
Panel Chair

9
Contents
Preface .................................................................................................................................... 5
Acknowledgements ................................................................................................................ 7
Acronyms, Units and Symbols ............................................................................................ 10
1. Introduction .................................................................................................................... 13
Coordinating lead author: Cecil Konijnendijk
Lead authors: Dikshya Devkota, Stephanie Mansourian and Christoph Wildburger
2. Framing the Interrelations Between Forests and Human Health ................................. 25
Coordinating lead author: Matilda van den Bosch
Lead authors: Agnes van den Berg, Payam Davand, Xiaoqi Feng, Serge Morand, Roseline Remans, Liisa Tyrväinen
and Sjerp de Vries
Contributing authors: Emma Gibbs and Joshitha Sankam
3. The Health and Wellbeing Effects of Forests and Natural Environments ..................... 77
Coordinating lead authors: Payam Dadvand and Sjerp de Vries
Lead authors: Nicole Bauer, Djibril S. Dayamba, Xiaoqi Feng, Serge Morand, Unnikrishnan Payyappalli,
Roseline Remans, Ranaivo Rasolofoson, Charlie Shackleton, Patricia Shanley, Liisa Tyrväinen,
Agnes van den Berg and Matilda van den Bosch
Contributing authors: Thomas Astell-Burt, Gregory Bratman, Matthew H. M. E. Browning, Geoffrey Donovan,
Elaine Fuertes, Cristina O'Callaghan-Gordo, David Rojas-Rueda, Giovanni Sanesi, Giuseppina Spano,
Margarita Triguero-Mas and Bo-Yi Yang
4. Forests for Human Health – Understanding the Contexts, Characteristics,
Links to Other Benets and Drivers of Change ........................................................... 125
Coordinating lead authors: Liisa Tyrväinen and Cecil Konijnendijk
Lead authors: Nicole Bauer, Djibril S. Dayamba, Serge Morand, Unnikrishnan Payyappallimana, Roseline Remans,
Charlie Shackleton, and Patricia Shanley
Contributing authors: Victoria Bugni and Sarah Laird
5. Response Options: Access, Spatial Dimensions, Design,
Communication and Economics .................................................................................. 163
Coordinating lead authors: Agnes van den Berg and Cecil Konijnendijk
Lead authors: Shureen Faris Abdul Shukor, Ranaivo Rasolofoson and Patricia Shanley
Contributing authors: Victoria Bugni and Nelson Grima
6. Key Messages and Conclusions ................................................................................... 201
Coordinating lead author: Cecil Konijnendijk
Lead authors: Agnes van den Berg, Matilda van den Bosch, Payam Dadvand, Dikshya Devkota,
Stephanie Mansourian, Liisa Tyrväinen, Sjerp de Vries and Christoph Wildburger
Appendices ......................................................................................................................... 217
Appendix 1: Glossary of Terms and Denitions
Appendix 2: List of Panel Members, Authors and Reviewers
9

1010
ACRONYMS, UNITS AND SYMBOLS
AD Alzheimer’s Disease
ADHD Attention Decit-Hyperactivity
Disorder
AIDS Acquired Immunodeciency
Syndrome
AMR Antimicrobial Resistance
ART Attention Restoration Theory
ASD Autism Spectrum Disorders
BMD Bone Mineral Density
BMI Body Mass Index
CBD Convention on Biological Diversity
CD Communicable Diseases
CICES Common International Classication
of Ecosystem Services
CITRO Center of Tropical Research
Investigations
CNS Connectedness to Nature Scores
COP Conference of the Parties
COPD Chronic Obstructive Pulmonary
Disease
CPF Collaborative Partnership on Forests
CRF Climate Resilience Framework
CVD Cardiovascular Disease
DALYs Disability-Adjusted Life Years
DEFRA Department for Environment, Food
and Rural Affairs
DOHaD Developmental Origins of Health
and Disease
EEG Electroencephalography
EFI European Forest Institute
EIA Environmental Impact Assessment
ES Ecosystem Service
EU European Union
EVI Enhanced Vegetation Index
FAO Food and Agriculture Organization
of the United Nations
FLR Forest Landscape Restoration
fMRI functional Magnetic Resonance
Imaging
FRA Forest Resources Assessment
GBD Global Burden of Disease
GBF Global Biodiversity Framework
GBIF Global Biodiversity Information
Facility
GHQ General Health Questionnaire
GPS Global Positioning System
HIA Health Impact Assessment
HDI Human Development Index
HeReS-C Health Restoration Soundscapes
Criteria
HIC High Income Country
IPAQ International Physical Activity
Questionnaire
IPBES Intergovernmental Science-Policy
Platform on Biodiversity and
Ecosystem Services
IPCC Intergovernmental Panel on
Climate Change
IPLC Indigenous Peoples and
Local Communities
IQ Intelligence Quotient
IUCN International Union for Conservation
of Nature
LDL Low-Density Lipoproteins
LiDAR Light Detection and Ranging
LMICs Low- and Middle-Income Countries
MEA Millennium Ecosystem Assessment
MERS Middle East Respiratory Syndrome
MT Metric Tonnes
NCD Noncommunicable Disease
NDVI Normalised Difference Vegetation
Index
NiV Nipah Virus
NLCD National Landcover Database
NTFP Non-Timber Forest Product
NWFP Non-Wood Forest Product
NYC New York City
OECM Other Effective area-based
Conservation Measure
OHHLEP One Health High-Level Expert Panel
PES Payment for Ecosystem Services
PM Particulate Matter
POMS Prole of Mood States
PSD Perceived Sensory Dimension
PTSD Post-Traumatic Stress Disorder
QoL Quality of Life
RCT Randomised Controlled Trial
RRI Rights and Resources Initiative
RS Remote Sensing
SARS Severe Acute Respiratory Disease
SAVI Soil Adjusted Vegetation Index
SDG Sustainable Development Goal
SES Socio-Economic Status
SESH Social-Ecological System Health
SRT Stress Reduction Theory
TEK Traditional Ecological Knowledge
TNC The Nature Conservancy
UK United Kingdom of Great Britain and
Northern Ireland
UNDP United Nations Development
Programme

1111
UNECE United Nations Economic
Commission for Europe
UNEP United Nations Environment
Programme
UNESCO United Nations Educational, Scientic
and Cultural Organization
UNFF United Nations Forum on Forests
USA United States of America
UV Ultraviolet
VCF Vegetation Continuous Fields
WEF World Economic Forum
WHO World Health Organization
WHOQOL WHO Quality of Life
WOAH World Organisation for Animal Health
WWF Worldwide Fund for Nature
ZIKV Zika Virus

1

13
Chapter 1
Introduction
Coordinating Lead Author: Cecil Konijnendijk
Lead Authors: Dikshya Devkota, Stephanie Mansourian and Christoph Wildburger
TABLE OF CONTENTS
1.1 Importance of Forests and Trees for Human Health ............................................................................. 14
1.2 Public Health Challenges .......................................................................................................................... 15
1.3 Current State of Forests ............................................................................................................................ 15
1.4 Global and Policy Context ........................................................................................................................ 16
1.5 Scope of the Assessment .......................................................................................................................... 18
1.6 Introducing the Global Forest Expert Panel on Forests and Human Health ....................................... 19
1.7 Structure of the Report ............................................................................................................................. 19
1.8 References .................................................................................................................................................. 22

14
1. INTRODUCTION
1.1 Importance of Forests and Trees
for Human Health
Forests, trees and green spaces1, hereinafter ‘forests
and trees’ for short, provide multiple goods and
services that contribute to human health. These in-
clude medicines, nutritious foods and other non-
wood forest products (NWFPs). Globally, at least 3.5
billion people use NWFPs, including medicinal
plants (FAO, 2020a; 2020b) which are particular-
ly important for vulnerable groups and Indig-
enous Peoples and local communities (IPLCs).
During periods of crises, such as the COVID-19 pan-
demic, demand for forest products typically in-
creases amongst these groups (FAO, 2020a; Kuuwill
et al., 2022). Forests and trees also contribute to
better health by playing a role in climate change
mitigation and adaptation, contributing to regulat-
ing the carbon cycle, but also moderating the mi-
cro-climate, ltering pollutants from the air and
protecting settlements against the effects of ex-
treme events such as droughts and ash oods.
They offer areas for recreation, contributing to our
overall mental and physical wellbeing and make
the places where we live, work, study and play,
healthy and liveable. In urban areas, not having ac-
cess to forests, trees and other green spaces can
result in poor mental, physical, social, as well as
spiritual, health (van den Bosch and Bird, 2018).
1 All terms that are dened in the glossary of this report (Appendix 1) appear in italics the rst time they are mentioned.
The link between forests, trees and health
can also be negative, for example, when zoonotic
diseases emerge from forests or when forest res
threaten people’s health. The Intergovernmental
Science-Policy Platform on Biodiversity and Eco-
system Services (IPBES) stressed the intricate links
between biodiversity in general and pandemics,
with overexploitation of forests and wildlife as an
important contributing factor (IPBES, 2020). Ac-
cording to global data released by WHO, wildres
and volcanic activity affected 6.2 million people
between 1998 and 2017 causing 2,400 deaths from
suffocation, injuries and burns (WHO, 2022b).
The relationship between forests and health is
multifaceted and often modulated by other factors
such as the ways in which humans manage for-
ests and wildlife, or the presence of forest roads
which open up access to forests and increase
human-wildlife encounters. Pandemics such as
the recent COVID-19 one can be traced back to
microbes carried by animal reservoirs, but their
emergence as pandemics is the result of human
activities leading to global environmental changes
that drive biodiversity loss and climate change,
including land-use change, agricultural expansion
and intensication, and wildlife trade and con-
sumption (IPBES, 2020). Land-use change alone
(which includes deforestation) is estimated to have
caused the emergence of more than 30% of new
diseases since 1960 (IPBES, 2020).
Figure 1.1
A visualisation of the benefits and contributions to the Sustainable
Development Goals (SDGs) of inner forests, nearby forests and faraway forests
Source: Cities4Forests, 2022

15
1. INTRODUCTION
1.2 Public Health Challenges
According to the United Nations’ estimates, less
than half of the global population is covered by
essential health services (WHO, 2022c). In addi-
tion, the COVID-19 pandemic has created fur-
ther healthcare disruptions, which could reverse
decades of health improvements, particularly
in low-income countries where healthcare sys-
tems and populations are more vulnerable. Al-
though the overall morbidity and mortality related
to infectious diseases have declined over the last
decades, there has been a recent surge in zoonot-
ic diseases, such as COVID-19, Severe Acute Res-
piratory Disease (SARS), Middle East Respiratory
Syndrome (MERS), Ebola, malaria and the avian
u due to environmental and climate disruptions.
Illness and deaths from such diseases are likely
to spike in the future. For instance, the range of
the malaria-bearing mosquito (Anopheles spp.) is
expected to greatly increase in the next decades
due to climate change (Rupasinghe et al., 2022).
Even with global warming staying under 2°C, the
potential occasions for transmission of diseases
from wildlife to humans are liable to double by
2070 (Carlson et al., 2022).
In addition to infectious diseases, non-com-
municable diseases are a major public health
threat. Due to a shift in risk factors for poor
health, the prevalence of chronic diseases such
as diabetes, cancer, cardiovascular conditions,
immune system disorders and depression has in-
creased across the world (GBD 2017 Risk Factor
Collaborators, 2018). Contemporary risk factors,
especially in high- and middle-income countries
but increasingly also in low-income areas, are
dominated by lifestyle related behaviours, such
as insufcient physical activity, chronic stress,
social isolation and poor diets (The Lancet, 2019).
Environmental factors, such as urbanisation, bi-
odiversity loss and climate change have result-
ed in major threats to human health, through
air pollution, noise and extreme weather events,
such as heatwaves, oods, hurricanes and pe-
riods of drought (which in turn threaten food
supplies) (WHO, 2022a) among others. A WHO
(2016) assessment on the links between human
health and environment highlights that prema-
ture death and disease can be prevented through
healthier environments. No less than 24% of
global deaths (and 28% of deaths among children
under ve) are due to modiable environmental
factors (WHO, 2016).
Climate change is an issue of major concern
also from a public health perspective. Many ex-
treme weather events and their consequences on
human health can be linked to climate change
(WHO, 2020).
1.3 Current State of Forests
The loss and degradation of forests have a negative
impact on the provision of crucial ecosystem ser-
vices (i.e., the direct and indirect benets humans
derive from ecosystems – MEA, 2005; FAO, 2020b).
The most recent Global Forest Resources Assess-
ment (FRA) observed that 10 million ha of forests
continued to be lost each year between 2015 and
2020 (FAO, 2020b). Although forest loss continues
at a signicant rate, a general decrease in the
overall rate of net forest loss has been observed
over the decade 1990-2020 (from 7.8million ha
per year in the decade 1990-2000 to 5.2millionha
per year in 2000-2010 to 4.7millionha per year
in 2010-2020) due to reduced levels of deforest-
ation in some countries combined with increas-
es in afforestation, reforestation and natural ex-
pansion of forests in other areas. Global gures
hide regional differences, with for example, the
rate of forest loss in Africa steadily rising since
1990 (FAO, 2020b). Furthermore, changes in the
amount of forest area do not paint the full pic-
ture, as the integrity and quality of forests, and
their functional capacity are crucial for the pro-
vision of ecosystem services. Forest degradation,
which is much harder to dene and measure, is
assumed to be much higher than deforestation.
Estimates suggest that human-induced degra-
dation affects 34% of agricultural land globally
(FAO, 2022). Moreover, with the world’s human
population continuing to grow, the per capita
area of forest is decreasing. According to the FRA
(FAO, 2020b), based on data from 2015, the world
has a total forest area of 4.06 billion hectares,
representing 31% of the total global land area. At
the time of publication, this amounted to 0.52 ha
per person – although forests are not distribut-
ed equally among the world’s peoples or geogra-
phies. There is often a lack of forests in urban ar-
eas where most of the world’s population live
(and where forest benets are invaluable), typi-
cally because urbanisation often results in for-
est loss and degradation, notably, through urban
sprawl.
The predominant drivers of forest loss differ
by geographical region. However, the main dri-
vers around the globe are the production of com-
modities (in particular soy, cattle and palm oil),
forestry, shifting cultivation and re (Curtis et al.,
2018), and climate change accentuates the impact
of these drivers. Ongoing urbanisation is also, to a
lesser extent, a driver of forest loss, although some

16
1. INTRODUCTION
cities across the world have made attempts to en-
hance their forest and tree cover in recognition of
the benets these provide to urban dwellers.
The FRA 2020, and the recent State of the
World’s Forests report (FAO, 2022), also highlight
that forests are exposed to many disturbances
that can adversely affect their health and vitali-
ty and reduce their ability to provide a full range
of goods and ecosystem services. Disturbance and
threats include, for example, insects, diseases and
extreme weather events – with the latter damag-
ing 40 million ha of forests in 2015, primarily in
the temperate and boreal regions. That same year,
forest res affected about 98 million hectares of
forests (FAO, 2022). Tropical forests were especially
hard hit, with 4% of their total area being burnt
that year alone.
1.4 Global and Policy Context
The Millennium Ecosystem Assessment (MEA)
released in 2005, set the stage for a better un-
derstanding of the contributions that nature
provides people (MEA, 2005; Diaz et al., 2018).
Since then, the Inter-governmental Science-Pol-
icy Platform on Biodiversity and Ecosystem Ser-
vices (IPBES) was established in 2012 to “strength-
en the science-policy interface for biodiversity
and ecosystem services for the conservation and
sustainable use of biodiversity, long-term human
well-being and sustainable development” (IPBES
online; Diaz et al., 2018). Through its research
outputs, the IPBES has contributed to improving
our understanding of the role of nature in pro-
viding benets to humans, and consequently, the
role that ongoing nature destruction is playing in
increasing health hazards, notably through forest
res and the spread of pathogens (IPBES, 2018).
There is growing research in, and recognition
of, the impacts of forests, trees and green spaces
on human health. A 2015 state-of-knowledge re-
port highlighted the important links between bio-
diversity more broadly and human health, dis-
cussing for example, zoonotic diseases, impacts at
different scales and for different parts of the hu-
man population, and the many linkages between
biodiversity and health (Romanelli et al., 2015).
The World Health Organization (WHO) is increas-
ingly calling for actions that address the essential
links between human health, environmental fac-
tors and climate change. A report from the 72nd
World Health Assembly, held in 2019, introduced
a new global strategy on health, environment and
climate change aiming to transform the way envi-
ronmental health risks are tackled by accounting
for health in all policies, and scaling up disease
prevention and health promotion (WHO, 2020).
The State of the World’s Forests report (FAO, 2022)
is one of the rst higher-level assessments and
policy reports that pays more than eeting atten-
tion to the important human health impacts of
forests. The report states that trees, forests and
sustainable forestry can help the world recover
from the COVID-19 pandemic and combat loom-
ing environmental crises, such as climate change
and biodiversity loss. It also highlights that for this
to happen, societies must better recognise the con-
siderable value of forests and their crucial roles in
building inclusive, resilient and sustainable econ-
omies. The report recognises that the application
of a broader framework for understanding human
health in a wider planetary context is still in its in-
fancy. Beatty et al. (2022) recently released a scien-
tic report that illustrates the evidence connect-
ing forests and human health. The report explores
ve categories of potential interactions between
forests and human health: noncommunicable dis-
eases like cancer and diabetes; environmental ex-
posures; food and nutrition; physical hazards; and
infectious diseases.
Several international policy processes and
commitments have called for the inclusion of
forests to contribute to human wellbeing, although
the focus has often been more broadly on biodi-
versity. In 2012, the report ‘Our Planet, Our Health,
Our Future’ jointly issued by several United Na-
tions organisations and conventions, called for
joint consideration of biological diversity, climate
change and desertication from a human health
perspective (Patz et al., 2012). The Convention on
Biological Diversity (CBD) states that it is “alarmed
by the continued loss of biodiversity and the threat
that this poses to human well-being" and the re-
cently adopted Kunming-Montreal Global Biodi-
versity Framework (GBF) highlights the urgent
need to reduce environmental degradation to re-
duce health risks and the implementation of ho-
listic approaches such as the One Health Approach
(CBD, 2022). Target 12 specically aims to increase
the area, quality, connectivity, access and benets
of urban green spaces in improving human health
and well-being. Additionally, the Quadripartite
partnership on One Health between the Food and
Agriculture Organization of the United Nations
(FAO), the WHO, the World Organization for Ani-
mal Health (WOAH) and the United Nations En-
vironment Programme (UNEP) advocates for the
implementation of a One Health approach and ad-
dresses the health risks of deforestation and land
degradation in several activities of its Joint Plan for
Action (FAO et al., 2022). In 2020, a group of experts
convened under the IPBES to assess the state of

17
1. INTRODUCTION
knowledge and provide policy options on COVID-19
and other zoonoses, including on the role of for-
ests, reduced deforestation and increased restora-
tion (IPBES, 2020). In other global processes, the
16th session of the UN Forum on Forests (UNFF 16)
expressed concern that biodiversity loss and eco-
system degradation were driving zoonotic diseases
for which we have no resistance, and issued a call
to build momentum to halt illegal and unsustain-
able forest practices to reduce the risk of future
threats to human wellbeing (ECOSOC, 2021).
The Global Forest Goals (United Nations, 2021)
highlight that forests in different settings, from ur-
ban areas to natural landscapes, provide livelihoods
and multiple products and services to communi-
ties. For example, the initiative Cities4Forests de-
veloped an overview of the forest continuum, from
urban centres, through peri-urban and rural areas,
to remote natural areas, calling these inner, near-
by and faraway forests, and linking them to vari-
ous benets and Sustainable Development Goals
(SDGs; see Figure 1.1). The State of the World’s For-
ests report (FAO, 2022) highlights three pathways
for securing and enhancing the essential roles of
forests: halting deforestation and maintaining for-
ests; restoration; and sustainable use. The latter
also relates to the need for a broader integrated
sustainable land management perspective.
Forests can enhance and maintain water quality, which is crucial for human health
Photo © Dikshya Devkota

18
1. INTRODUCTION
The implementation of the United Nation’s
Agenda 2030 for Sustainable Development and
its 17 SDGs aim to strengthen the momentum for
combatting pressing challenges to enable a sus-
tainable development for all. The third SDG speci-
cally focuses on health and aims to “Ensure
healthy lives and promote well-being for all at all
ages”. Linkages between human health and forests
can be found in several SDG targets, for example:
target 3.3 “end the epidemics of AIDS [Acquired
Immunodeciency Syndrome], tuberculosis, malar-
ia and neglected tropical diseases and combat
hepatitis, water-borne diseases and other commu-
nicable diseases”; target 3.4 “reduce by one third
premature mortality from noncommunicable
diseases through prevention and treatment and
promote mental health and well-being”; target 3.9
“substantially reduce the number of deaths and
illnesses from hazardous chemicals and air, water,
and soil pollution and contamination”; and target
11.7 “universal access to safe, inclusive and ac-
cessible, green and public spaces, in particular for
women and children, older persons and persons
with disabilities” (United Nations, 2015). Moreover,
promoting the interlinkages between forests and
human health can directly or indirectly contribute
to achieving all SDGs (FAO, 2020a). A recent study
(Katila et al., 2019) analysed potential impacts of
SDG implementation on forests and forestry. The
authors state that understanding the potential im-
pacts of SDGs on forests, forest-related livelihoods
and forest-based options to generate progress to-
wards achieving the SDGs, as well as related trade-
offs and synergies, is crucial for reaching these
goals. Another study on forest landscape restora-
tion (FLR) demonstrated how the broadening agen-
da of FLR meant that it could support the achieve-
ment of many SDGs (Mansourian, 2018). Although
global environmental governance systems have in-
creasingly acknowledged the health-environment
nexus, explicit interlinking of forests and human
health is still limited.
To tackle health challenges by recognising that
human health is closely related to the health of
other species, ecosystems and the planet as a
whole, novel and more integrative health frame-
works have been developed. The State of the
World’s Forests 2022 report notes that the imple-
mentation of novel frameworks is still not opti-
mal and that “it has become apparent, however,
that addressing the ecosystem-health dimension
through responsible land-use planning and the
greater involvement of the forest and wildlife
sectors as well as natural-resource managers is
equally important. Continuous monitoring and
surveillance, data-sharing and evidence-based
decision-making are essential for minimising im-
pacts and adjusting policies over time and as con-
ditions change” (FAO, 2022). The report introduces
a ‘One Health’ perspective, in recognition of the
interlinkages between the health of humans and
that of other living beings, and ecosystems.
1.5 Scope of the Assessment
Understanding of the net impacts of forests on
human health is still incomplete and only a few
policies and initiatives have made a tangible ef-
fort to prioritise the multifaceted role of forests
in maintaining or improving human health in a
sustainable manner. In urban areas, especially in
high-income countries, it has become increasingly
common to consider the positive impacts of for-
ests, trees and green spaces on mental, physical
and social health, even though the evidence base
is still not complete. Elsewhere, aspects such as
zoonotic diseases and food and nutrition have re-
ceived more, although still insufcient, attention.
Initiatives are often fragmented, unsustainable
and not always evidence-based, or focus on only
one or a few aspects of the many forest-health
relations.
This assessment highlights that although the
various impacts – often positive, but in some cases
potentially negative – of forests on human health
and wellbeing are increasingly being studied and
acknowledged, these impacts are not reected
in relevant policies, programmes and activities,
thus preventing adequate integration in ongoing
and future strategies. In addition, despite a recent
surge in research, there are still substantial knowl-
edge gaps on the impacts that forests have on
human health and wellbeing. The present Expert
Panel aims to assess the current state of knowl-
edge and highlight knowledge gaps, while also
identifying trade-offs, synergies and opportunities
for strengthening policies, programmes and spe-
cic activities to enhance positive health impacts
of forests on urban, rural and forest-dependent com-
munities.
The purpose of this assessment is to assess ex-
isting evidence on the linkages between forests,
trees outside forests and green spaces on the one
hand, and human health on the other.
This assessment takes a multi-layered per-
spective to the human-forest relationship in ur-
ban, rural and forest-dependent communities. It
aims to assess and interpret the evidence around
the interdependence between the health of for-
ests and that of people. The focus is on forest and

19
1. INTRODUCTION
tree-based environments, considered broadly, and
including trees outside forests and green spaces
in urban areas. In this assessment, we take a prag-
matic social-ecological systems approach based on
the concept that social and ecological systems
are interrelated and interdependent (Berkes and
Folke, 1998). We build upon three inuential inter-
connecting concepts that are particularly relevant
for assessing the forest-human health interaction:
One Health; Planetary Health; and EcoHealth.
1.6 Introducing the Global Forest Expert Panel
on Forests and Human Health
This report presents the ndings of the GFEP as-
sessment on Forests and Human Health, which
was in operation from mid-2021 through early
2023. In the frame of the IUFRO-led Joint Initiative
of the Collaborative Partnership on Forests (CPF),
the GFEP on Forests and Human Health had as its
task to carry out a comprehensive global assess-
ment of available scientic information on the
interactions between forests and human health
and to prepare a report to inform relevant interna-
tional policy processes and the discussions on the
2030 Agenda for Sustainable Development.
More specically, the assessment addresses the
following main thematic elements:
• The different dimensions of the relationships
between forests and human health, including
benets and challenges;
• Synergies and trade-offs between human
health, and the conservation, restoration and
sustainable management of forest ecosys-
tems, their biodiversity (including wildlife), as
well as trees in other land-uses; and
• Response options relevant to policy context,
including governance frameworks, in econom-
ic, health, socio-cultural and environmental
domains at various levels (sub-national, na-
tional, regional and international).
The GFEP on Forests and Human Health com-
prises 16 scientists from various disciplines with
recognised expertise in the assessment topics, in-
cluding forestry, ecology, landscape design, envi-
ronmental psychology, and medicine and public
health. The Expert Panel was further supported by
16 contributing authors. Panel members and con-
tributing authors are from across the globe and
represent different genders.
The Expert Panel decided to take a broad view
of forests, trees and green spaces, and to look at
these in diverse contexts. The focus is on urban,
rural, as well as forest-dependent communities.
Equally the Panel takes a broad perspective of
human health, including all aspects of physical,
mental, spiritual and social health and wellbe-
ing of people, while also considering links to the
health of other beings and ecosystems.
1.7 Structure of the Report
The next chapter offers a framework for the re-
mainder of the report and introduces relevant
transdisciplinary concepts, such as One Health
and Planetary Health. It also provides an over-
view of key health aspects and pathways through
which forests and trees are linked to human
health. Next, Chapter 3 provides a comprehensive
overview of the current evidence on the impacts
of forests and trees on human health at different
life stages. It also provides insights into current
knowledge gaps and research needs. Chapter 4
investigates how specic forest types, settings
and characteristics are linked to different health
impacts. This chapter also discusses synergies
and trade-offs between human health impacts of
forests and other ecosystem services and bene-
ts provided by forests. Although health benets
may go hand-in-hand with other benets of for-
ests, there are also cases where different benets
may be in conict. Chapter 5 offers an overview of
different response options that can enhance the
positive health impacts of forests and trees, while
also minimising negative impacts. The chapter
presents response options related to accessibili-
ty and management, spatial aspects, design, gov-
ernance and economics, and communications.
Chapter 6, presents a summary and conclusion
of the report, while also providing key messages
for decision-makers and identifying important
knowledge gaps.

20
1. INTRODUCTION

21
1. INTRODUCTION

22
1. INTRODUCTION
1.8 References
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Folse, M. and Cody, A. 2022. The Vitality of Forests:
Illustrating the evidence connecting forests and human
health, Washington DC: Worldwide Fund for Nature.
Berkes, F. and Folke, C. 1998. Linking social and ecological
systems for resilience and sustainability. In: Berkes,
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Systems: Management Practices and Social Mechanisms
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Carlson, C. J., Albery, G. F., Merow, C., Trisos, C. H.,
Zipfel, C. M., Eskew, E. A., Olival, K. J., et al. 2022.
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CBD 2022. Kunming-Montreal Biodiversity Framework,
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Cities4Forests. 2022. A Call to Action on Forests and
Climate [Online]. Cities4forests. Available: https://
cities4forests.com/ [Accessed 2 January 2022].
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Hansen, M. C. 2018. Classifying drivers of global
forest loss. Science, 361(6407), 1108-1111.
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B., Watson, R. T., Molnár, Z., Hill, R., et al. 2018.
Assessing nature’s contributions to people. Science,
359(6373), 270-272.
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on the sixteenth session, New York: United Nations
Economic and Social Council.
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Strengthening the forest–health–nutrition nexus, Rome:
Food and Agriculture Organization of the United
Nations.
FAO 2020b. Global Forest Resources Assessment 2020: Main
report, Rome: Food and Agriculture Organization of
the United Nations.
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Food and Agriculture Organization of the United
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FAO, UNEP, WHO and WOAH 2022. One Health Joint Plan
of Action (2022–2026): Working Together for the Health
of Humans, Animals, Plants and the Environment,
Rome: FAO, UNEP, WHO and WOAH.
GBD 2017. Risk Factor Collaborators 2018. Global,
regional, and national comparative risk assessment
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and metabolic risks or clusters of risks for 195
countries and territories, 1990–2017: a systematic
analysis for the Global Burden of Disease Study
2017. The Lancet, 392(10159), 1923-1994.
IPBES online. Work programme - IPBES rolling out
work programme up to 2030 [Online]. Bonn:
Intergovernmental Science-Policy Platform on
Biodiversity and Ecosystem Services Available:
https://ipbes.net/work-programme [Accessed 5
February 2023].
IPBES 2018. Summary for policymakers of the assessment
report on land degradation and restoration of the
Intergovernmental Science-Policy Platform on
Biodiversity and Ecosystem Services. In: Scholes, R.,
Montanarella, L., Brainich, A., Barger, N., Ten Brink,
B., Cantele, M., Erasmus, B., Fisher, J., Gardner, T.
and Holland, T. G. (eds.). Bonn, Germany: IPBES
Secretariat.
IPBES 2020. Workshop Report on Biodiversity and Pandemics
of the Intergovernmental Platform on Biodiversity and
Ecosystem Services. Daszak P., Amuasi J., das Neves
C.G., Hayman D., Kuiken T., Roche B., Zambrana-
Torrelio C., Buss P., Dundarova H., Feferholtz Y.,
Földvári G., Igbinosa E., Junglen S., Liu Q., Suzan G.,
Uhart M., Wannous C., Woolaston K., Mosig Reidl P.,
O’Brien K., Pascual U., Stoett P., Li H. and H.T. Ngo,
Bonn: IPBES Secretariat.
Katila, P., Colfer, C. P., Jong, W., Galloway, G., Pacheco, P.
and Winkel, G. (eds.) 2019. Sustainable Development
Goals: Their Impacts on Forests and People, Cambridge:
Cambridge University Press.
Kuuwill, A., Kimengsi, J. N. and Campion, B. B. 2022.
Pandemic-induced shocks and shifts in forest-
based livelihood strategies: learning from COVID-19
in the Bia West District of Ghana. Environmental
Research Letters, 17, 064033.
Mansourian, S., 2018. In the eye of the beholder:
Reconciling interpretations of forest landscape
restoration. Land Degradation & Development, 29(9),
2888-2898.
MEA 2005. Chapter 2 – Ecosystems and their services.
Ecosystems and Human Wellbeing: A framework for
assessment. Washington DC: Island Press.
Patz, J., Corvalan, C., Horwitz, P., Campbell-Lendrum,
D., Watts, N., Maiero, M., Olson, S., et al., 2012. Our
planet, our health, our future. Human health and the
Rio conventions: biological diversity, climate change and
desertification. Geneva: WHO.
Romanelli, C., Cooper, D., Campbell-Lendrum, D.,
Maiero, M., Karesh, W. B., Hunter, D. and Golden,
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23
1. INTRODUCTION
Rupasinghe, R., Chomel, B. B. and Martínez-López, B.
2022. Climate change and zoonoses: A review of the
current status, knowledge gaps, and future trends.
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[Accessed 4 June 2022].
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Agenda for Sustainable Development, New York: UN
Department of Economic and Social Affairs.
United Nations 2021. The Global Forest Goals Report 2021.
New York: UN Department of Economic and Social
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van den Bosch, M. and Bird, W. (eds.) 2018. The Oxford
Textbook on Nature and Public Health, Oxford: Oxford
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WHO 2016. Preventing disease through healthy
environments: a global assessment of the burden of
disease from environmental risks, Geneva: World
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WHO 2020. WHO global strategy on health, environment
and climate change: the transformation needed to
improve lives and wellbeing sustainably through healthy
environments, Geneva: World Health Organization.
WHO 2022a. Climate change and health [Online]. Geneva:
World Health Organization. Available: https://www.
who.int/news-room/fact-sheets/detail/climate-
change-and-health. [Accessed 5 June 2022].
WHO 2022b. Health Topics: Wildfires [Online].
Geneva: World Health Organizations (WHO).
Available: https://www.who.int/health-topics/
wildfires#tab=tab_1 [Accessed 23 January 2023].
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World Health Organization. Available: https://www.
who.int/health-topics/universal-health-coverage.
[Accessed 5 June 2022].

24
2

25
Chapter 2
Framing the Interrelations between Forests and Human Health
Coordinating Lead Author: Matilda van den Bosch
Lead Authors: Agnes van den Berg, Payam Davand, Xiaoqi Feng, Serge Morand, Roseline Remans,
Liisa Tyrväinen and Sjerp de Vries
Contributing Authors: Emma Gibbs and Joshitha Sankam
TABLE OF CONTENTS
2.1 Introduction ................................................................................................................................................. 26
2.2 Multidimensional States of Forests and Human Health ........................................................................ 29
2.3 Ecocentrism, Traditional Ecological Knowledge, and the Reciprocal Relation Between Human
and Forest Health ....................................................................................................................................... 29
2.4 What is Health? ........................................................................................................................................... 31
2.5 Multifactorial Determinants and Modiers ............................................................................................. 33
2.6 Human Health and the Environment - Central Frameworks and a Systems Approach ..................... 36
2.7 Framing the Health Impacts of Forests .................................................................................................... 43
2.8 Conclusion ................................................................................................................................................... 51
2.9 References .................................................................................................................................................... 52

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
26
Abstract
There is no such thing as human health without a healthy planet. Forests are a central part of
the planet’s ecosystems and, as such, understanding human-forest interdependence is central to
achieving optimal health for all, now and for future generations.
Contemporary human health challenges differ across the globe. In high-income countries, there
is a dominance of non-communicable diseases that, to some extent, are related to a disconnect
from, and unhealthy interactions with, forests. In other parts of the world, health is related to
interactions with forests through, for example, nutrition and other services provided by forests or
through infectious diseases, such as malaria, that are in turn all impacted by forest management
and practices.
Planetary health approaches provide a way of considering environmental protection as an in-
herent part of the solution to health. In this context, forests play an important role. Positive inter-
actions with healthy forest ecosystems can contribute to various services, such as promotion of
healthier lifestyles, prevention of disease and livelihoods.
This chapter denes common concepts and discusses the need for systems thinking when ad-
dressing the complex and dynamic relationships between forests and human health, including the
importance of acknowledging voices and knowledge from Indigenous peoples and local commu-
nities. It outlines the consequences of urbanisation and humans’ disconnect from nature as well
as various theories, pathways and mechanisms that support evidence on positive health impacts
of forests. Finally, it provides a framework that brings together the information provided in the re-
mainder of the report.
2.1Introduction
In many parts of the world, humans are increas-
ingly disconnected from nature. This disconnect
has resulted in a loss of recognition that, as a spe-
cies, we are merely one small element in a much
larger system. In so-called modern societies there
also seems to be a lack of understanding that if
any part of this system is broken, everything, in-
cluding humans, will be affected. In many parts
of the world, we are now starting to see the dire
consequences of this failed understanding. Iron-
ically, the harmful consequences of Western life-
styles are predominantly experienced by those
populations who have remained connected to
their surrounding natural environments, for ex-
ample, forest-dependent communities2.
In an inuential review from 2012 entitled “A
symbiotic view of life: we have never been individ-
uals” – Gilbert et al. (2012) argue that human beings
should not be considered as individual entities but
rather as ecosystems living in continuous sym-
biotic and interactive relations with animals and
plants around us. For example, we carry at least
300-fold more microbial genes than human genes,
and microbial cells clearly outnumber the human
cells of a body (O'Hara and Shanahan, 2006). Nev-
ertheless, over the last centuries an increasingly
2 All terms that are dened in the glossary of this report (Appendix 1) appear in italics the rst time they are mentioned
anthropocentric worldview has come to dominate,
inuencing how we consider ourselves and how we
relate to the environment around us (Kortenkamp
and Moore, 2001; Goralnik and Nelson, 2012). This
has resulted in major achievements in economics,
human health and social welfare, but this progress
has come at the cost of natural resource depletion
and global environmental change (Whitmee et al.,
2015). In turn, these environmental changes are
affecting human health. A paradigm shift in our
thinking and our collective worldview is therefore
urgently needed, including to better recognise the
interrelation between forests and human health.
Acknowledging this interrelation to its full extent
signies that when we discuss impacts on the
health of forests and ecosystems in this report,
we implicitly connect them to a direct or indirect
impact on human health. We use a multi-layered
perspective reecting our understanding of the
human-forest relationship in urban, rural and for-
est-dependent communities as multidimensional.
By doing so, we provide the best possible assess-
ment and interpretation of the evidence around
the interdependence between the health of forests
and the health of people as it stands today.
This chapter provides a framework for the re-
mainder of the report (Figure 2.1), introducing vari-
ous concepts that will be used throughout the text.

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
27
The chapter addresses the need for a paradigm
shift in our scientic thinking around forests and
human health. It outlines denitions of human
and forest health, and modiers that act in the re-
lation between them. Further information on such
modiers is provided in Chapter 3. We introduce
central frameworks, such as Planetary Health, One
Health, and EcoHealth. These frameworks, and in-
teractions between them, are referred to through-
out the report. Adding to this system thinking, we
also present resilience approaches as they relate to
forest and human health interactions, including
drivers and solutions, which are further discussed
in Chapter 4. Finally, to provide a background to
the evidence presented in this report, the chapter
reviews the history and development of forest and
human health research, including aspects of na-
ture disconnection. In Appendix 2 we outline com-
mon research designs, methods, measurements
and indicators.
Figure 2.1 introduces a model for the rest of the
report, including the synthesis of our ndings and
expert assessment. The framework builds upon a
systems approach related to Planetary Health, One
Health and Ecohealth, and brings together a diver-
sity of pathways that connect forests and human
health from an ecological and human health per-
spective. The model thereby brings together key el-
ements that are used across the report, including:
(1) the use of typologies to note that different char-
acteristics of forests and of population groups can
inuence the types, directions and extent of for-
est-human health interactions in multiple ways;
(2) the concept of ecosystem services and how
they connect to different pathways that affect hu-
man health; (3) a life cycle approach to consider
multiple and diverse inuences on human health
and wellbeing across the life course; and (4) a clear
two-way, dynamic nature of interactions between
forests and human health where forests inuence
human health and where human health-related
behaviours and response options also inuence
forests and ecosystems.
A boy and a girl sitting on a tree stem in the forest on a sunny summer day
Photo © Olya Humeniuk

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
28
Global
health
Wellbeing
Forest management,
policies and incentives
Health care, policies
and incentives
Gobal trends:
climate change, forest loss , vulnerability and
restoration, urbanization, population growth,
pandemics, conflicts
Anthropogenic impact
Response options
One Health
Planetary health
Ecohealth
Effect modifiers
Socio-economic status, gender, ethnicity,
urbanity & rurality, forest characteristics
Rural forests and
agroforestry
Remote/ Large
wild natural
forests
Urban forests and
green spaces
FORESTS AND
RELATED
BIODIVERSITY
Provisioning
services
e.g. food, water,
bio-medicine, bio-fuel
Regulating
Services
e.g. disease regulation,
climate regulation,
soil health
Cultural
Services
e.g. recreational space,
spiritual, culinary
Dis-services
e.g. vector-borne
diseases, remoteness,
human-wild-life conflict
Provisioning forest
products
Enriching
environmental
microbiota
Heat reduction
Air quality mitigation
Noise mitigation
Stress reduction
Attention
improvement
Social cohesion
Physical activity
Transmission /
Control of
infectious diseases
ECOSYSTEM SERVICES & PATHWAYS
DEPENDENT
POPULATION
GROUPS
Forest
dependent
Rural
Urban
HEALTH
OUTCOMES
Physical health
Mental health
Across the
life cycle
Positive health
outcomes
Negative health
outcomes
Active ageing
Adolescent &
adult health
Healthy inviroment
Infant & child health
Perinatal care
Figure 2.1
Model framework for the complex interactions between forests and human health,
and related synergies, trade-offs and practices.
The gure shows types of forests and populations on the left, and health outcomes on the right. The overlap represents pathways
between forests and human health, and the yellow arrows and boxes represent feedback dynamics.

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
29
2.2 Multidimensional States of Forests and
Human Health
Neither humans nor forests are homogenous en-
tities. This means that while the inherent inter-
dependence between humans and forest environ-
ments is universal, the type and consequence of
the interdependence are multidimensional. Many
‘natural’ forests have been set aside as reserves,
wilderness areas or national parks (Li and Bell,
2018). These areas can present opportunities for
entering a different ‘universe’ and provide un-
mediated, direct contact with nature.
There are also large areas of managed nat-
ural forests, for example for timber production.
These may not be optimal for spiritual or aes-
thetic experiences, but can provide opportunities
for physical recreation, such as running or skiing,
and can also provide health benets through in-
come that improves livelihoods. Forests may also
be established on previously non-forest land or
re-established through afforestation or reforesta-
tion programmes, following previous clearance for
agricultural land or urban expansion. Depending
on the type of forest re-established, these can also
serve a wide range of social and ecological pur-
poses. Finally, urban or peri-urban forests can be
part of a city’s infrastructure and are sometimes
specically planted for human health and wellbe-
ing. However, they can also serve as biodiversity
hotspots (Nielsen et al., 2014; Almohamad et al.,
2018). The multidimensionality of forest land-
scapes is met by the multidimensionality of in-
dividuals, communities, cultures, ethnicities, and
geographical and climate contexts – all of which
contribute to a complex pattern of interactions be-
tween humans and forests.
2.3 Ecocentrism, Traditional Ecological
Knowledge, and the Reciprocal Relation
Between Human and Forest Health
Applying an ecocentric perspective to knowl-
edge generation and implementation may facili-
tate the recognition of the inherent interdepen-
dence between forest and human health and
their non-hierarchical relationship (Figure 2.2).
Contrary to an anthropocentric worldview, an
ecocentric perspective, or ecocentrism, acknow-
ledges the intrinsic value of ‘non-human’ nature
and ecosystems (Batavia and Nelson, 2017). The
‘wellbeing’ of nature is thus as important as the
health and wellbeing of people (Devall and Sessi-
ons, 1985). This means that every living organism
has an intrinsic value, independent of its useful-
ness for human beings. The ecocentric worldview
is integrated in the lifestyles, values and know-
ledge generation of many Indigenous peoples and
local communities (IPLCs), which has resulted in
sustainable use of natural resources and a mu-
tuality in their relation to forests (Arquette et al.,
2002).
In the anthropocentric model, a human male is at the top of the hierarchy, followed by large mammals and all the way down to
invertebrates, considered the lowest of species. The anthropocentric model is human-centred and states that only humans possess
intrinsic values. The ecocentric model, on the other hand, acknowledges the intrinsic and equal value of every living organism and
the human species is just one part of a non-hierarchical system (Source: Ehrnström-Fuentes, 2016).
Figure 2.2
Anthropocentric versus ecocentric worldview

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
30
Paradoxically, post-enlightenment Western sci-
ence, which is largely based on anthropocentrism,
may have lost sight of basic fundaments for long-
term advancement of science, or more specically
its sustainable implementation. While the rigour
of quantitative research methods (see Appen-
dix2) may be necessary to provide generalisable
evidence and while the results from last centu-
ry’s scientic achievements have had tremendous
impacts on health and longevity, a more holistic
framework may be required to fully understand
how we can continue to reduce poverty, improve
wellbeing and increase life expectancy across the
globe without the threat of a dying planet and ris-
ing inequalities (Whitmee et al., 2015). Despite the
exceptional scientic advancements over time, we
still need to develop and progress with innovative
and complementary research methods to optimise
solutions with both people and environment in
mind. A rst step may be to expand the meaning
of “Standing on the shoulders of giants” (Newton,
1675) to consider also insights from, for example,
Traditional Ecological Knowledge (TEK), as part of the
‘gigantic’ contributions to scientic understanding
about long-term relationships between people and
the natural environment (Berkes et al., 2000). TEK
is a knowledge system based on longitudinal data
collected over generations from observations and
feedback learning of various cultural and ceremo-
nial expressions particularly among IPLCs. It has
recently started to be applied in environmental
health and climate change research (Pert et al.,
2015; Maldonado et al., 2016). TEK as a valid and
complementary knowledge system is also becom-
ing an important component in global, regional and
thematic assessments, for example in processes of
the Intergovernmental Science-Policy Platform on
Biodiversity and Ecosystem Services (IPBES) (Tengö
et al., 2017) and the Intergovernmental Panel on
Climate Change (IPCC). In these assessments, the
information and knowledge from TEK contribute
signicantly to understanding of ecosystem gov-
ernance, deforestation control, carbon storage ca-
pacity, climate change and how to sustain resilient
natural landscapes (Mistry and Berardi, 2016). The
ofcial IPLC response to the IPCC 2019 report (RRI,
2019) states that “Finally, the world’s top scien-
tists recognize what we have always known”. Evi-
dence suggests that forests that are legally owned
or designated for use by Indigenous peoples are
linked to, for example, less degradation (Blackman
et al., 2017; Wehkamp et al., 2018), lower carbon
emissions and higher carbon storage (Blackman
and Veit, 2018), better biodiversity conservation
(Garnett et al., 2018), more benets for more peo-
ple (Arce, 2019) and better social, environmental
and economic outcomes overall (Dudley et al.,
2018) – all compared to conventional practices
that are based mainly on Western science (Kumar
Dhir et al., 2020).
Addressing the root causes of health issues
An important result of the reciprocal thinking –
that forest health and human health mutually
inuence each other – is that we move beyond
the typical linear reasoning around risk factors
and human health. Instead, through a systems
approach, the fundamental causes threatening
human health are addressed rather than the im-
mediate risk. Such an approach recognises the in-
trinsic value of forests and the interdependence
between forests and human health as being part
of the same system. We must (re)learn how to in-
teract in this system to keep it – including hu-
mans – intact and healthy. This re-learning could
make use of TEK-based theories and practices.
For example, while forests provide habitats for
malaria vectors (most commonly the Anopheles
mosquito), the drivers of malaria transmission
are complex (Tucker Lima et al., 2017) and some
research suggests that deforestation is actually
related to an increased incidence of malaria dis-
ease (Guerra et al., 2006; Vittor et al., 2009). Thus,
a solution to the malaria epidemic is not to remove
the vector habitat (the forest and wetlands), but
to invest in sustainable forest management and ur-
banisation processes that avoid loss of natural
habitats for malaria vectors and unhealthy in-
teractions between humans and vectors. Malaria
prevalence and mortality are highest in low-in-
come countries and apart from natural resource
management and proper land cover planning,
investments are naturally also needed in control
and treatment programmes to combat the epi-
demic (Cohen et al., 2012).
Also, other examples of misconceptions relat-
ed to ‘harmful’ consequences of nature exist, such
as allergy-inducing pollen emissions from urban
forests. First, allergy is a consequence of a dys-
regulation of the immune system and up to the
end of the 19th century, allergy was an unknown
phenomenon (Platts-Mills, 2015) but allergies have
increased exponentially over the last decades
(WAO, 2011). Industrialisation, urbanisation (with
changed hygiene patterns), environmental chang-
es and substantially reduced contact with nature
and diverse microorganisms, have led to a change
in the composition of our gut microbiome and im-
paired immune systems as a result (Haahtela et
al., 2013), making us vulnerable to inammatory
conditions, including allergies. Another issue is
that allergenic weeds with abundant pollen pro-

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
31
duction thrive on land where natural vegetation
has been disturbed by humans (Dahl et al., 2018)
which, in combination with climate change and
atmospheric pollution, induce prolonged pollen
seasons (Ziello et al., 2012). In fact, allergic diseas-
es are more prevalent in high income countries
(WAO, 2011) and are often caused by mould spores
in homes, pet dander, dust and trafc or smoking
related air pollution, more often than by pollen
(Baldacci et al., 2015; Stewart and Robinson, 2022).
This reinforces the importance of lifestyle changes
and biodiversity protection as strategies to reduce
the burden of allergenic illness.
Ecosystem services 
Forests are essential providers of ecosystem ser-
vices (ES). The concept of ES was popularised
through the Millennium Ecosystem Assessment
(MEA, 2005). In the original ES model, all servic-
es were considered to result in various constitu-
ents of human wellbeing, including health (MEA,
2005). The services are classied into four catego-
ries (Table 2.1): supporting, provisioning, regulat-
ing and cultural; all of which are dependent on
biodiversity.
SUPPORTING PROVISIONING REGULATING CULTURAL
Biomass production Food and water Climate regulation Recreation
Nutrient and water cycling Timber Flood control Aesthetic experiences
Soil formation Wood fuel Water purification Physical and mental restoration
Habitat provision Medicinal plants Carbon storage Education
Table 2.1
The four ES categories and examples
Source: MEA, 2005
As described in the MEA framework, these ser-
vices interact and relate to different aspects of hu-
man health and wellbeing. The relative impact on
human health depends on, for example, socio-eco-
nomic status and socio-demographic context. Ac-
cording to the MEA, the provision of ES results in
freedom of choice and action and the opportunity
to achieve one’s life goals. Consequently, changes
in ecosystems will have fundamental impacts on
the prospects of thriving societies.
The nature-health connection was further em-
phasised in the most recent IPBES reports (IPBES,
2019) and the Common International Classica-
tion of Ecosystem Services (CICES) version 5.1. In
CICES 5.1, ES are dened as the contributions that
ecosystems make to human wellbeing. These ser-
vices are considered nal in the sense that they
are the end-outputs from ecosystems that direct-
ly impact human health (Potschin and Haines-
Young, 2011).
In this report, we refer to ES as they were orig-
inally outlined in the Millennium Ecosystem As-
sessment. This is consistent with the 2015 review
by WHO/Convention on Biological Diversity (WHO,
2015). The ecosystem services framework is use-
ful for realising and communicating the human
health benets of forests and their services. Nev-
ertheless, the notion of 'services’ has been criti-
cised for being anthropocentric (Adams, 2017). In
contrast, an ecocentric approach emphasises rec-
iprocity in the system where humans are part of
the ecosystem and ecosystem services go hand in
hand with services to ecosystems in a healthy so-
cio-ecological system (Comberti et al., 2015). 
2.4 What is Health?
2.4.1 Denitions
Human health
The meaning of human health has changed over
time and still varies across populations and in-
dividuals. From a strict biomedical point of view,
health has been dened as functional organ sys-

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
32
tems without signs of disease, injury, defect or
physical pain (Engel, 1977). The World Health Or-
ganization (WHO), on the other hand, states that
health should be dened “not merely as the ab-
sence of disease or inrmity”, but as a resource-
ful state of “complete physical, mental and social
wellbeing” (WHO, 1948). From this perspective,
health is a multidimensional state with an in-
terdependence between physical, psychological
and social domains of wellbeing, where wellbeing
is dened as “an individual’s experience of their
life as well as a comparison of life circumstances
with social norms and values” (WHO, 2012a). More
specically, physical wellbeing indicates pursuit
of healthy lifestyles, such as being physically ac-
tive and eating healthily. It may also indicate not
being hindered by physical limitations and expe-
riences of bodily pain (Capio et al., 2014). Mental
wellbeing relates to, for instance, subjective hap-
piness, life satisfaction, experiences of pleasure,
and positive psychological and emotional func-
tioning (WHO, 2004). Social wellbeing refers to in-
teractions between individuals and is determined
by the quality of meaningful relationships with
others. Having high levels of social wellbeing indi-
cates feelings of authenticity, safety and personal
value (Lee and Keyes, 1998). As of late, a fourth di-
mension of health has been introduced: spiritual
health (Chirico, 2016) which is considered distinct
to mental health in that it regards the spirit of a
person rather than the psyche. It is closely con-
nected to a person’s sense of purpose and mean-
ing in life, typically acknowledging that the world
contains something beyond the powers of oneself
and recognising a connection to the earth, the
planet and the universe (Hawks et al., 1995; Dhar
et al., 2013). It could also relate to eudaimonic
wellbeing, which corresponds to resources and
strengths and on life meaning, authenticity and
purposefulness (Di Fabio and Palazzeschi, 2015).
A concept that is closely related to health is
quality of life (QoL), dened by WHO as “an indi-
vidual's perception of their position in life in the
context of the culture and value systems in which
they live and in relation to their goals, expecta-
tions, standards and concerns” (WHO, 2012b).
Even before WHO coined its denition of health,
the French physician George Canguilhem suggest-
ed the notion of health as the ability to adapt to
one’s environment, moving beyond the biomedical
model (Canguilhem, 1943). Later denitions sim-
ilarly suggest incorporating aspects of resource-
Forests provide essential ecosystem services including provisioning (e.g. timber) and cultural (e.g. recreation) services
Photo © Nelson Grima

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
33
fulness, adaptability and capacity to self-manage
(WHO, 1986; Huber et al., 2011). Interestingly, this
mirrors ecological denitions of healthy environ-
ments as resilient and capable of maintaining a
stable system within a dened operating space
(Rockström et al., 2009).
Recognising that health is not merely dened
by absence of disease has implications for actors
in the eld, acknowledging that the health of in-
dividuals and populations is a common responsi-
bility to be approached not just as a medical issue,
but also from societal and environmental perspec-
tives. The research agenda of WHO in 1997 for ex-
ample, reected the following 'emerging themes',
among others: urbanisation; population; migra-
tion; environmental problems; and value systems
(Mansourian, 1997).
Dening health is challenging and many de-
nitions are open to interpretation. In the remain-
der of this report, we refer to health in accordance
with the well-established WHO denition, while
also recognising the importance of connected con-
cepts such as spiritual health, QoL, adaptability
and resilience.
Public health
Public health as a discipline or eld of work has
been dened as “the art and science of prevent-
ing disease, prolonging life, and promoting health
through the organised efforts of society” (Acheson,
1988). This relates to the continuum of care that
can be summarised as promotion, prevention,
intervention and rehabilitation. ‘Health promo-
tion’ refers to enabling individuals to maintain or
improve their health, for example, by providing
healthy environments for everyone independent
of income, education or ethnicity. ‘Disease pre-
vention’ can be described as efforts to reduce risk
factors, such as air pollution on a population or
smoking on an individual. ‘Intervention’ is what
may typically be considered as health care, such
as treatment to stabilise or cure a medical condi-
tion. ‘Rehabilitation’ refers to providing support
and opportunities to an individual to recover from
a disease or adapt to a new condition following
illness or injury. Most of the research on nature
and human health has operated on the levels of
health promotion (e.g., providing green spaces for
physical activity) and disease prevention (e.g., ur-
ban trees to prevent heat related morbidity), and
to some extent on intervention (e.g., forest thera-
py) or even rehabilitation (e.g., rehabilitation after
post-traumatic stress disorder, PTSD). A prominent
example of using forests as a public health strate-
gy, is the practice of Shinrin-yoku (‘Forest Bathing’)
(Tsunetsugu et al., 2011). Shinrin-yoku originates
from Japan and is based on the understanding
that forest environments open humans’ senses
and thereby bridge the gap between humans and
the natural world. Studies have suggested a num-
ber of measurable health effects of Shinrin-yoku,
including impact on stress hormones, blood pres-
sure and immune function (Li, 2010; Tsunetsugu
et al., 2011; Li and Bell, 2018).
Forest health
Forest health is mainly discussed in the forest
sciences, but does not have a universally accept-
ed denition. Forest health refers to the health of
an entire forest system, including trees, plants,
soil, wildlife and water, while tree health refers to
the health of an individual tree. A certain amount
of insect activity, disease, mortality and decay
is normal and healthy within a forest system.
Most denitions represent either an ecological
or a utilitarian perspective emphasising human
needs. From an ecological perspective, healthy
forest ecosystems are dened as being able to
maintain their organisation and autonomy over
time while remaining resilient to stress (Costan-
za, 1992). In contrast, the utilitarian perspective
sees a forest as healthy if managers’ and land-
owners’ objectives are met (Kolb et al., 1994). This
denition may be adequate for single manage-
ment objectives, but is inadequate when multi-
functionality is pursued. Using a combination of
both perspectives, forest health can be dened
as a condition of forest ecosystems that sustains
their complexity and resilience while simultane-
ously providing for human needs (O'Laughlin et
al., 1994; Teale and Castello, 2011). The denition
can, in principle, be applied also in assessing for-
est health (or its capacity) for delivering human
health benets through, for example, improved
microclimates, carbon sequestration, absorbing
pollutants or noise abatement. The capacities of
different types of forests to deliver health bene-
ts are further discussed in Chapter 4.
Today, forest health is threatened by pressures
from human activities worldwide. The main driv-
er of deforestation is the expansion of agricultural
land for commodity production, including cattle
ranching (Curtis et al., 2018; Feltran-Barbieri and
Féres, 2021). Human activities also threaten for-
est ecosystem quality, as in the case of large-scale
monoculture plantation forestry.
2.5 Multifactorial Determinants
and Modiers
The complexity of the interrelations between for-
est environments and human health cannot be

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
34
overstated. Aside from the fact that human health
and forests are concepts that elude simple de-
nitions, there are a number of more or less inter-
dependent contextual factors that determine or
modify the character and degree of interrelation
or impact. Although there is incomplete scientic
evidence of how context may inuence the rela-
tions, based on what we currently know, a number
of contextual factors are considered in this report
and outlined below.
2.5.1 National income level
The World Bank categorises economies into four
income groups: low, lower-middle, upper-middle
and high-income countries (World Bank website).
In this report, we group economies into low-,
middle- and high-income countries. Due to un-
equal distribution of resources and funding for
research, most of the evidence on forest and hu-
man health interrelations is based on data from
high- and, to some extent, middle-income coun-
tries (Gallegos-Riofrío et al., 2022). This hampers
our understanding of how income and economy
affect the relations; the health benets from for-
ests in low-income countries are likely different
from those in high-income countries. Generally,
low-income countries are more likely to obtain
health benets from forests through provisioning
ecosystem services, such as supply of food and
timber for livelihoods, while cultural ecosystem
services, such as recreation and stress relief, may
dominate the health benets in high-income
countries (MEA, 2005).
The Human Development Index (HDI) is a com-
posite indicator of life expectancy, education and
economics, currently used by the United Nations
Development Programme (UNDP). A high level of
HDI is reached when the lifespan, education lev-
els and gross national income per capita are all
high. A global comparative study shows that the
level of forest resources of nations tends to be posi-
tively correlated with the HDI, suggesting that the
forest resources of nations improve with progress
in human development and wellbeing (Kauppi et
al., 2018).
A detailed discussion about socio-economic
factors as modiers of the nature and health in-
terrelation is provided in Chapter 3.
2.5.2 The urban-rural gradient
Very little research has been conducted that spe-
cically compares health effects of urban versus
non-urban forests or how people perceive or ben-
et from forests depending on whether they are
urban or rural residents. One recent study sug-
gested an urban-rural gradient whereby exposure
to green spaces and forests increased further from
an urban centre, while access remained the same
(Jarvis et al., 2020a). This is highly context de-
pendent though and we could assume that differ-
ences exist and that cultural ecosystem services
may be relatively more signicant in urban than
in non-urban forests (Devisscher et al., 2019). On
the other hand, less managed, remote areas, na-
tional parks and other non-urban forests carry im-
mense values for people’s needs for recreation and
to escape from city stress (Bell, 2012; Li and Bell,
2018). Nevertheless, with a number of exceptions
(Kovarik and Körner, 2005), the character of an ur-
ban or peri-urban forest is, in general, different
from a large forest land, be it managed or ‘biologi-
cally intact’, which likely has consequences for the
experiences and benets people obtain from the
environment (Konijnendijk, 2018). Further, health
benets also vary based on whether communities
are urban, rural or forest-dependent (see further
details in Chapter 4).
2.5.3 Climatic and geographical zones
Limited research has directly compared health
impacts of forests across larger climatic and geo-
graphical zones, possibly reecting the difculty
in selecting a health indicator that would apply
for such a comparison. However, climate and geo-
graphic regions are naturally important to con-
sider as modiers of human health and forest as-
sociations with, for example, the experiences and
health benets of a Russian taiga being different
from those of a tropical rainforest.
2.5.4 Landscape types and qualities,
and ecological factors
Ecological indicators, such as faunal and oral spe-
cies, habitats and ecosystem functionality all mod-
ify the relationship between human health and
forests. In general, the relative impact on health
likely depends on the type of outcome in question.
For example, a serene forest may be more impor-
tant for restoration and mental health (Annerstedt
[van den Bosch] et al., 2012), while a forest’s shad-
ing capacity may be the most important factor for
heat-related morbidity or mortality (Graham et al.,
2016; Ziter et al., 2019). There is still a large knowl-
edge gap in our understanding of how different
types of forests may inuence health differently.
Chapter 4 further outlines different qualities and
characteristics that may modify the impact of for-
ests on human health.

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
35
2.5.5 Socio-demographic factors
Age, gender, ethnicity and other individual or
behavioural factors determine or modify the im-
pact of any environment on a person’s health. For
gender differentiated health impacts of forests,
results are generally inconsistent (Richardson
and Mitchell, 2010; Sillman et al., 2022). Research
on the modifying impact of ethnicity is rela-
tively scarce, but studies on general greenness
exposure suggest that there may be differences
(Dadvand et al., 2014; Browning and Rigolon,
2018), although it is difcult to disentangle these
from interconnected factors such as income. Gen-
der, ethnicity and income are further discussed in
Chapter 3.
The impact of forests on human health is im-
portant across the life course and Chapter 3 out-
lines the evidence for health impacts of forests by
different age categories. In general, there is reason
to believe that early life exposures to forests would
have the highest impact since those modulate vul-
nerability to disease and resilience to stress later
in life, in accordance with the Developmental Ori-
gins of Health and Disease (DOHaD) paradigm
(Gluckman and Hanson, 2006a; 2006b).
2.5.6 Climate change
The precise scale and type of impact of climate
change on future interrelations between forests
and human health is difcult to predict. Howev-
er, based on modelling of current and evolving
events, we know that the impacts will be vast and
devastating, particularly in low- and middle-income
countries (IPCC, 2022). From a forest-health inter-
action perspective, we can expect increased neg-
ative health effects related to forest res, altered
host interactions and zoonotic diseases, impaired
food security, and much more (Watts et al., 2018;
IPCC, 2022).
In the 2020 Lancet Countdown on health and
climate change, urban green space is included as
one of the indicators for adaptation, planning and
resilience for health (Watts et al., 2021). Equally,
the carbon stock of large forest areas is substantial
with a modifying impact on climate change (FAO,
2020). In general, implementation of the evidence
provided in this report will be much determined
by the inherent dynamics related to climate
change and the consequences for forest environ-
ments across the globe. We should keep in mind
that these consequences will be felt strongest in
low-income parts of the world and this is where
the lion’s share of investments for maintaining
healthy forests for healthy human lives should be
directed. During the 27th Conference of Parties to
the United Nations Convention on Climate Change
(UNFCCC COP27) in Egypt (2022), this was recog-
nised, not as support or aid, but rather as ethical
payback from high-income countries, historical-
ly responsible for the problems caused by inad-
equate fossil fuel extraction, land use and forestry
since pre-industrial times.
Forests and green spaces support human and animal health by providing fodder and shelter in Phobjikha, Bhutan
Photo © Dikshya Devkota

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
36
2.6 Human Health and The Environment -
Central Frameworks and a Systems
Approach
Interactions between humans and forests are
studied across disciplines, including forestry, soci-
ology, economics, ecology, biology, medicine, vet-
erinary medicine, climate science, public health,
among others. Incorporating knowledge from
different elds, we take a pragmatic social-eco-
logical systems approach in this report. Such an
approach is based on the concept that social and
ecological systems are interrelated and interde-
pendent (Berkes and Folke, 1998; Ostrom, 2009).
Health and forest integrity can be dened as a
coupled social-ecological system which needs
governance systems structured as a network of
different actors supporting human health, land-
use planning and forest conservation (Figure 2.3).
Recently, a social-ecological system health (SESH)
framework has been proposed to explicitly link
health and ecosystem management in order to
prevent and cope with emerging health and en-
vironmental risks (de Garine-Wichatitsky et al.,
2021). While this framework originally focused
on agricultural transitions and biodiversity con-
servation, it could be adapted to other situations
such as urban areas.
Figure 2.3
Conceptual model of a social-ecological system
Ecosystem
functions
Ecosystem structure
and processes
Individual and
collective choices
Societal
institutions
and values
Wellbeing
Human
activities
Ecosystem
services
SOCIAL-ECOLOGICAL
SYSTEM
AGENCY
Source: Arctic Council, 2016
Studies of interlinked human and natural sys-
tems have been emerging as a growing eld, pro-
moting interdisciplinary dialogue, collaboration,
and action in various areas and practices (Colding
and Barthel, 2019). Pragmatically, applying a sys-
tems approach can contribute to nding unexpect-
ed solutions and lead to more sustainable solutions
that consider and can manage synergies, trade-offs
and feedback loops between multiple goals (Myers,
2017; Colding and Barthel, 2019).
In the context of a systems approach, we build
upon three inuential interconnecting concepts
that are particularly relevant for assessing the for-
est – human health interaction: One Health, Eco-
Health and Planetary Health, the latter being the
main framework that is considered for the contents
of this report. We describe these frameworks and
concepts and give an overview of how their appli-
cation in science, policy and practice can add val-
ue to understanding and acting upon the relation
between forests and human health. Finally, we dis-
cuss how these concepts are interlinked through
the perspective of resilience.
2.6.1 One Health
‘One Health’ is dened as “an integrated, unifying
approach that aims to sustainably balance and op-
timise the health of people, animals and ecosys-
tems” (OHHLEP, 2021).

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
37
One Health was rst used in 2003–2004, as the
connecting concept between human and animal
health, and was associated with the emergence of
severe acute respiratory disease (SARS), followed
by the spread of the highly pathogenic avian in-
uenza H5N1. Amidst complex patterns of global
change and pandemics, growing evidence under-
lined the inextricable connectivity between hu-
mans, livestock, domestic animals and wildlife,
necessitating integrated approaches to human and
animal health and their respective social and en-
vironmental settings (Mackenzie and Jeggo, 2019).
A set of strategic goals known as the ‘Manhat-
tan Principles’ recognise the threats that zoonot-
ic diseases pose to ecosystem and biodiversity
integrity, human health and economies, and the
importance of collaborative and cross-disciplinary
approaches to emerging and resurging disease re-
sponse. Specically, wildlife health was recognised
as a key component of global disease prevention,
surveillance, control and mitigation (Cook et al.,
2004).
The concept emphasises the consequences, re-
sponses and actions at the ecosystem-animal-hu-
man interface, for emerging and endemic zoonoses.
Responsible for a greater burden of disease in the
low- and middle-income countries, these zoonoses
cause major social implications in resource-poor
settings and antimicrobial resistance (AMR), which
can arise in humans, animals or the environment,
and spread between countries (Mackenzie and
Jeggo, 2019).
The concept of One Health further evolved
and has been recently dened by the One Health
High-Level Expert Panel (OHHLEP) – led by the
Joint Quadripartite of the Food and Agriculture
Organization of the United Nations (FAO), the
World Health Organization (WHO) and the World
Organization for Animal Health (WOAH), and the
United Nations Environment Programme (UNEP) –
as “An integrated, unifying approach that aims to
sustainably balance and optimize the health of
people, animals and ecosystems'' (OHHLEP, 2021)
(Figure 2.4).
One Health thereby explicitly recognises the
interdependence between the health of humans,
wild and domesticated animals, and ecosystems.
With roots in animal and human health science,
it entails a coordinated, collaborative, multidisci-
plinary and cross-sectoral approach at national,
regional and global levels to achieve socio-envi-
ronmental health and wellbeing, and address po-
tential or actual dangers such as zoonotic diseases
and related potential pandemics (Mackenzie and
Jeggo, 2019; OHHLEP, 2021).
Figure 2.4
Schematic representation of the new definition of One Health
endorsed by the One Health quadripartite with a holistic, integrative,
and ecocentric vision of human, animal and ecosystem health
Source: WHO, 2021b

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
38
Forests and tropical forests in particular, yield
a variety of products and ES that benet humans
in several ways. Shifting landscapes and envi-
ronmental change, particularly felt in low- and
middle-income contexts, are having signicant
consequences on ecosystem functioning and
biodiversity protection, and on human and ani-
mal health and wellbeing.
Using a One Health lens, we can understand the
relationship between forests and health through
the following perspectives (a – c):
a) Biodiversity, habitat loss and health
Flourishing ecosystems lead to ourishing soci-
eties, and reducing environmental harms (both
to ecosystems and to wild and domesticated ani-
mals) can mitigate harm to human health (IPCC,
2022). Undertaking practices of sustainable natu-
ral resource management across forests, agricul-
ture and aquaculture, and harmonising conser-
vation practices with livelihoods and health, can
help to achieve a collective One Health (Bauch et
al., 2015; Morand and Lajaunie, 2021).
Forest fragmentation and habitat loss, as a result
of deforestation and increased agricultural produc-
tion, can lead to increased interactions between
pathogens, parasites, bacteria and wildlife in the
biosphere, to humans, livestock and semi-domes-
tic wildlife in the domestic landscape (Wilkinson
et al., 2018). Deforestation can inuence disease
emergence by altering the feeding behaviour of
reservoir hosts (Guégan et al., 2020). Habitat deg-
radation can also alter the eating habits of certain
wildlife species that use human products as food
supplies, thereby increasing interactions at the hu-
man-domestic-animal interface, such as the intro-
duction of the Nipah Virus (NiV) (Chua et al., 2002).
Increases in infection rates of vector-borne dis-
eases are also associated with forest ecosystems
and habitat loss (Morand and Lajaunie, 2021). For
example, upland deforestation causes soil ero-
sion and oods, which has resulted in epidemics
of leptospirosis in individuals living downstream;
as well as water-borne infections such as noro-
virus, campylobacter, cholera and giardia. Live-
stock health plays a crucial inter-connecting role
between landscape health and human health, as
livestock can act as intermediary pathogen hosts
and enable spillover, impacting human and land-
scape immunity – the ecological conditions that
maintain the immunity of wild species, thus pre-
venting high rates of pathogen shedding in the
environment (Brierley et al., 2016; Plowright et al.,
2021; Reaser et al., 2022). Poorly regulated wildlife
trade and associated pathogen spillover is also in-
creasing human health threats.
b) Food security, food safety and anti-microbial
resistance (AMR)
We can also understand the relationship between
forests and human health, through the avail-
ability, accessibility and safety of food and food
products. This also includes the safe handling of
forest-sourced wild meat (Ndoye and Vantomme,
2017).
One of the biggest threats to food security and
safety is AMR – a phenomenon whereby drug-re-
sistant bacteria increase rates of infection, dis-
ease spread and mortality among humans and
animals (Prestinaci et al., 2015). A notable prev-
alence of AMR also exists where wild animals are
in close proximity to livestock and to humans,
causing wider health concerns for an accelerat-
ed evolution of environmental bacteria resistance
(Martinez et al., 2009; Radhouani et al., 2014). In
addition, antimicrobial resistance has now been
discovered deep within forest areas (Ramey, 2021).
Low- and middle-income countries (LMICs) are
signicantly impacted by the effects of AMR,
which threaten to destabilise food systems, live-
lihoods and healthcare systems (Murray et al.,
2022).
c) Forest-based economies
One Health also allows us to understand the dy-
namic connections between forest foods and prod-
ucts (such as non-wood forest products (NWFPs)
and medicines), and human health, livelihoods
and economies. An estimated one billion people
depend on forest-based foods and products (FAO
and UNEP, 2020), directly increasing nutrition, gut
health and immunity; and through their sale, in-
creasing accessibility to other healthy foods and
products (WHO, 2020). These include wild meats,
fruits, nuts, mushrooms, vegetables, sh, insects,
mushrooms and honey. Forest beekeeping and the
trade of honey and beeswax provide crucial local
and community income (Lowore, 2020), and may
even provide incentives for stronger local forest
management (Elzaki and Tian, 2020). Studies con-
ducted in tropical forest areas found that forest
products including food, fuel, fodder and construc-
tion materials, accounted for around 20% of house-
hold income and livelihood stability (Angelsen
et al., 2014; Duchelle et al., 2014). The commercial-
isation of wild foods or forest foods such as ani-
mals, plants and fungi, is also often vital for ac-
cessing medical treatment at public health centres
and hospitals, or traditional or ancestral medicine
systems (Asprilla-Perea and Díaz-Puente, 2019).
2.1

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
39
2.6.2 EcoHealth
An ‘EcoHealth’ approach is dened as “committed
to fostering the health of humans, animals, and
ecosystems and to conducting research which
recognizes the inextricable linkages between the
health of all species and their environments”
(EcoHealth Journal). EcoHealth has its roots in
social-ecological systems thinking (Berkes and
Folke, 1998; Ostrom, 2009) and emphasises the
mutual interdependencies between people and
nature. It has developed as a eld of research,
education and practice that adopts systems ap-
proaches to promote the health of people, ani-
mals and ecosystems in the context of social and
ecological interactions (Lerner and Berg, 2017).
To the social-ecological systems thinking, it adds
a focus on and connection to human health; to
human health, it adds a body of knowledge, ap-
proaches and solutions from studying complex
systems dynamics. EcoHealth research draws
on the natural sciences, health sciences, social
sciences, the humanities and beyond, often work-
ing in collaboration with interested parties and
community members to address issues at the in-
terface of health, ecosystems and society.
In practice, an EcoHealth approach focuses on
protecting and/or restoring high value ecosystems
and improving human health through pathways
of enhanced ecosystem management. For exam-
ple, the EcoHealth Alliance project ‘Forest Health
Futures’ in Liberia (EcoHealth website) applies a
land-use planner framework to identify forested
areas for conservation to maximise economic de-
velopment, avoid loss of high carbon stocks and
biodiversity, and minimise the risk for increased
infectious disease burden.
2.6.3 Planetary Health
‘Planetary Health’ was launched by the Rocke-
feller-Lancet commission and is dened as “the
achievement of the highest attainable stand-
ard of health, wellbeing, and equity worldwide
through judicious attention to the human sys-
tems – political, economic, and social – that shape
the future of humanity and the Earth’s natural
systems that dene the safe environmental limits
within which humanity can ourish” (Whitmee et
al., 2015). In simple terms, Planetary Health is the
health of human civilisation and the state of the
natural systems on which it depends (Horton et
al., 2014; Whitmee et al., 2015). The concept aims
to respond to the fact that an increasing share of
the global burden of disease is driven by the pace
and scale of human disruption of Earth’s natural
systems (Whitmee et al., 2015).
An increasing evidence base shows that hu-
man activities are changing fundamental Earth
system biophysical conditions at rates that are
much higher than in the history of humankind
(Rockström et al., 2009; Steffen et al., 2015). These
biophysical changes are taking place across at
least six dimensions: (1) disruption of the global
climate system; (2) widespread pollution of air,
water and soils; (3) rapid biodiversity loss; (4) re-
conguration of biogeochemical cycles, including
those of carbon, nitrogen and phosphorus; (5) per-
vasive changes in land use and land cover; and (6)
resource scarcity, including fresh water and arable
land (Rockström et al., 2009; Steffen et al., 2015).
All of these changes are interrelated and inuence
the impact of forests on human health (Figure 2.5).
Each of these dimensions interacts with the
others in complex ways, altering the quality of
air, water, food and the habitability of the plan-
et. Changing environmental conditions also alter
exposures to infectious diseases and natural haz-
ards such as heat waves, droughts, oods, res
and tropical storms. These changes to natural life
support systems are negatively impacting human
health in a variety of ways, including by affecting
food availability and nutrition, increasing both in-
fectious and noncommunicable diseases, increas-
ing displacement and conict and worsening men-
tal health, and are expected to account for most of
the global burden of disease in the coming century,
disproportionately affecting today's most vulnera-
ble, and future generations (Whitmee et al., 2015;
James et al., 2018).
To protect human health, Planetary Health
calls for collaboration across disciplinary and na-
tional boundaries, as well as across knowledge sys-
tems and the promotion of wellbeing economies.
Planetary Health solutions involve characterising
and quantifying the health effects associated with
changes in a particular natural system, such as
forests, and then working with communities, gov-
ernments, businesses, nongovernmental and in-
ternational organisations to improve management
of that system so as to optimise health outcomes.
Taking a Planetary Health approach to the rela-
tionship between forests and human health stimu-
lates investigation and action in at least four ways.
First, a Planetary Health approach adds a dynamic
nature to studying the relationship between for-
ests and human health. It emphasises the impor-
tance of understanding the drivers of change, in
particular the consequences of human activities,
that might change the relationship between for-

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
40
ests and human health. Second, Planetary Health
acknowledges forest crises related to human ac-
tivities and the impact thereof for human health,
including climate change effects on forests and
deforestation and fragmentation of forest habi-
tats. For example, an increasing number of stud-
ies in the eld of Planetary Health show that de-
forestation is leading to more infectious diseases
in humans (Fawzi et al., 2020; Rodriguez-Morales
et al., 2021). Third, Planetary Health emphasises
a broader action and solutions space for human
health including forest management and protec-
tion. For example, Myers (2017) notes that the no-
tion of public health workers should not only apply
to those in the conventional public health system
but also to landscape managers, forest managers
and others, emphasising the need for joint human
health and environmental stewardship. Fourth, a
Planetary Health approach encourages collabora-
tive learning from different knowledge systems,
including TEK (see Introduction), as these have
been more consistent with stewardship of natural
landscapes and ecosystems (Wabnitz et al., 2020).
Applying a Planetary Health approach to the
relationship between forests and human health,
thereby raises questions such as: How does de-
forestation inuence infectious disease patterns,
diet quality or mental health? How does this differ
for rural, urban and forest-dependent communi-
ties, for low- versus high-income settings, for trop-
ical versus temperate settings? What are opportu-
nities to work with forest managers in addressing
certain human health concerns? How do changes
in the environment due to agroforestry inuence
human health? Several of these questions are dis-
cussed in the coming chapters.
2.6.4 Resilience
An important concept from social-ecological sys-
tems approaches is resilience which is dened in
various ways, including by the IPCC as: “The abil-
ity of a social, ecological or social-ecological sys-
tem to absorb disturbances while retaining the
same basic structure and ways of functioning, the
capacity for self-organisation, and the capacity to
adapt to stress and change” (IPCC, 2007).
The essential quality of resilience is the capaci-
ty to withstand shocks and rebuild when necessary.
The idea that resilience always means that things
go back to the way they were after a shock or stress
– like a spring – is only part of the story. Folke et al.
(2010) call this ‘engineering resilience’. In the com-
plex, inter-dependent social and ecological systems
in which we live, resilience also includes the capac-
ity for transformation when systems cross thresh-
olds. This is ‘social-ecological resilience’ (Folke et al.,
2010) and can be captured as a system’s capacity to
manage change while continuing to develop. Such
resilience approaches address ecosystems as a
whole, rather than their component parts. This is a
departure from conventional approaches that seek
Figure 2.5
Illustration of the impacts of anthropogenic change on human health
Consumption
Demographic shifts
Technology
Underlying drivers Ecological drivers Proximate causes Mediating factors Health effects
Malnutrition
Infectious disease
Non-communicable disease
Displacement and conflict
Mental health
Air quality
Food production
Infectious disease exposures
Access to fresh water
Natural hazards
Climate
change
Resource
scarcity
Biodiversity
loss
Altered
biogeochemical
cycles
Global
pollution
Land use and
land cover
change
Culture and behavior
Technology
Philanthropy
Wealth
Governance
Source: Myers, 2017

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
41
to maximise the yield of commercially important
resources, such as sh or timber. Trees and sh do
not exist in isolation however, they are enmeshed
in ecosystems of breathtaking complexity. By fo-
cusing on one resource or outcome, forest manag-
ers may create unintended effects that disrupt and
weaken the larger system with eventual impact on
human health.
Resilience thinking has proved itself practical
in holistically addressing local needs while offer-
ing an avenue to reach clear and specic actions,
and has gained prominence with growing concerns
on the impacts of climate change. For example, a
climate resilience framework (CRF) was developed
as a systems-based approach to building resilience
to climate change. This framework has proven
helpful particularly for local governments working
with multi-stakeholders and cross-sectoral issues
that arise when trying to address climate change,
uncertainty and planning.
In this report, we build on resilience thinking as
part of a pragmatic systems approach to better en-
gage in complex contexts of forests-human health
interactions. We thereby consider for example crit-
ical dynamics and vulnerabilities of forest-human
health relationships (see Chapter 4 for further
details), principles for building resilience in so-
cial-ecological systems (see Chapter 5 for further
details) and potential shifts in practice for sustain-
able development (Reyers et al., 2013; Bennett and
Reyers, 2022).
2.6.5 Implications of systems frameworks and
concepts for assessing the forest-human health
interactions
The various systems concepts and frameworks
have evolved over time and, increasingly, more
similarities than differences can be found be-
tween them (Lerner and Berg, 2017). In this report,
we build upon these systems concepts to identify
four main implications to better understand and
engage with forests – human health interactions
(Figure 2.6).
Villagers resting under a tree on a hot summer day in Nepal
Photo © Sital Uprety

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
42
Figure 2.6
Illustration of how this assessment builds upon the convergence
of three systems approaches: One Health, Planetary Health and EcoHealth –
each with roots in different backgrounds, but with increased convergence
in the science-policy-practice space
OneHealth Planetary
Health
EcoHealth
OneHealth
Background roots in animal health –
human health studies, centered
around how the environment and
environmental management im-
pact zoonotic diseases Pandemics –
including COVID-19, ebola, zika
and others - have increased ur-
gency to act upon this.
OneHealth science & practice have
contributed to an increased evi-
dence-base, awareness and poli-
cy space about the links between
environmental management and
zoonotic diseases.
Planetary Health
Background roots in Earth system –
human health studies, centered
around how human-induced envi-
ronmental change impacts human
health.
Climate change impacts including
extreme weather events, changing
temperatures and droughts, have
increased urgency to act upon this.
Planetary Health science & practice
have contributed to an Increased
evidence-base, awareness, and
policy space about how climate
change & environmental degrada-
tion affect human health.
EcoHealth
Background roots in biodiversity,
ecosystem services and social-eco-
logical systems studies.
The increased attention to, and
impacts of, biodiversity loss con-
tribute to further connect this field
to human health and the urgency
to act upon this.
EcoHealth science & practice have
contributed to an increased evi-
dence-base, awareness and policy
space on the linkages between bio-
diversity and human health.

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
43
First, multiple dimensions of health (not only
zoonotic diseases) are affected by and can benet
from improved forests-health management. Sec-
ond, forests-human health interactions are not
static but take place within dynamic social-eco-
logical systems. It is therefore crucial to consider
major drivers of change and how these impact for-
est-human health relationships. This also includes
recognising forest crises and related implications
on human health (Chapter 4) and anticipating and
managing trade-offs (Chapters 4 and 5). The impli-
cation is that situations that are benecial to the
health and functioning of humans, forests and the
economy can be created. Third, taking a systems
approach broadens the action and solution space
for human health and for forest management and
stewardship, emphasising a space for win-win-win
actions. Fourth, connecting the dots through these
systems approaches for forests-human health in-
teractions, underlines the urgency to act and to
invest in social-ecological resilience (Chapters 5
and 6).
2.7 Framing the Health Impacts of Forests
2.7.1 Disconnect between humans and forests
The opportunities for forest contact have been
substantially reduced with urbanisation (Fig-
ure2.7). Before industrialisation, daily and regu-
lar contact with nature was the norm. For mil-
lennia, humans evolved as hunter gatherers from
the savannahs of Africa and migrated across the
globe. But with adaptation to new and contrasting
environments, humans developed new technol-
ogies attending to many necessities and desires
including forms of housing, industry, food pro-
duction, transport, sanitation, healthcare and en-
tertainment. Innovation clustered geographically
and this drew in more people, with wave after
wave of migration from rural areas to urban cen-
tres driving rapid urbanisation. These processes
have generated increasing distances between
where people live and forests and other natural
settings to which they might seek connection. To-
day, in urbanised societies, the vast majority of
people spend their time indoors (Klepeis et al.,
2001) without contact with or connection to the
natural world. Of particular concern is children’s
increasing disconnect from nature, since it will
inuence their relationship with, and attitude to-
wards, the environment for the rest of their lives,
in addition to depriving them from the number
of health benets related to nature exposure in
childhood (Louv, 2008).
This disconnect may have created or reinforced
pre-existing anthropocentric notions of humanity
as separate from the natural world. Some suggest
that this underpins apathy to preventing environ-
mental degradation (Louv, 2008; Whitburn et al.,
2020). The spatial and cultural mismatch between
humans and the ‘more than human world’ may
be a driver of the declining importance of nature
in contemporary dictionaries (Flood, 2015), ction
books, song lyrics and movie storylines in the Eng-
lish language (Kesebir and Kesebir, 2017), com-
pounded by reverence for sports and music stars,
TV and social media personalities (Aruguete et al.,
2020). Some research indicates that children and
adolescents spend more time indoors looking at
This assessment builds upon the convergence between these three systems approaches and
thereby underlines four related implications for understanding and acting upon forests-human
health interactions:
• Multiple dimensions of health (beyond zoonotic diseases) are affected by and can benefit from for-
ests-health management. This assessment thereby takes a holistic life span approach (Chapter 3).
• Forests-human health interactions are not static but dynamic social-ecological systems. It is therefore
crucial to consider major drivers of change and how these impact forest-human health relationships.
This also includes the recognition of forest crises and related implications on human health (Chapter 4).
• These systems approaches broaden the action and solution space for human health and for forest man-
agement & stewardship, emphasising a space for win-win-win actions and for anticipating & managing
trade-offs (Chapter 5).
• Connecting the dots through these systems approaches for forests-human health interactions under-
scores the urgency to act and to invest in social-ecological resilience.

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
44
screens than outdoors (Marshall et al., 2006; Larson
et al., 2019). This deprivation of contact with na-
ture and the ample human-made alternative de-
mands for our attention may reduce a sense of
connectedness with nature to such a degree that
it becomes socialised and passed on inter-gener-
ationally, shifting the experiential baseline and
generating a so-called ‘environmental generation-
al amnesia’ (Kahn Jr et al., 2008). The net impact
being new generations of humans living in a more
dangerously unsustainable world without expe-
rience or knowledge of the rich diversity of life
that once also called this planet home. This is fur-
ther reinforced by an exaggerated risk perception
where a growing sense of ‘fear of nature’ may oc-
cur (Ball and Ball-King, 2013, 2018). The result is
generations that are unfamiliar with the natural
environment and that consequently do not know
how to interact with, or behave in, these settings.
Deforestation and lack of urban forests in
cities reduce the availability and thereby oppor-
tunities for connection. There are also socio-eco-
nomic aspects to this availability. For example,
studies have reported that socio-economically
disadvantaged populations tend to have lower lev-
els of urban forest provision in many high-income
countries (Feng and Astell-Burt, 2017; Markevych
et al., 2017; Ferguson et al., 2018). An emerging lit-
erature indicates similar or more severe inequities
in low- and middle-income countries (Rigolon et
al., 2018). Nonetheless, there is appetite for using
technologies to address the disconnect with na-
ture via ‘augmented reality’, such as the Pokémon
GO smartphone application that gamied being
outdoors and encouraged people to visit nature
(Adlakha et al., 2017; Marquet et al., 2018). To what
extent such an approach contributes to addressing
individuals’ disconnect from nature or just merely
attracts those with already strong senses of con-
nection with natural environments is unclear.
2.7.2 Reconnection to nature
History and theory development
Environmental psychology
The nature and health discipline of environ-
mental psychology emerged in the 1980s with
the publication of the rst experimental studies
Figure 2.7
Sebeta Town in Ethiopia. Land cover change from 2003 to 2016,
illustrating a significant increase in built up land at the expense of green spaces
Source: Girma et al., 2019

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
45
demonstrating the stress reducing and atten-
tion-promoting effects of viewing and walking
through nature (Ulrich, 1979; 1984; Hartig et al.,
1991). Until then, mainstream science had shown
little interest in studying health benets of na-
ture. Belief in the ‘healing powers of nature’ was
considered by many a kind of superstition that
had become obsolete with the rise of modern
medicine (Wagenaar, 2005). However, once the
topic was opened to empirical investigation, the
accumulating evidence sparked a new interest
in the health-supportive functions of forests and
other natural environments as a complement to
regular therapy and treatment.
Research on the health effects of exposure to
natural environments has for a long time been
guided by two dominant theoretical perspectives:
Attention Restoration Theory (ART) (Kaplan and
Kaplan, 1989) and Stress Reduction Theory (SRT)
(Ulrich et al., 1991). ART proposes that natural en-
vironments are rich in ‘soft fascinations’ which
automatically draw our attention without requir-
ing effort, thereby replenishing people’s cognitive
capacity and reducing their mental fatigue and
increasing their focus and attention. SRT states
that exposure to nature activates the parasympa-
thetic nervous system as a ‘vagal break on stress’
and thereby facilitates psychophysiological stress
recovery. Both theories refer to the innate connec-
tion of humans with nature developed through
evolution as a possible ultimate explanation for
the positive responses to nature. This evolutionary
approach has been elaborated in more detail by
the biophilia hypothesis (literally meaning ‘love of
life’) which states that humans have an inherent
preference to seek connections with other forms
of life and with nature, and derive many benets
from making that connection (Wilson, 1984).
Theories and studies in environmental psy-
chology have also suggested that exposure to nat-
ural environments and engaging in nature-based
activities can increase pro-environmental atti-
tudes and stimulate pro-environmental behaviour.
This relation may, to some extent, be explained by
automatic physiological reactions (Annerstedt van
den Bosch and Depledge, 2015). But there is also
strong evidence that the positive inuence of na-
ture exposure on pro-environmental behaviour is
mediated by feelings of connectedness to nature,
which make people more caring and respect-
ful towards the environment (Martin et al., 2020;
Whitburn et al., 2020).
Environmental epidemiology
Methodologically, around the turn of the 21st cen-
tury, research on health benets of nature took a
new turn. Until then, research mostly consisted
of experimental studies conducted by environ-
mental psychologists. Epidemiologists, howev-
er, also became interested in studying the rela-
tionship between nature and health with their
own methods (Takano et al., 2002; de Vries et
al., 2003; Groenewegen et al., 2006). Using resi-
dentially geocoded information to connect data
on green space in the living environment with
public health data, epidemiological studies demon-
strated strong positive relationships between the
amount of green space and a wealth of health
indicators, including morbidity and mortality
rates (Twohig-Bennett and Jones, 2018). This line
of research has gained much ground, with some
studies suggesting even greater health benets
of green space for those living in deprived areas,
thereby potentially reducing income-related in-
equalities in health (Mitchell and Popham, 2008;
Dadvand et al., 2014; Wolch et al., 2014) although
the ndings are inconsistent, with other studies
indicating a stronger association in wealthier ar-
eas (Crouse et al., 2017).
A key question for – experimental as well as
epidemiological – research has evolved around the
health impacts of different types of natural set-
tings (Purcell et al., 2001). This knowledge would
be central for urban planners to optimise health
benets within a constrained space. However, the
matter is complicated since different types of na-
ture likely inuence different health outcomes
and in different populations; thus, there is no one-
size-ts-all. The results also vary in the literature
with some studies nding no clear distinction in
impact depending on nature type (van den Berg et
al., 2014; Gidlow et al., 2016a; van den Berg, 2021),
and others suggesting differences (Jarvis et al.,
2020b; Jarvis et al., 2022). If anything, there seems
to be a certain convergence towards the particu-
larly benecial impact of trees, in comparison to,
for example, grass cover (Wolf et al., 2020).
Today, nature and health research has matured
into a recognised, multidisciplinary eld with its
own unique theories and methods, and a substan-
tive output of hundreds of peer-reviewed papers
per year, including critical systematic reviews and
meta-analyses (Mygind et al., 2019; Rojas-Rueda et
al., 2019; Davis et al., 2021). One of the important
contributions of this research which has provid-
ed evidence on the health and wellbeing benets
of nature, is that it has made people aware of the
importance of connecting to nature. Important-
ly, this has resulted in policy and practice imple-
mentation and high-level recognition of the value
of nature, seeing forests and green spaces high-
lighted in WHO public health policies (WHO, 2016)

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
46
as well as in the Sustainable Development Goals
(Devisscher et al., 2019) and as one of the indica-
tors for adaptation, planning and resilience for
human health in the latest Lancet Countdown on
climate change and health (Watts et al., 2021).
Pathways and mechanisms
Following up on the theories and studies described
in the previous section, signicant research has
been carried out to improve the understanding of
why nature has an impact on health, exploring
the potential pathways and mechanisms that un-
derlie any association. This knowledge is essen-
tial to provide causal evidence and also to better
describe which components and types of nature
are benecial for which health outcomes. It also
helps research to rule out alternative explana-
tions for associations, such as self-selection. By
providing causal evidence, the arguments for
urban green planning, biodiversity conservation
and reforestation increase with clear planetary
health benets.
In the remainder of this section, different
pathways that have been studied will be briey in-
troduced, with a focus on the link between nature
and the mediating variable. Links between path-
ways and specic health outcomes are addressed
in Chapter 3. A summarising model of how the
pathways between nature exposure and health
outcomes operate is provided in Figure 2.1.
From the early days of research on nature’s
impact on human health, a common way to de-
scribe the associations has been to refer to so-
cio-behavioural pathways. These pathways are
typically related to stress recovery, physical activ-
ity and social cohesion and some of them, but not
all, may be considered as cultural ecosystem ser-
vices. A relatively recent paper by Bratman et al.
(2019) suggests a model where mental health, as
identied through, for example, cognitive func-
tion and emotional wellbeing, is specically ac-
knowledged as an ecosystem service.
Stress recovery and attention restoration
A number of studies, from the nature and health
discipline’s early days, have demonstrated that
nature may facilitate stress recovery as indicated
both through physiological measurements and
self-reports. The stress recovery may be a result
of direct sensory stimulation from nature, such
as exposure to fractal patterns, (Hägerhäll et al.,
2008), smells (Matsumoto et al., 2014), sounds
(Hunter et al., 2010), or stemming from opportu-
nities for recreation and getting away from every-
day demands.
Experimental studies tend to show bene-
cial (short-term) effects by just looking at natu-
ral scenes, compared to urban scenes, although
the evidence seems stronger for self-reported
stress measures than for physiological stress
measures (Mygind et al., 2021; Bolouki, 2022).
Kondo et al. (2018) arrived at similar conclusions
based on studies in which participants were ex-
posed to natural and built-up environments. As
for epidemiological research, recent research
has analysed allostatic load levels, which may
be considered the physiological counterpart of
chronic stress. Egorov et al. (2017) and Egorov et
al. (2020) showed that, on average, people with a
greener residential environment including a larg-
er tree canopy cover, had a lower allostatic load
level. Another indicator for chronic stress is the
amount of the stress hormone cortisol in hair.
Recent studies have found benecial associations
between the local amount of green space and hair
cortisol levels (Levhar et al., 2021; Verheyen et al.,
2021), although an earlier study did not nd an
association (Gidlow et al., 2016b). It is important
to conrm the stress recovery impact in further
high-quality studies because chronic stress is a
major risk factor for many non-communicable
diseases, as discussed in Chapter 3.
Physical activity
Like chronic stress, physical inactivity is a major
risk factor for many diseases (see Chapter 3), and
therefore, it is crucial to know if nature stimulates
physical activity in a population. This could occur
by simply providing a suitable environment (also,
a cooler one during periods of heat) for running
or using training equipment in a recreational
forest or a park. A recent review concluded that
physical activity is the most studied pathway be-
tween urban green spaces and health (Dzhambov
et al., 2020) and it has even been suggested that
the health benets of physical activity are larger
if they are conducted in a natural environment
compared to an indoor setting (Thompson Coon et
al., 2011; Wang et al., 2021). The ndings are mixed
however, with some studies indicating a positive
association (de Vries et al., 2013; Konijnendijk et
al., 2013), and others not (Maas et al., 2008; Trigue-
ro-Mas et al., 2015). Some studies support the role
of physical activity as a mediator in the nature and
health association (van den Berg et al., 2019) but
the magnitude of this impact remains unclear. The
inconsistency in evidence is likely due to several
factors that interact and determine the impact,
such as, for example, real accessibility (socio-cul-
turally and physically) and quality and amenities

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
47
of the area. In addition, study designs and meth-
ods for measuring exposure and outcome differ
substantially between studies.
Social cohesion
Social cohesion can be understood as a sense of
shared values, cooperation and interactions in
a community. Natural environments can serve
as democratic settings for social interactions be-
tween neighbours thereby creating social cohesion
and a sense of community in both urban and ru-
ral areas (Elands et al., 2018). Social interactions
in public spaces can provide relief from daily rou-
tines and offer opportunities to relate to people of
various backgrounds (Dines et al., 2006). Several
studies suggest a positive association between
social capital and green spaces (Maas et al., 2009;
Peters et al., 2010; Dadvand et al., 2016), but similar-
ly to physical activity, research on the role of social
cohesion as a mediator to health outcomes is not
entirely consistent (Zhang et al., 2021). The mixed
ndings may be due to the difculty in measuring
social cohesion objectively and it is also likely that
the quality and type of green space may be more
important than the mere amount of green.
Place attachment
Place attachment, sometimes referred to as sense
of place, represents an individual’s emotional con-
nection to a physical landscape (Lewicka, 2011).
Natural elements and urban green spaces have
been found to predict place attachment (Bonaiuto
et al., 1999), although social factors are stronger
determinants. Place attachment can, in turn, con-
tribute to perceived restorativeness of a place (Liu
et al., 2020) and thereby act as mediator to vari-
ous health outcomes. A concept that is related to
place attachment is solastalgia (Albrecht et al.,
2007), which basically represents the distress pro-
duced by change of home environment, the place
to which people are connected through, for exam-
ple, place attachment. Solastalgia can occur as a
result of displacement, notably because of natural
disasters and climate change (Warsini et al., 2014;
Ellis and Albrecht, 2017).
Old friends
A relatively recently introduced pathway that
relates to nature’s potential for direct health im-
pact is through its capacity to inuence humans’
immune systems (Rook, 2013). This is sometimes
referred to as the ‘hygiene hypothesis’, ‘biodiver-
sity hypothesis’, or the ’old friends hypothesis’
(Rook et al., 2014; Rook, 2018). Modern life, espe-
cially in high-income countries, is characterised
by high hygiene levels and indoor living, which
results in insufcient exposure to natural micro-
organisms and thereby an impaired development
Reconnecting to nature is essential, especially for urban societies
Photo © Nelson Grima

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
48
of our immune systems. This may be one of the
explanations behind the exponential increase in,
for example, allergies, asthma and inammatory
bowel syndrome (Hanski et al., 2012; Logan et al.,
2016). According to recent studies, exposure to di-
verse microorganisms in nature can inuence the
human microbiome resulting in a more diverse
composition of gut (Roslund et al., 2021) and skin
(Lehtimäki et al., 2018) microbiota. This counter-
acts the dysbiosis associated with modern living,
and thereby stimulates the development of a
functioning immune system, (Roslund et al., 2020;
Roslund et al., 2021), sometimes referred to as
‘natural immunity’ (von Hertzen et al., 2011).
Regulating ecosystem services
Heat: Urban trees and forests regulate the climate
by reducing heat (TNC, 2016; van den Bosch and
Ode Sang, 2017), particularly the urban heat island
phenomenon (Oke, 1973). With global warming,
this service will likely become of increasing im-
portance to reduce heat-related morbidity and
mortality (Watts et al., 2021). Green space can
cool the environment through shading and evap-
otranspiration (Loughner et al., 2012; Qiu et al.,
2013; Napoli et al., 2016). The shading mecha-
nisms prevent heat storage in impervious sur-
faces and its later release. Large trees are, in this
context, more important than grass or lower veg-
etation. The evapotranspiration effect refers to
trees’ water transportation which increases la-
tent heat storage because some of the sun’s en-
ergy will go to converting water from its liquid to
its vapour form, rather than increasing air tem-
perature. These effects can substantially reduce
maximum summer daytime air temperatures at
pedestrian level. Existing evidence suggests that
urban greenspace can reduce the temperature
by up to 3°C on average (i.e., not considering the
impact on maximum temperature), depending on
local context (Fryd et al., 2011). The spatial extent
of the heat reducing effect also varies with con-
text but, as a general rule, the maximum cool-
ing distance amounts to approximately one park
width from the park (or forest patch) (TNC, 2016).
Research on the role of heat reduction as a me-
diator of health impacts supports this pathway
(Graham et al., 2016).
The fruit and rhizomes of Hedychium spicatum, a plant commonly found in Asia and Africa, is used for medicinal and religious
purposes
Photo © Arun Kumar

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
49
Altogether, the cooling impact of urban trees
will likely have a substantial impact on thermal
comfort and health in the future, especially in
heat vulnerable populations such as children, the
disabled and the elderly. This impact will be of
particular importance in countries that are most
impacted by climate change, often in low-income
areas of the world with a large amount of the labour
force working outdoors (Kjellstrom, 2009; 2015).
Air pollution: Ambient air pollution is currently
the largest environmental health threat with more
than seven million people dying prematurely each
year due to its harmful impacts (Landrigan et al.,
2018). A disproportionate burden is taken by low-
and middle- income countries. Therefore, even
small reductions of air pollution levels can have a
large impact on a population level.
Urban green spaces can improve air quality by
modifying the concentrations of gaseous and par-
ticle pollutants (Janhäll, 2015). Trees can impact
gaseous pollutants through uptake by leaf stoma-
ta, absorption and adsorption to plant surfaces
(Escobedo and Nowak, 2009). In the health liter-
ature, much attention has been given to particle
pollutants (particulate matter, PM) because of the
strong association with morbidity and mortality.
Green spaces interact with PM by deposition, dis-
persion and modication.
Deposition refers to direct capturing of PM
through, for example, absorption. In practice, the
net impact of this mechanism is difcult to esti-
mate because the value is also inuenced by re-
suspension of PM due to wind, precipitation or de-
foliation. On a local scale (typically a distance of
between 10 and 500m), the effect can be substan-
tial, with a removal capacity of up to 60% (Pugh et
al., 2012; Steffens et al., 2012).
Dispersion is typically characterised by a phys-
ical or ltering green space barrier, which changes
the velocity and trajectory of PM. In this case, it is
clear that the positioning of the vegetation, rela-
tive to dominant air ows and emission sources, is
important. In some cases, local PM concentrations
may actually increase if the vegetation blocks air
ows and keeps the polluted air trapped in, for ex-
ample, street canyons (Gromke and Blocken, 2015).
Modication occurs when green spaces alter
inherent properties of PM, which can acceler-
ate deposition or even reduce the toxicity of the
particles (Weyens et al., 2015). A large number of
modelling and quasi-experimental studies have
assessed green spaces’ impact on air pollution
and converging evidence suggests that there is a
positive effect, although the magnitude is relative-
ly small (Diener and Mudu, 2021). Nevertheless,
given the scale of the problem, small effects can
translate into large health impacts, especially if
urban forest interventions are carefully planned
with a focus on the most vulnerable populations
in areas with high pollution levels.
Noise: Another way by which green space is
assumed to protect health, is by reducing noise.
Whereas the effect of vegetation on actual noise
levels may be small, it can help to reduce the noise
annoyance (Salmond et al., 2016). The same ob-
jective noise level may result in less noise annoy-
ance if green space is present (Dzhambov et al.,
2018; Mueller et al., 2020). This could be labelled
a psycho-acoustic effect of the vegetation. Recent
studies suggest an impact of trees also on objec-
tive noise levels (Zhao et al., 2021) as well as a me-
diating pathway role (Jarvis et al., 2021). Another
way in which nature may help to reduce noise an-
noyance is by way of natural sounds – in particular
birdsong (Van Renterghem, 2018) – masking man-
made sounds (including trafc noise).
Disease transmission regulation: Only a small
number of studies directly analyse the links be-
tween ecosystem services and the regulation of
infectious disease transmission. The ‘dilution ef-
fect’, or the ‘negative diversity–disease’, has been
proposed as an ecological mechanism of an eco-
system service of disease regulation. The dilution
effect postulates that biodiversity losses may pro-
mote disease transmission (Keesing et al., 2006;
2010). Global land use changes, including forest
conversion, may favour zoonotic reservoirs and the
risks of zoonotic diseases (Gibb et al., 2020). De-
forestation and biodiversity loss favour reservoir
and/or vector populations, which affect disease
transmission dynamics. For example, re-emer-
gence of arthropod-borne leishmaniasis has been
found to be associated with deforestation (Chaves
et al., 2008). The ecological mechanism proposed is
that forest fragmentation and biodiversity loss lead
to the loss of ecological regulation of small mam-
mals, which are main reservoirs of Leishmania
species (Gottwalt, 2013). The fact that biodiversity
prevents the emergence and spill-over of infectious
diseases is currently of increasing concern as we
become aware of the dire human health conse-
quences of the COVID-19 pandemic (Kache et al.,
2021). Moreover, global trade and climate change
favour invasive species, which are new potential
vectors or reservoirs in invaded localities increas-
ing the risks of infectious diseases (Hulme, 2014).
A number of other regulating services are relat-
ed to positive human health outcomes, although
they have rarely been considered as mediators in

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
50
the nature and health studies. Nevertheless, for-
ests’ capacity to reduce ooding and retain water
contributes to lower risk of injuries and mortality
related to ooding hazards (WHO, 2021a). Water
purication is another service that reduces wa-
ter contamination and related infectious diseases
(Chiabai et al., 2018). This is further discussed in
Chapters 4 and 5. The role of forests in disaster
risk reduction and prevention has a large impact
(Al Kautsar and Mulyono, 2021), not only on phys-
ical health, but also on mental health because of
the distress and anxiety associated with extreme
events (Sudmeier-Rieux et al., 2021).
Provisioning ecosystem services
Provisioning services are of high importance for
food security, fresh water and fuel supply, and
medicinal plants among others, especially in for-
est-dependent communities (Dhar et al., 2018).
These are all essential components of healthy
lives and even survival for large populations
across the world.
Forest foods and tree products have been ne-
cessary components of rural diets for millennia.
Food security is grounded in the diversity of bio-
ta, landscapes and production units, and forests
and trees are critical for maintaining that diversity
(Vira et al., 2015). Forests also provide high qual-
ity nutrients with impact on specic conditions
related to undernourishment and micronutrient
deciency, such as osteoporosis, cardiovascular
diseases, and many other non-communicable dis-
orders (Afshin et al., 2019). A number of studies
have found a positive association between having
access to forests and various indicators of diet
and nutrition (Rowland et al., 2017; Baudron et al.,
2019) and a recent study from Tanzania was able
to provide evidence for a causal relation between
deforestation and decline in dietary quality (Hall
et al., 2022).
In addition, more than one-third of the global
population relies on fuel from forests for cooking
and it is a vital source of energy for local econo-
mies. Medicinal plants from forests improve health
not only in forest-dependent communities, but
also form the basis of many pharmaceutical prod-
ucts produced globally. For example, wild forest re-
sources include compounds that carry therapeutic
properties, such as muscle relaxants, steroids and
contraceptives (from wild yam). Quinine and arte-
misinin against malaria are also based on forest
products, as are the anti-oxidant cancer drugs vin-
blastine, etoposide and taxol (Rao et al., 2004).
Making better use of TEK and combining it with
western scientic knowledge could increase the
role of forests in food security and nutrition (FAO,
2013). Indigenous people and local communities
hold an immense knowledge base on the cultiva-
tion, harvesting and preparation of forest foods
and other products. Another important aspect is
to acknowledge women’s often specialised knowl-
edge of forests in terms of species diversity, uses
for various purposes, and conservation and sus-
tainable management practices, something that is
currently typically underappreciated (FAO, 2013).
Altogether, we can conclude that the number
and types of pathways between forests and hu-
man health are varied, multifaceted and high-
ly interactive. There is overwhelming evidence
supporting the notion that forests and natu-
ral environments are related to healthy behav-
iours and services that evidently lead to positive
health outcomes (WHO, 2016; van den Bosch and
Nieuwenhuijsen, 2017; van den Bosch and Ode
Sang, 2017; Watts et al., 2021).
Trade-offs
Forest environments are not silver-bullet solutions
to the extremely complex challenges the world is
facing now and will be facing in the future. Hu-
man health is inuenced by the local and global
economy, war and conicts, infrastructure and ac-
cess to health care, education, lifestyles, and much
more. Many of these factors are not, or only pe-
ripherally, related to forests. In many cases, trade-
offs occur, for example when new infrastructure
must be built on forest land to provide access to
health care clinics or schools. This is often a more
common problem in low-income countries where
critical infrastructure expansion is still under de-
velopment. For this reason, it is even more impor-
tant to consider optimisation of investments, both
from a human health and environmental perspec-
tive. One way of addressing this is through Envi-
ronmental and Health Impact Assessments (EIA
and HIA), which use systematic approaches and
methodologies to estimate future consequences
of proposed projects, activities, plans or policies.
The aim is to identify and mitigate trade-offs and
also nd solutions to strengthen any investment
or strategy for the benet of both humans and the
environment (Vohra et al., 2018). The focus areas
for an EIA typically include ora and fauna; water,
air and soil quality/quantity; noise; landscape and
visual amenities; archaeology and heritage; and so-
cio-economic environments (Morris and Therivel,
2001). An EIA usually only considers potentially
adverse impacts of an activity. HIAs, on the other

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
51
hand, tend to identify both positive and negative
impacts on communities, and health and well-
being. This is an important aspect for evaluating
the positive effects of, for example, reforestation
or urban green planning activities, while at the
same time considering trade-offs. An HIA can in-
clude several focal areas, for example, food access,
economic stability, recreation opportunities, air
and water quality, and safety. A thorough discus-
sion of trade-offs and synergies in the interactions
between forests and human health is provided in
Chapter 4.
2.8 Conclusion
This framing chapter has outlined how the inter-
relations between forests and human health can
only be understood within the context of plane-
tary health and related concepts. From this per-
spective, human health is understood as a mul-
tidimensional state that encompasses physical,
mental, spiritual and social wellbeing, but also
a capacity for adaptation and resilience, similar
to a healthy forest environment from an ecologi-
cal point of view. Disruptions to natural environ-
ments directly affect our own health.
To improve our understanding of these inter-
related disruptions, we must also improve our un-
derstanding of the benets that humans can ob-
tain from healthy forests and how these benets
can be achieved in a context of reciprocity where
ecosystem services are part of a circular system
and can be returned through environmentally
aware forest management methods and ecolog-
ically sound resource conservation (Comberti et
al., 2015). This kind of knowledge requires trans-
disciplinary efforts, where not only different scien-
tic disciplines collaborate, but also stakeholders,
politicians, and practitioners as well as minorities,
all genders, and Indigenous peoples, are involved
throughout the knowledge generation process.
This chapter has also described how and why
our disconnect with forest environments has oc-
curred, why it prevails, and how the discipline
around nature and health relations has developed
from initial environmental psychology theories to
research around pathways and mechanisms be-
hind human health benets from forests, some
more evident than others. In doing so, we also ad-
dress the current state of the art and how the evi-
dence has been generated based on different study
designs and measurements. These descriptions lay
the foundations for how the knowledge presented
in the rest of the Assessment can be interpreted
and understood.
As reected in this chapter, there is a deep in-
justice related to knowledge about interrelations
between forests and human health. While many
people in low- and middle-income countries de-
pend on forest environments for their livelihoods,
most of the research is conducted in high-income
countries, with a predominant focus on urban for-
ests. It is clear that we also need to ll the knowl-
edge gaps that relate to how human health and
forest interrelations are, and will be, impacted by
the global increase in socio-economic inequalities
and climate change.
In summary, human health does not exist with-
out forest health. It is pivotal that this message be
communicated to, and fully understood by, politi-
cians, decision-makers, and everyone living on this
planet because, despite the simplicity of the mess-
age, the way we treat our forests demonstrates
that we are very far from having achieved this sim-
ple realisation and an outdated, anthropocentric
worldview prevails.

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
52
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Appendix to Chapter 2
Research Design, Methods and Indicators
Introduction
The current evidence base on human health impacts of forests is developed from studies using diffe-
rent types of research designs, methods, tools and indicators. Here we provide an overview of methods
typically used in traditional ecological knowledge (TEK) systems and give a brief overview of how Wes-
tern, mainly quantitative, scientic knowledge has been generated, focusing on study designs and how
aspects of exposure and outcome have been measured. It should be noted that a vast majority of studies
on the direct impact of forests on human health have been conducted in urban environments, predomi-
nantly in Europe, North America and Australia (Gallegos-Riofrío et al., 2022).
The most considered modiers are socio-demographic factors on an individual or neighbourhood level,
such as socio-economic status and gender (although evidence is inconsistent with regard to gender-relat-
ed differences). With few exceptions, modiers and contexts related to national income level, urban-rural
gradient, geographical zone and climate-change impact have not been included in the analyses. More re-
cently, the quality of green space has increasingly been considered (Knobel et al., 2019; Jarvis et al., 2020),
especially in urban settings, but evidence is scarce and inconsistent.
Traditional Ecological Knowledge (TEK)
In general, Western science is characterised as objective and systematic, while TEK is contrasted as being
more subjective. However, it is important to consider that any knowledge or data are produced by socially
situated actors and are value-laden (Weiss et al., 2013). TEK tends to be local and context-specic and is
typically acquired longitudinally, orally or through demonstration, and made general through dialogue
and a shared social memory. The data are ltered and analysed through the individual human brain,
developing predictions of future events based on comparisons between what has happened in the past
and what is happening now, within a constantly changing environment (Freeman, 1992). This interactive
and longitudinal methodology that integrates a large number of variables qualitatively allows for a con-
text-dependent knowledge and understanding of increasingly complex situations that are characterised
by uncertainty, nonlinear dynamics and conicting perspectives – all common elements in forest-health
research. For this reason, real-life problems may be best addressed by considering TEK and Western sci-
ence as complementary systems, with their distinct designs and methodologies. Because ndings from
TEK are rarely documented in scientic publications, due to the very nature of this approach – verbal
rather than written – it is a challenge to provide a systematic list of TEK methods. This calls for locally
conducted research and transdisciplinary approaches, where any stakeholder is included in the formula-
tion of research questions, project design, and aims (Annerstedt, 2010). Data usually take the form of oral
expressions or symbols, rather than written text or numbers.
Western science
Study design
In the Western science tradition, a hierarchy of study designs is typically considered when evaluating
the quality of evidence generated from research. Briey, this means moving from the lowest level of
evidence obtained from case studies, through cross-sectional studies, case-control studies, cohort stu-
dies, to the highest level of evidence derived from randomised controlled trials (RCTs). Finally, systematic
reviews can determine signicance and effect sizes through meta-analyses of available RCTs. However,
it should be noted that this evidence hierarchy has its origin from the practice of evidence-based me-
dicine (EBMWG, 1992) used, for example, to guide clinicians to the most recommended treatment for a
specied diagnosis. Moving towards more complex, interdisciplinary research questions, this hierarchy
may not be an optimal way to assess the level of evidence (Concato, 2004). A complicating factor is also
that RCTs are difcult to conduct on a complex and dynamic subject such as a forest.

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
65
From the Western science evidence hierarchy perspective, most nature and health studies would actu-
ally be considered as having a relatively high risk of bias and thereby the evidence would be assessed as
limited. However, as resources for this area of research increase and rened methods and designs are de-
veloped, ndings from observational studies have started to be conrmed in controlled trials (Lederbogen
et al., 2011; Bratman et al., 2015). In addition, the sheer number of studies pointing in the same direction,
supports the evidence of nature’s positive impact on health. Most importantly, we may need to consider a
more holistic approach to evidence generation, including complementary information and data in trans-
disciplinary projects and analyses.
Many of the observational studies on nature and health are of a cross-sectional design (see e.g., Boll
et al., 2020; Fan et al., 2020). In these studies, exposure and outcome are measured at the same point
in time, meaning that it is difcult to assess causality and there is a risk of self-selection bias, i.e., that
those who are already of high income and good health are also those that live nearby green spaces. In
a case-control study (see e.g., Demoury et al., 2017; O'Callaghan-Gordo et al., 2018; Helbich et al., 2020),
cases (e.g., individuals getting diabetes) are compared with controls (e.g., individuals not getting diabetes)
retrospectively and the respective exposure to green space is determined. This means that it is possible
to identify whether exposure protects against disease (e.g., are those exposed to green space at lower risk
of getting diabetes?).
The next level of evidence would be retrieved from longitudinal cohort designs. These studies follow a
dened cohort over time, making it possible to determine a causal relationship in the sense that exposure
precedes outcome (see e.g., Annerstedt [van den Bosch] et al., 2012; Dadvand et al., 2017; Astell-Burt and
Feng, 2020). In natural experiments, researchers can take advantage of a change in the environment, as
induced by, for example, deforestation and compare data on health outcome before and after, although
randomisation in this case is impossible (see e.g., Donovan et al., 2015). The highest level of evidence,
according to the Western science hierarchy model, can be obtained from an RCT, where most confound-
ing bias can be eliminated through randomisation and the mechanism behind a causal relation can be
identied. Fully powered RCTs in nature and health research are difcult to conduct in real settings, but
a few examples exist (South et al., 2018; Sobko et al., 2020). For example, the study by Sobko et al. (2020)
randomly assigned two groups of children to more or less biodiverse environments and found that the
group that was exposed to biodiversity obtained a more diverse gut microbiome following the intervention
compared to the control group.
Qualitative study designs are not aimed at establishing numerical evidence but strive to get an as
rich and detailed in-depth understanding of a specic phenomenon or topic as possible, through a sub-
jective approach. This can provide insights into, for instance, the meaning of nature for individuals and
how people use, perceive and experience landscapes (Lygum et al., 2013; Bell et al., 2018). Another im-
portant aspect of qualitative research is how it can identify research questions and provide insights for
how to interpret results from quantitative data analysis. It is also fundamental for being able to conduct
mixed-methods studies, which often provide a holistic perspective of complex situations (Phoenix et al.,
2013; Stigsdotter et al., 2017).
Measurement methods
Outcome assessments: Human physical, mental, social, and spiritual health and wellbeing
The measurement of human health and wellbeing has been approached in a variety of ways in the na-
ture and health literature. The following paragraphs provide a summary of indicators and measurement
methods.
Observational and physical data
Evidence from observational studies can be based on available data of risk factors, morbidity or mortality.
These types of data can be from registers of the health system, including health insurance providers, from
statistical ofces, or from cohorts with specic research purposes. To measure risk factors, reported data
on, for example, Body Mass Index (BMI), blood pressure, and birth weight, have been used. These relate
to the identied pathways. Regarding diagnosed diseases, prevalence (how many people suffer from a
disorder at a certain point or period in time) or incidence (the number of people being diagnosed with a
disorder within a certain period) measures are typically used. Data on prescription of medicine have also
been used as proxy measures for disease (Marselle et al., 2020). Existing data on all-cause or cause-specic

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
66
mortality can be used, typically to assess reduction in premature mortality. Recent studies have included
estimates of Disability-Adjusted Life Years (DALYs) to assess impact (Mueller et al., 2017). Physical activity
can be measured by various smartphone applications and accelerometers, sometimes in combination
with Global Positioning System (GPS) to track activity patterns.
Self-reported data
Impacts of forest on health can be measured through self-reported data using validated tools or scales
of states of health and wellbeing or symptoms. These can be collected through surveys or questionnaires
that are distributed to a population through mail, e-mail, phone calls or face-to-face. Research has
indicated that there is an association between both self-reported measures and objectively measured
health factors, including mortality (Idler and Benyamini, 1997; Krijger et al., 2014). A vast array of scales
has been used: for example, the World Health Surveys (WHO online); EQ-5D (Yi et al., 2021); SF-36 Health
Survey (Ware Jr and Gandek, 1998; van den Berg et al., 2019); and the General Health Questionnaire,
GHQ-12 (van den Berg et al., 2010). Measures of quality of life (QoL) include, for example, the WHO
Quality of Life scale (WHOQOL) (Hipp et al., 2016). The WHO-instruments for wellbeing focus on mental
wellbeing (WHO-5), especially depression, whereas the WHOQOL have a much broader perspective,
where being in good health is considered as a contribution to high QoL.
Scales that measure symptoms, pathways or risk factors can indicate, for example, perceived stress
(e.g., the Perceived Stress Scale (Cohen, 1988); physical activity (e.g., International Physical activity
Questionnaire, IPAQ (Loder and van Poppel, 2020)); social cohesion (e.g., Social Support List (Maas et
al., 2009); or different mood states and happiness, (e.g., Prole of Mood States, POMS (Lin et al., 2019)).
To measure nutrition status collection of indicators such as dietary diversity scores or consumption of
certain nutritious food groups, for example fruits and vegetables, can be used (Hall et al., 2022).
Biomarkers and physiological data
Some cohorts have included sampling of biomarkers from, for example, blood, saliva, hair, skin or stool.
Such sampling methods are often also used in experimental studies. The outcome measures that can be
derived from biological samples include genetic material, for example telomere length (an early marker of
ageing (Miri et al., 2020)), indicators of stress, such as cortisol (Ward Thompson et al., 2012) or allostatic load
(a composite measure reecting levels of chronic stress (Egorov et al., 2020)) and gut microbiome (related
to immune system function (Roslund et al., 2021)). Experimental studies have also included non-invasive
measurements of the autonomous nervous system to evaluate stress and stress recovery, for example
blood pressure (Adhikari et al., 2021) and heart rate variability (Annerstedt [van den Bosch] et al., 2013). It is
also possible to monitor impact of forest on brain function through various neuroimaging techniques, such
as electroencephalography (EEG) (Olszewska-Guizzo et al., 2020), functional Magnetic Resonance Imaging
(fMRI) (Tost et al., 2019; Chang et al., 2021), and neural blood ow (Bratman et al., 2015). A number of studies
on Shinrin-yoku, specically from Japan, have measured a broad set of biomarkers, for example, natural
killer cells, anti-cancer proteins and adiponectin (regulating inammation and metabolism) (Li et al., 2008;
Li, 2010; Yi et al., 2022). The increased use of biomarkers and clinical measurements will contribute to an
improved understanding of the biological fundaments for human health impacts of forests.
Qualitative data
To obtain information on people’s subjective health experiences, perceptions and feelings related to
forest environments, qualitative data through, for example, interviews or thematic writing are collected
(Lee et al., 2019; Puhakka, 2021). These kinds of data can provide a deeper understanding of the meaning
of forest environments to individuals and their personal wellbeing. Qualitative data have been used to
measure, for instance, social cohesion and place attachment (Elliott et al., 2014).
Qualitative data is an important resource for understanding aesthetical and spiritual experiences in
nature and how nature can be symbolised. It is also central for providing insights into childhood experi-
ences of nature and how this can inuence perceptions and pro-environmental behaviours across the life
course. Several methods can be used for conducting qualitative research. Phenomenological studies ex-
amine people’s lived experiences in nature through their own, personal descriptions. This provides insight
into the meaning that experiences hold for the participants. Ethnographic research, on the other hand,
looks more at data about cultural groups. This can be carried out, for example, with the researcher living
with the group under study, such as a forest-dependent community, and becoming a part of their culture.
By interviewing key informants or through observations, further knowledge can be obtained. As a nal

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
67
example of qualitative methods in nature and health research, case studies can be mentioned. These are
in-depth examinations of a group in a specic situation, such as children’s engagement in nature play,
and may sometimes also include the collection of quantitative data. Case studies and other ndings from
qualitative research can be central for developing hypotheses or theories and lay the ground for further
quantitative examinations.
Exposure assessment: Environmental indicators
Exposure to natural environments has various dimensions, each of which could be relevant to different
mechanisms and health benets. For example, while access to green spaces could be predominantly rele-
vant to physical activity as a mechanism, residential surrounding green space could be more relevant for
mitigation of harmful exposure, such as air pollution, noise and heat, which would be another mechanism
towards health outcomes. Ecological indicators of, for example, below- or above-ground biodiversity are
other components that may have particular impacts on humans’ microbiome composition with subse-
quent health impacts (Rook, 2013). As such, the assessment of multifaceted exposure to natural environ-
ments is complex and methods are still evolving.
Urban forest and green space indicators
At a city level, several tools and indicators have been developed to assess different types and qualities
of urban forests. These range from land use and land cover databases that can indicate, for example
public versus private land or type of vegetation (e.g., deciduous or coniferous trees) (European Union,
2011; Williams et al., 2018), to qualitative indicators that consider people’s experiences and perceptions
of the natural environment (Grahn and Stigsdotter, 2010; Gidlow et al., 2012; Knobel et al., 2020).
To date, studies evaluating the health effects of urban natural environments have mainly relied on one
or more of the following dimensions and assessments:
Surrounding natural environments
Indicators of surrounding natural environments estimate the amount of green space within buffer zones
of various sizes (e.g., 100m, 300m, 500m, 1000m, etc.) around a point (or several points) of interest (e.g.,
home, workplace or school). To abstract these indicators, studies have relied on remote sensing-based in-
dexes of green space or land cover/use maps. The Normalised Difference Vegetation Index (NDVI) (USGS, 2018)
is one of the most widely used indices in the studies of the health effects of green space (Davis et al., 2021).
Its values range between minus 1 and plus 1 with higher values indicating more photosynthetically active
vegetation land cover. Other examples of remote sensing derived measures that have been increasingly
applied because of the improved level of precision and specicity are Vegetation Continuous Fields (VCF)
(Anabitarte et al., 2022) and unmixed pixel percentage data (Jarvis et al., 2021). In addition to these 2-di-
mentional (2D) indicators of greenspace, more recently studies have relied on 3D indicators of green space
such as number and height of trees or size of their canopy and biomass around the point(s) of interest,
mainly using Light Detection and Ranging (LiDAR) data (Zhao et al., 2021).
Physical access
Proximity to green spaces has been widely used as a surrogate of access to these spaces (Expert Group on
the urban environment, 2001). This indicator could be assessed objectively or subjectively. The objective
proximity to natural environment is mainly based on the Euclidean or network distance between the
point(s) of interest (e.g., home, workplace or school) and the nearest natural space, usually identied with
a land use/land cover map or by self-reports (e.g., by asking the participants whether there is a park with-
in a 10-minute of walk from their homes). For example, WHO-Europe denes residential access to green
spaces as living within 300m from a green space with an area of one hectare or more (Annerstedt van
den Bosch et al., 2016; WHO, 2016). Based on the characteristics of the indicator applied to identify natural
environments, it is possible to also extract proximity indicators for different types of green spaces. The
subjective proximity to natural spaces is an indicator of perceived access to these spaces.
Visual access from indoors
Indoor visual access to natural environments can be assessed subjectively or objectively. Questionnaires
could be applied to obtain subjective information on the access (e.g., having a window with a natural
view), intensity (e.g., the proportion of the window that is covered by the natural view) and frequency (e.g.,

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
68
the frequency of watching the natural view through the window) to natural environments. Other possibil-
ities are using image processing techniques to quantify the nature view through the window in the photos
taken from the window(s) of interest or relying on 3D maps of outdoor natural environment and modelling
their view through the window(s).
Quality of natural environments
Quality characteristics of natural environments, such as safety, amenities, sport/play facilities, aesthetics
and walkability could inuence the use and corresponding health outcomes from these spaces (McCor-
mack et al., 2010). Quality of green spaces can be assessed by interviews, individually or in focus groups,
or systematic observation of these spaces by eldworkers (or study participants) applying tools developed
for this aim as listed in a recent systematic review (Knobel et al., 2019). Given the logistical constraints of
conducting large-scale eld surveys, there have been efforts to use remote sensing images (e.g., Google
Earth Pro (Taylor et al., 2011)) to characterise quality of natural spaces, which have shown a strong corre-
lation with the assessments made by eld surveys. Biodiversity is a specic component of nature quality
and is further discussed in the section on ecological indicators.
Streetscape
Recently, there has been an increasing interest in characterising the view in the streets surrounding the
point(s) of interest (e.g., home, workplace, school) or commuting routes. These studies have been mainly
relying on the Google Street View images to characterise, among others, different types of vegetations
including trees that are visible in a given street, through use of image processing techniques (e.g., Nagata
et al., 2020).
Use of natural environments
Data on the use of green spaces could be obtained subjectively through interviews, questionnaires and di-
aries. This data relates to the qualitative aspects of people’s experiences of forest environments contribut-
ing to a deeper understanding of the meaning people attribute to spending time in nature. Validated scales
and tracking devices can be applied to obtain objective and quantitative data on various aspects of nature
use, including the type of activities and the type of natural environment visited. Tracking devices, such as
GPS or smartphone applications, can be applied to obtain data on the time (and the level of physical ac-
tivity) that the participants have spent in natural environments by overlaying the recorded time-stamped
geolocations on land cover/use maps.
Non-urban indicators
Studies that have analysed health impacts of deforestation (and in rare cases, reforestation) have usually
operated on an ecological study scale, using time-series analysis of unit-based exposures (e.g., loss of
vegetation per km2 as measured by remote sensing products) in relation to trends in a health outcome of
interest, such as changes in infectious diseases, including vector-borne and zoonotic diseases (Morand and
Lajaunie, 2021; Poirier et al., 2021; Pereira da Silva et al., 2022).
Biodiversity and ecological indicators
Biodiversity is the variability of living organisms, and it includes diversity within species, between spe-
cies and of ecosystems (UN, 1992). Because biodiversity is the fundament of healthy forests and ecosys-
tems, both in urban and rural settings, it is a crucial aspect to consider and properly measure in health
and nature research. Without biodiversity none of the ecosystem services or other health benets from
forests can be derived. This recognition is pivotal at a time when biodiversity loss is accelerating at an
unprecedented rate due to human activity (IPBES, 2019).
Apart from assessing people’s wellbeing reactions to or perception of biodiversity (Dallimer et al., 2012;
Cameron et al., 2020; Fisher et al., 2021), accurate indicators of biodiversity also have enormous impor-
tance for developing knowledge around how to identify ‘hotspots’ of potential drug sources in forests
(Holzmeyer et al., 2020), which is urgent given the escalating emergence of multidrug-resistant bacteria.
Biodiversity indicators are also important for a number of other reasons, such as to identify medicinal
plants and prioritise conservation efforts (Cahyaningsih et al., 2021), to monitor distribution of disease
vectors (e.g., Aedes aegypti) (Portilla Cabrera and Selvaraj, 2020), or distribution of allergenic species to
quantify allergy risk across large areas (Rasmussen et al., 2017). Biodiversity indicators are important to

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
69
assess the ecological regulation of reservoirs and vectors of infectious diseases and the quality of the eco-
system service of disease regulation.
A useful resource for studying biodiversity is the Global Biodiversity Information Facility (GBIF, https://
www.gbif.org/). This is an international network and data infrastructure that provides open access data
about all types of life on Earth based on records of where and when various species occur. The informa-
tion is derived from a variety of sources ranging from museum and institutional collections to geotagged
smartphone photos by amateurs and eventually the data are compiled using the Darwin Core Standard
(TDWG, 2017).
Another large-scale option for assessing biodiversity is remote sensing (RS) techniques. Based on the
principles of image spectroscopy across the electromagnetic spectrum, RS can record biochemical, bio-
physical, physiognomic, morphological, structural, phenological and functional characteristics of vegeta-
tion diversity at all scales, from the molecular and individual plant levels to communities and the entire
ecosystem (Lausch et al., 2020).
Indicators of biodiversity in nature and health research have focused on both above-ground (e.g.,
assessments of bird species) and below-ground (e.g., microbial composition of soil) diversity. There is a
certain correlation between above- and below-ground biodiversity (Wardle et al., 2004). Most commonly,
biodiversity is considered in terms of species richness, species diversity and community composition.
Various methods for assessing these components exist, one common approach being through sequencing
of genetic material (e.g., 16S ribosomal RNA, rRNA) and subsequent alignment against an rRNA database
and classication based on opensource software for describing and comparing microbial communities.
The following sub-sections provide an outline of general assessments and links to nature and health
research for species richness, species diversity and community composition.
Species richness
Species richness is dened as the number of species that occupy a particular area, habitat or a particular
biological entity (i.e., species richness of parasites in a host) and can be expressed as the number of tax-
onomic entities in a list of recognised species. In health and nature research, species richness has been
assessed on several levels. Species richness can be assessed through questionnaires, expert point count
(Fisher et al., 2021), GBIF or through citizen science initiatives, using applications such as iNaturalista or
eBirds (Den Broeder et al., 2018). One approach is to study a specic taxon, for example, birds. Birds are
relatively commonly used as a proxy for biodiversity because they are highly visible (and would thus
theoretically have an impact on human wellbeing) and are also indicators of ecosystem functions. Plant
species richness is positively associated with diversity in soil microorganisms (Baruch et al., 2021), which
would have implications for how we can assess microbial diversity and study health associations related
to exposure to microbial components, such as bacteria, fungi and viruses. Species richness is one indicator
of the dilution effect and disease regulation (Keesing et al., 2006; Magnusson et al., 2020).
Species diversity
Species diversity takes into account not only the number of species but also their relative abundances in
a community (habitat, biological entity) (Kiester, 2013). Many indices have been developed for measuring
species diversity (e.g., Simpson diversity index, Shannon–Wiener index), from microbial organisms to larg-
er plants, trees and animals. The terms alpha, beta and gamma diversity were coined by Whittaker (1972)
to describe and understand the species diversity in a landscape (gamma diversity) as the combined result
of the species diversity at a local scale (alpha diversity) and the compositional heterogeneity of species
among localities (beta diversity). While the alpha and gamma diversity describe the species diversity at
small and large spatial scale, the beta diversity assesses the turnover of species within a small spatial
scale resulting from highly differing ecological conditions. On a molecular level, species identication is
assessed using the sequencing, or barcoding, of adequate molecular genes that are validated for a group
of taxa. These kinds of methods have been used when assessing species richness among microorganisms
with impact on human microbiota (Roslund et al., 2021).
Community composition
A community is dened as all forms of life that coexist and interact with each other in a particular
habitat, i.e., a community of trees in a forested habitat, or a community of microbes in a gut of an animal.
Studies on human health and nature have rarely specied what component of biodiversity is particularly
important, therefore we lack information about the relative importance of community composition.

2. FRAMING THE INTERRELATIONS BETWEEN FORESTS AND HUMAN HEALTH
70
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76
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3

77
Chapter 3
The Health and Wellbeing Effects of Forests, Trees and Green Space
Coordinating Lead Authors: Payam Dadvand and Sjerp de Vries
Lead Authors: Nicole Bauer, Djibril S. Dayamba, Xiaoqi Feng, Serge Morand, Unnikrishnan Payyappallimana,
Roseline Remans, Ranaivo Rasolofoson, Charlie Shackleton, Patricia Shanley, Liisa Tyrväinen,
Agnes van den Berg and Matilda van den Bosch.
Contributing Authors: Thomas Astell-Burt, Gregory Bratman, Matthew H.E.M. Browning, Geoffrey Donovan,
Elaine Fuertes, Cristina O'Callaghan-Gordo, David Rojas-Rueda, Giovanni Sanesi, Giuseppina Spano,
Margarita Triguero-Mas and Bo-Yi Yang
TABLE OF CONTENTS
3.1 Introduction ................................................................................................................................................. 78
3.2 Early Life - Perinatal Period, Childhood and Adolescence ...................................................................... 78
3.3 Adulthood ..................................................................................................................................................... 86
3.4 The Elderly ................................................................................................................................................... 93
3.5 Other Health and Wellbeing Effects .......................................................................................................... 97
3.6 Modiers of Forest Potentials to Improve Health .................................................................................... 98
3.7 Global Health Challenges ......................................................................................................................... 101
3.8 Conclusion ................................................................................................................................................. 104
3.9 References .................................................................................................................................................. 106

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
78
Abstract
This chapter provides an overview of the empirical evidence regarding the association between
green space in general, and forests and trees in particular, and health outcomes. The evidence is
organised by life stage, and within the three life stages – early life (Section 3.2.), adulthood (Sec-
tion 3.3.) and the elderly (Section 3.4.) – by type of health outcome. At the end of each of these
three sections, the strength of the evidence for the presence (or absence) of a benecial or detri-
mental association for a particular health outcome, as assessed by the authors, is summarised.
Section 3.6. is devoted to modiers of the aforementioned associations, such as gender, ethnicity
and socio-economic status. In the next section (3.7.), the evidence is placed in the context of glo-
bal health challenges through elaborating on the potential of green space, and forests and trees
in particular, in tackling major contributors to the global burden of disease. The nal section con-
cludes that the available evidence already strongly supports a wide range of benecial associa-
tions including neurodevelopment in children, mental health and wellbeing, spiritual wellbeing
and cardiometabolic health in adults, and mental health and wellbeing, cognitive ageing and lon-
gevity in the elderly. However, this evidence is predominantly based on studies on the health and
wellbeing effects of green space, and the available evidence for such effects for forests and trees
is still limited for most health outcomes. Moreover, these studies have been mainly conducted in
high-income countries, with their generalisability to low- and middle-income countries not being
self-evident. Furthermore, the causality of the observed associations is not always clear. Never-
theless, given that many of the involved health outcomes are among the major contributors of
the global burden of disease, forests, trees and green spaces have a great potential for improving
health and wellbeing of humans across all life stages in our rapidly urbanising world.
3.1 Introduction
An accumulating body of evidence has document-
ed the potential of natural environments, includ-
ing forests, trees and green spaces3, to enhance
mental and physical health and wellbeing. This
chapter provides an overview of the available ev-
idence, with a focus on forests and trees where
possible, through all stages of life. To date, most
studies of the health effects of natural environ-
ments have looked at nature or green space in
general (sometimes termed ‘greenness’), although
most of these studies have included forests and
trees as part of their assessment. Moreover, the
pathways and mechanisms underlying the health
effects of natural environments and green spaces
in general, and forest and trees in particular, are
likely to be similar to a large extent. Therefore, all
available evidence on health and wellbeing effects
of these different types of nature are included in
this chapter. Regarding outcome measures, this
chapter mostly covers studies that focused on di-
rect indicators of mental and physical health and
wellbeing, such as diseases, physiological indica-
tors and quality of life. Studies on the mechanisms
(i.e., ‘pathways’) underlying the health effects of
natural environments, such as exposure to envi-
ronmental hazards (e.g., air pollution, noise, and
3 All terms that are dened in the glossary of this report (Appendix 1) appear in italics the rst time they are mentioned.
heat), physical activity, social contacts and stress,
are not included in this chapter as they are dis-
cussed in Chapter 2. However, each sub-section
starts with a brief overview of the relevant possi-
ble pathways leading from nature to that particu-
lar health outcome.
Following the stages of life, the chapter starts
with evidence regarding pregnancy and birth out-
comes, followed by that on the mental and physi-
cal health of children and their development. Sub-
sequently, the evidence regarding the mental and
physical health and wellbeing effects in adults is
presented, and nally that in the elderly. The chap-
ter then discusses factors that can modify these
associations and effects. Section 3.7 then explores
the potential of natural environments and espe-
cially forests and trees to tackle the main contrib-
utors to the global burden of disease. Finally, dif-
ferences between low-, middle- and high-income
countries are discussed.
3.2 Early Life – Perinatal Period,
Childhood and Adolescence 
3.2.1 Pregnancy
The benecial effects of forests, trees and green
spaces can be traced back to the foetal life. In this

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
79
section, we will discuss two types of pregnancy
outcomes: pregnancy complications of the mother
and birth outcomes of newborns.
Healthy pregnancy
Evidence on the association of exposure to natu-
ral environments, including forests and trees, and
pregnancy complications remains limited, with
existing studies having mainly focused on gesta-
tional diabetes (high blood sugar that develops in
women during pregnancy) and hypertensive dis-
orders of pregnancy. The most commonly used
green space metric in studies of the pregnancy
outcomes is the Normalised Difference Vege-
tation Index (NDVI) in buffers around maternal
residential addresses ranging in size from 50m
(Laurent et al., 2013) to 2,000m (Sun et al., 2020).
Some studies (Xiao et al., 2021) have used the
enhanced vegetation index (EVI), which is less
susceptible to atmospheric conditions than NDVI
and may be better at accounting for vegetation
structure (Huete et al., 2002). The next most com-
mon exposure metric is distance from maternal
address to parks or other natural areas expressed
continuously or dichotomised – less than 300m
from a natural area of at least 5,000m2, for exam-
ple (Agay-Shay et al., 2014). A handful of studies
used tree cover as an exposure metric. Tree-cov-
er data were derived from street-tree inventories
(Abelt and McLafferty, 2017), classied aerial im-
agery (Donovan et al., 2011; Yin, 2019), or Light
Detection and Ranging (LiDAR – (Donovan et al.),
2019). Land-cover data – such as the US National
Landcover Database (NLCD) – have also been used
to create exposure metrics (Ebisu et al., 2016).
In a birth cohort study of more than 5,000 preg-
nant women from Guangdong province, China,
Qu et al. (2020) studied the association between
green space surrounding the residential address
of pregnant women (assessed using NDVI, see
Box 3.1) during pregnancy and gestational diabe-
tes. They found that the risk for gestational dia-
betes decreased in residential areas with greater
surrounding green space and that the benecial
associations were stronger among women with
lower socio-economic status (Qu et al., 2020). Like-
wise, a cohort study of more than 6,000 mothers,
performed in central China, reported that living
in greener environments was associated with re-
duced maternal glucose levels as well as reduced
risk of gestational diabetes and impaired glucose
tolerance (Liao et al., 2019). However, other studies
with comparably large samples of pregnant wom-
en in the USA did not detect signicant associa-
tions between gestational diabetes and the extent
of green spaces (e.g., beach parks, local parks and
wildlife preserves [forests]) (Young et al., 2016) or
proximity to recreational natural environments
(including forests) (Choe et al., 2018).
In a retrospective cohort study among nearly
240,000 pregnant women in the USA, Runkle et
al. (2022) investigated the associations between
gestational hypertension and pre-eclampsia and
exposure to green space, with the latter being es-
timated using three indicators: green space per
county, green space per person, green space within
a 10-minute walk. They found that higher levels of
green space per person and green space within a
10-minute walk were associated with reduced risk
of pre-eclampsia, a serious condition during preg-
nancy (formerly called toxemia) that causes high
blood pressure in pregnant women, protein in their
urine and swelling in their legs. Another cohort
study of nearly 2,000 American pregnant wom-
en found that those with more tree canopy cov-
er around their homes were less likely to develop
gestational hypertension or pre-eclampsia (Tiako
et al., 2021). Similarly, another population-based
case-control study of 77,406 women in the USA,
found that higher levels of residential green space
(assessed using NDVI) were signicantly associat-
ed with a lower risk of pre-eclampsia (Weber et al.,
2021). However, in a US cohort study of over 60,000
pregnant women, Choe et al. (2018) assessed res-
idential surrounding green space using NDVI and
proximity to recreational facilities and found that
these metrics were neither associated with gesta-
tional hypertension nor with pre-eclampsia (Choe
et al., 2018). Similarly, two other studies, both con-
ducted in the USA, did not nd any signicant as-
sociation between exposure to green space and
pre-eclampsia (Laurent et al., 2013; Young et al.,
2016). To summarise, the available studies on the
associations of exposure to natural environments
and complications of pregnancy are still limited
with heterogeneous (but no detrimental) ndings,
but tend to suggest a benecial effect (Zhan et al.,
2020).
Birth outcomes
Forests, trees and green space may affect the
health of new-born infants through similar me-
chanisms that inuence pregnancy outcomes of
the mother: reduction of stress, mitigation of ex-
posure to air pollution, noise and heat, and in-
creased physical activity.
The two most commonly studied categories of
birth outcomes are foetal growth and length of ges-
tation. Birth weight (measured continuously or di-
chotomised as small for gestational age at birth or

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
80
low birth weight [e.g., birth weight <2500g]), birth
length, head circumference and in utero measures
of abdominal circumference, head circumference
and femur length have been applied as indicators
of foetal growth in studies of the effects of natural
environments and forests on pregnancy outcomes.
Similarly, length of gestation has been measured
continuously or dichotomised as pre-term (baby
born before 37 weeks of pregnancy).
A recent meta-analysis of 29 studies of green-
ness and birth outcomes concluded that there was
moderate evidence that babies born to mothers
in greener neighbourhoods are less likely to be
born underweight (Hu et al., 2021). Specically, a
0.1-unit increase in NDVI was associated with an
increase in birthweight of 8-15 grammes. Sever-
al studies also found that greenness surrounding
maternal residential address was benecially as-
sociated with other birth outcomes such as a low-
er risk of the baby being born small for gestational
age (Casey et al., 2016; Villeneuve et al., 2022), a
lower risk of pre-term birth (Hystad et al., 2014;
Lee et al., 2021), and greater abdominal and head
circumference (Lin et al., 2020). However, in gen-
eral, across all studies the evidence for a relation-
ship between green space and gestational age and
pre-term birth is still mixed and no rm conclu-
sions can be drawn.
Two studies have used forest or tree cover as
an exposure metric, both in the USA. Donovan et
al. (2011) found that higher tree cover within 50m
of the maternal address was associated with a re-
duced risk of a small gestational age at birth. Also
in the USA, Abelt and McLafferty (2017) found that
having more street trees within 250-500m from
the maternal address was associated with a re-
duced risk of pre-term birth.
In conclusion, multiple studies have support-
ed a positive association between birth weight and
the natural environment around a mother’s home
address. This relationship persists even after ac-
counting for a mother’s socio-economic status,
race and exposure to air pollution. Although most
studies focused on green space rather than trees
specically, several studies did nd mothers who
live in neighbourhoods with more trees are more
likely to have healthy babies.
3.2.2 Childhood and adolescence
Studies on health benets of contact with nature
for children and adolescents have included a va-
riety of health and developmental outcomes. In
this section we distinguish between outcomes in
ve main developmental domains: (1) brain de-
velopment and mental health; (2) cardiometabo-
lic development; (3) respiratory and allergic out-
comes; (4) infectious diseases; and (5) malnutrition.
Brain development and mental health
Contact with nature may affect brain develop-
ment and mental health directly or through
mediating pathways. Natural environments, for
example, provide children with opportunities to
bolster creativity, engagement and risk taking;
empower a sense of self; and promote psycho-
logical restoration, which, in turn, could benet
brain development and mental health in children
(Kahn and Kellert, 2002; Kellert, 2005). The inu-
ence of nature on brain development could also
be mediated through nature’s ability to promote
social interactions (Dadvand et al., 2019), to in-
crease physical activity (De la Fuente et al., 2021),
to mitigate the exposure to harmful environmen-
tal hazards such as air pollution (Dadvand et al.,
2015b) and noise (Schäffer et al., 2020) and by en-
riching microbial input (Rook, 2013).
Early studies were mainly small-scale exper-
imental studies looking at the short-term ‘ther-
apeutic effects’ of the brief contact with nature
for children with neuro-developmental problems.
Taylor and Kuo (2009), for example, observed in
their study of 17 American children with atten-
tion decit-hyperactivity disorder (ADHD) that a
20-minute walk in a park could signicantly im-
prove the attentional function. This is similar to
their earlier ndings that demonstrated a reduc-
tion in symptoms among children with ADHD af-
ter play in outdoor natural environments (which
did not occur in built and indoor environments)
(Taylor et al., 2001). More recently, an increasing
number of large-scale epidemiological studies
have emerged on the long-term effects of exposure
to natural environments on brain development
and mental health. In one of the rst studies of
this kind, Amoly et al. (2014) reported a reduced
risk of behavioural and emotional problems and
ADHD symptoms in a sample of over 2,500 pri-
mary schoolchildren in Spain, related to more
time spent playing in natural environments and
with higher residential surrounding green space.
Following this research, a number of studies have
suggested a lower risk of similar problems asso-
ciated with cumulative exposure to natural envi-
ronments among both children and adolescents
(Davis et al., 2021). A recent longitudinal study
from the UK, suggested that urban woodlands but
not grasslands were associated with lower risk of
emotional and behavioural problems for adoles-
cents (Maes et al., 2021). A study in the Nether-
lands found an inverse association between the
greenness of the residential environment (within

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
81
250m) and the use of ADHD-related medication
among 248,270 children between 5 and 12 years of
age, especially in low-income neighbourhoods (de
Vries and Verheij, 2022). A study in the USA also
found an inverse association between exposure
to natural environments and prevalence of au-
tism spectrum disorders (ASD) (Wu and Jackson,
2017). A recent systematic review has concluded
that while the available evidence on the effect of
exposure to natural environments on behavioural
development is still limited with regards to some
behavioural aspects, it is suggestive of a benecial
association (Zare Sakhvidi et al., 2022).
An emerging body of evidence has also, rela-
tively consistently, associated nature contact with
improved cognitive development in children (de
Keijzer et al., 2016). A longitudinal study conduct-
ed among Spanish school children, for example,
demonstrated that a higher amount of green space
in school premises was associated with enhanced
development of working memory and attention-
al function over a period of one year (Dadvand
et al., 2015a). Similarly, large cohort studies from
Canada found associations between cumulative
exposure to natural environments and early life
development, including dimensions of social com-
petence, emotional maturity, language develop-
ment and communication skills (Jarvis et al., 2021;
Jarvis et al., 2022). Other studies have, although in-
consistently, associated natural environment ex-
posure with increased intelligence as determined
by intelligence quotient (IQ) tests (Reuben et al.,
2019; Bijnens et al., 2020; Asta et al., 2021). Also,
more green space on school premises has been
associated with improved academic performance
(Browning and Rigolon, 2019; Kuo et al., 2021).
There is also preliminary evidence on the poten-
tial impact of exposure to natural environments
on motor development (Kabisch et al., 2019).
Regarding general mental health and wellbeing,
most studies suggest a benecial impact of natural
environments for children and adolescents (Ward
et al., 2016; Andrusaityte et al., 2020). However, a
few studies have suggested no (Söderström et al.,
2013) or even inverse associations (Larson et al.,
2018; Tillmann et al., 2018). The few studies that
have analysed health-related quality of life (Kim et
al., 2016) and social functioning (Flouri et al., 2014;
Richardson et al., 2017) in young people have con-
sistently found positive associations with expo-
sure to natural environments. A recent systematic
review (Stier-Jarmer et al., 2021) specically look-
ing at forest environments, reported that spending
time in forests and forest-based activities could
reduce depressive and anxiety symptoms, and
negative emotions such as aggression and anger,
and improve social skills, perceived quality of life
and mental wellbeing.
All in all, the available evidence on the impact
of contact with nature on brain development and
mental health is still limited but accumulating
and the ndings generally converge to indicate a
benecial role of natural environments, including
forests (Davis et al., 2021).
Cardiometabolic development
Natural environments may affect children’s car-
diometabolic development by reducing environ-
mental hazardous exposures (e.g., air pollution
and noise), increasing physical activity and redu-
cing mental stress, which are all involved in the
pathogenesis of cardiometabolic disorders. Many
epidemiological studies have investigated the as-
sociations between green space and cardiometa-
bolic risk factors.
In children, overweight and obesity, as a result
of sedentary lifestyles, are linked to several fac-
tors that increase the risk for cardiovascular dis-
ease, such as hypertension, disturbed cholesterol
and glucose levels, and systemic inammation
(McPhee et al., 2020). In a systematic review of 45
individual studies (41 studies were observational),
Fyfe-Johnson (2021) concluded that the strength of
evidence concerning nature and childhood over-
weight/obesity was ‘moderate’, and exposures
were mostly assessed using residential green
space in those individual studies.
Epidemiological studies have also examined
green space exposure and blood pressure. In a
national cross-sectional survey with over 60,000
Chinese children and adolescents, Luo et al. (2022)
observed inverse associations between residential
surrounding green space, measured by NDVI and
soil adjusted vegetation index (SAVI), and both
blood pressure levels and hypertension prevalence.
Similar benecial associations were also observed
in a study of 10-year-old children living around the
city of Munich, Germany (Markevych et al., 2014).
These ndings are in line with those of an Aus-
tralian national cohort study (Putra et al., 2022)
reporting that increases in perceived green space
quality tracked from age 0 to age 12 years were
associated with lower blood pressure in boys aged
11-12 years. However, no signicant associations
were observed between green spaces and blood
pressure in studies in Iran (Abbasi et al., 2020), the
Netherlands (Bloemsma et al., 2019) and four Eu-
ropean countries combined (France, Greece, Spain
and the UK) (Warembourg et al., 2021).
Other studies have focused on the potential ef-
fect of green space exposure on blood-based bio-
markers, such as lipids (e.g., cholesterol) and sugar

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
82
(i.e., glucose) levels. In a cross-sectional study of
over 3,000 Portuguese children, Ribeiro et al. (2019)
found that having a green space near (within 400-
800m) the children’s school/home was associated
with lower lipid levels. An Australian longitudinal
cohort study reported children with consistently
high availability of quality green space had low-
er lipid levels at ages 11-12 compared with peers
who had low availability of quality green spaces
(Putra et al., 2022). However, no signicant asso-
ciation for greenspace and lipid levels was ob-
served in two studies that were conducted with
children from Germany (Markevych et al., 2016)
and the Netherlands (Bloemsma et al., 2019).
Dadvand et al. (2018) examined the associations
with time spent in green spaces (parks, woods or
other natural green spaces, private gardens or ag-
ricultural elds) with fasting blood glucose levels
in a multicentric sample of more than 3,800 Irani-
an schoolchildren. They found that time spent in
green spaces, especially in forests and other nat-
ural green spaces, was inversely associated with
fasting glucose levels. However, another cohort
study of 460 infants did not observe any signi-
cant association between exposure to green space
and insulin resistance as a cause of high glucose
levels (Jimenez et al., 2020).
Metabolic syndrome is a cluster of cardio-meta-
bolic disorders, which is generally used as a com-
prehensive predictor of cardiovascular disease.
Three studies calculated the metabolic syndrome
index using adiposity metrics (e.g., waist circum-
ference and percent body fat), blood lipids, blood
glucose and blood pressures, and assessed green
space using NDVI, percent of green space, and per-
cent of park and recreation areas (Dengel et al.,
2009; Gutiérrez-Zornoza et al., 2015; Bloemsma et
al., 2019). However, only one of them observed a
signicant association between more green space
and a lower metabolic syndrome score (Dengel et
al., 2009).
All in all, the evidence for the potential effects of
natural environments on children’s cardio-meta-
bolic health is still emerging and heterogeneous,
with some suggestions for benecial associations
for a number of cardiometabolic risk factors.
Respiratory and allergic outcomes
Forests, trees and green spaces may affect respi-
ratory and allergic health during childhood and
adolescence in various ways, such as by promo-
ting physical activity, reducing stress, improving
the composition of the microbiome of children
in very early life, and by improving air quality
(Eisenman et al., 2019). Forests and trees can also
be a major source of pollen, which could trigger
allergic and respiratory symptoms in sensitised
individuals.
Studies have examined whether living or going
to school near green spaces (forests, parks, agri-
cultural land) or areas of higher vegetation (often
measured using the NDVI) is associated with less
asthma and other allergic health outcomes in
childhood. With respect to urban forests, one of
the rst studies reported that areas in New York
City, USA, with more street trees within 1 km2 had
lower childhood asthma prevalence, but not fewer
asthma hospitalisations (Lovasi et al., 2008). How-
ever, tree cover was not protective for childhood
asthma in a follow-up analysis in New York City
using individual-level data (Lovasi et al., 2013). In-
consistent results have continued to be observed
for several asthma-related outcomes across differ-
ent studies, as summarised in a systematic review
published in 2022 (Mueller et al., 2022).
Studies suggest that forest type is likely rele-
vant, as living near gorse (Ulex europaeus) or exot-
ic conifers in New Zealand (Donovan et al., 2018),
coniferous forests in Europe (Parmes et al., 2020),
and ‘allergic trees’ in Germany (Markevych et al.,
2020) was associated with a greater risk of child-
hood asthma and other allergic symptoms. It is
also possible that vegetation diversity, as a mark-
er of microbial diversity (Donovan et al., 2018), is
more informative than only the presence, distance
to, or quantity of surrounding vegetation. Overall,
meta-analyses and systematic reviews summaris-
ing the effects of various green environment met-
rics (including forests) on asthma, allergic respira-
tory diseases and atopic sensitisation in childhood
report that the evidence is highly heterogeneous
and inconclusive (Lambert et al., 2017; Lambert et
al., 2018; Hartley et al., 2020; Mueller et al., 2022).
Studies on lung function in childhood and ado-
lescents are more limited and also show mixed
ndings. A longitudinal British analysis reported
that children whose homes are in more vegetated
places or in close proximity to green spaces have
better lung function up to 24 years of age (Fuertes
et al., 2020). However, other studies report no asso-
ciation, such as in children from several European
countries (Agier et al., 2019) and in western Aus-
tralia (Boeyen et al., 2017) in relation to vegetation
levels around the home. In China, benecial asso-
ciations with vegetation levels appeared to be con-
founded by pollution (Yu et al., 2021) or restricted
to lower-pollution settings (Zhou et al., 2021).
When considering the health effects of pollen
released from vegetation sources (split between
grass, trees, weeds and conifers), a systematic
review and meta-analysis concluded that pollen
exposure is an important trigger for childhood

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
83
asthma exacerbations requiring emergency de-
partment attendance (Erbas et al., 2018). This
result was conrmed in a further systematic re-
view and meta-analysis in which short-term (one
day) pollen concentrations were positively asso-
ciated with allergic and asthmatic symptoms in
both children and adults (Kitinoja et al., 2020).
This same review did not nd evidence for asso-
ciations with daily lung function levels, although
only a limited number of studies were included in
the analysis. However, an Australian study did nd
that exposure to high levels of pollen was associ-
ated with poorer lung function development into
adolescence (Lambert et al., 2019).
In conclusion, forests and other aspects of the
natural environment appear to affect respiratory
health in various ways, including through bene-
cial pathways such as reducing pollution or inu-
encing the development of the immune system,
but they can also act as a source of pollen depend-
ing on the species which can exacerbate symp-
toms among those sensitised.
Infectious diseases
Research on infectious diseases in relation to na-
ture and forest exposure has been of global inter-
est though, often, of particular relevance in low-
and middle-income countries (LMICs) and poor
households. Forests may affect children’s risk to
contract an infectious disease mainly through
the presence of reservoirs and vectors of infec-
tious diseases such as wildlife and mosquitoes
(Tucker Lima et al., 2017; Guégan et al., 2020). On
the other hand, forests could also have a positive
effect on the contraction of infectious diseases by
enriching the microbiome of children and thereby
improving their immune function, or by providing
medicinal plants for the treatment of human in-
fectious diseases.
While much of the available research in this
domain includes adults, the ndings are highly ap-
plicable to children since they are more vulnerable
to infectious diseases. Children under 5 are par-
ticularly vulnerable to infectious diseases like ma-
laria, pneumonia, diarrhoea, HIV and tuberculosis.
Regarding malaria as a serious health threat in
LMICs, conditions such as vegetation cover, tem-
perature, rainfall and humidity, provided by for-
ests, are conducive to distribution and survival
of malaria vectors (Kar et al., 2014). Losing forest
cover also affects the transmission of the parasites
that cause infectious diseases such as human ma-
laria (Guerra et al., 2006; MacDonald and Mordecai,
2019), though the direction of the effect (positive/
negative) might depend on type of environment
created after the forest is cleared (suitability of
habitat for the vector/species), the geographic loca-
tion, etc. Some studies reported that deforestation
increases malaria risk in Africa and the Americas
while it diminishes it in Southeast Asia (Guerra et
al., 2006; MacDonald and Mordecai, 2019). Howev-
er, no association between deforestation and ma-
laria prevalence was observed in a recent study
by Bauhoff and Busch (2020) in 17 sub-Saharan
countries. Differences across regions are therefore
useful hypotheses for future research. Moreover, a
Forests and green spaces provide areas for physical activity and wellbeing
Photo © Nelson Grima

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
84
study in Malawi found that when deforestation
increases, access to clean drinking water decreas-
es (Mapulanga and Naito, 2019) and this might
mediate the occurrence/spread of infectious dis-
eases. In line with this, studies conducted in sev-
eral LMICs concluded that upstream tree cover af-
fects water quality downstream and consequently
the prevalence of diarrhoea (Herrera et al., 2017;
Rasolofoson et al., 2020).
In addition to forest ecosystems as a whole, in-
dividual plants are also very relevant to infectious
diseases. The use of medicinal plants for the treat-
ment of human infectious diseases is well docu-
mented in the scientic literature, especially for
well-known malarial, diarrhoeal, Zika virus (ZIKV)
and respiratory infections (Holetz et al., 2002; Zuo
et al., 2012; Chinsembu, 2015; Rehman et al., 2017;
Debalke et al., 2018; Calzada and Bautista, 2020;
Haddad et al., 2020; Vista et al., 2020; Owusu et al.,
2021). However, only a few publications relate the
ndings to life stages. Many medicinal plants are
being used in different parts of the world against
different diseases and for the general wellbeing
of children (Ndhlovu et al., 2021). For instance,
Mukungu et al. (2016) reported on tree/shrub species
with suggested high anti-plasmodial activity, such
as Albizia gummifera (J.F.Gmel.), C.A.Sm., Tithonia
diversifolia and Harungana madagascariensis Lam.
ex Poir., used by communities in the treatment
of malaria. However, though the benet of these
medicinal plants justies efforts toward their sus-
tained use throughout generations (Towns et al.,
2014; Bruschi et al., 2019), some medicinal plants
have strong toxicity in humans, and this can cause
acute poisoning and complications such as hepat-
ic or renal failure, and can be life-threatening in
children as reported in some systematic reviews
(Ghorani-Azam et al., 2018; Tajbakhsh et al., 2021).
Some studies therefore recommend further re-
search on toxicity and dosage to ensure the safety
of medicinal plants (Gahamanyi et al., 2021).
In summary, the effect of forests on infectious
diseases is mixed, depending on the type of hu-
man-forest interaction and the type of infectious
disease and, if relevant, the behaviour of their reser-
voirs and vectors.
Malnutrition
Malnutrition is the condition that develops when
the body is deprived of vitamins, minerals and oth-
er nutrients it needs to maintain healthy tissues
and organ function. Undernutrition occurs when
not enough essential nutrients are consumed or
when they are excreted more rapidly than they
4 Wild meat is also called bushmeat in some regions (particularly in Africa)
can be replaced for example because of diar-
rhoea. Overnutrition occurs in people who eat too
much, eat to reduce stress (emotional eating), eat
the wrong things, do not exercise enough or take
too many vitamins or other dietary replacements
(John Hopkins Medicine website).
The Global Burden of Disease study on di-
etary risks (GRD, 2019) estimates that one in ve
deaths globally is associated with poor diet, and
highlights that diet contributes to a wide range of
chronic diseases in people around the world. Diets
worldwide are far from being healthy and have not
improved over the last decade (2021 Global Nu-
trition Report). Fruit and vegetable intake is still
about 50% below the recommended healthy level
of ve servings per day (60% and 40% respectively),
and legume and nut intakes are each more than
two thirds below the recommended two servings
per day (2021 Global Nutrition Report; EAT-Lancet,
2019). In contrast, red and processed meat intake
is on the rise and almost ve times the maximum
recommended level of one serving per week, while
the consumption of sugary drinks, which are not
recommended in any amount, is also increasing
(2021 Global Nutrition Report; EAT-Lancet, 2019).
Lower-income countries continue to have the low-
est intakes of key health-promoting foods such
as fruits and vegetables and the highest levels of
underweight, while higher-income countries have
the highest intake of foods with high health and
environmental impacts, including red meat, pro-
cessed meat and dairy, and the highest levels of
overweight and obesity.
Forests can contribute directly to children’s
diets through the harvest of wild meat4, sh,
wild fruits, wild vegetables, fungi and other for-
est-sourced foods (MEA, 2005; Baudron et al., 2019;
Asprilla-Perea et al., 2020). There are both benets
and risks for human health identied with forest
foods. On the one hand, a growing evidence base
suggests that forest foods are of critical impor-
tance to the dietary diversity and food security
of adults and children living in close proximity to
forests – especially in communities with poor ac-
cess to markets (Nasi et al., 2011; Vira et al., 2015;
Rowland et al., 2017; Baudron et al., 2019). Forest
foods play this critical role because: 1) they are of-
ten high in micronutrients (e.g., fruits) and quality
protein (e.g., wild meat and sh); 2) the diversity of
forest foods spans different seasons, and they are
of particular importance in the lean season or dur-
ing food crises, when agricultural and other food
sources are scarcer (Vincenti et al. 2008; Rowland
et al 2017; Hall 2021). In line with these ndings,

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
85
people living in or near areas with greater tree
cover consume more diverse and nutritious diets
(Johnson et al., 2013; Ickowitz et al., 2014; Galway
et al., 2018; Rasolofoson et al., 2018; Baudron et
al., 2019), while forest loss is associated negative-
ly with dietary diversity and consumption of nu-
tritious foods (Galway et al., 2018; Jendresen and
Rasmussen, 2022).
In addition to the ‘direct pathway’ of forest
foods contributing to people’s dietary quality, two
additional pathways are identied for how forests
contribute to dietary diversity: the income path-
way through which the sale of forest products
contributes to improved food access on markets,
and the agroecological pathway, through which
forests support diverse crop and livestock produc-
tion through an array of regulating ecosystem ser-
vices (Baudron et al. 2019). Assessing seven tropi-
cal landscapes, Baudron et al. (2019) identify that
these mechanisms can vary signicantly from one
site to another, and that the positive contributions
of forests to rural diets cannot be generalised.
On the other hand, forest foods, particularly
wild animal sourced foods, are considered poten-
tial vectors of rapidly spreading diseases world-
wide (Asprilla-Perea et al., 2020; Zhou et al., 2022).
The recent COVID-19 pandemic has been traced
back to zoonotic transmission, with bats and pan-
golins identied as primary reservoirs for a wide
variety of coronaviruses (IPBES, 2020). For many
communities, wild meats are their only source of
protein and may also hold cultural values (Vira et
al., 2015; Roe et al., 2020). However, unsustainable
markets for wildlife across several low-income set-
tings referred to as the ‘bushmeat crisis’ (Robinson
and Bennett, 2002) highlight the political economy
and management challenges associated with wild
meat. The illegal and unsustainable trade in wild
meat – driven notably, by a growing population
and changes in lifestyles – threatens livelihoods
and wildlife alike. Deforestation and forest degra-
dation also bring people and animals in closer
proximity (IPBES, 2020).
3.2.3 Summary
Table 3.1 provides an overview of the strength of
the evidence for associations of natural environ-
ments and forests with health and wellbeing in
early life stages, based on the expert judgment
of the authors. The evidence for all of the includ-
ed health domains is generally positive, with the
strongest and most consistent evidence for brain
development and mental health in childhood.
There is also strong evidence for positive contri-
butions of forests to the prevention and reduction
of childhood infectious diseases and malnutrition,
especially in LMICs. However, in these domains
there is also a (smaller) risk of some negative
health impacts of forests. Evidence for health ben-
ets (for both mother and child) in the perinatal
period is strongly positive for foetal growth but
somewhat mixed for gestational age at delivery
and complications of pregnancy, which also ap-
plies to the evidence for cardiometabolic deve-
lopment and respiratory and allergic outcomes in
childhood and adolescence.
Note: Sign indicates type of association: + benecial association, 0 no association, - detrimental (harmful) association. Number of
same signs indicates strength of evidence for a particular type of association.
EARLY LIFE: STRENGTH OF THE EVIDENCE
PERINATAL PERIOD
CHILDHOOD AND ADOLESCENCE
Pregnancy
complications
+/0
Neurodevelopment
and mental health
++
Pre-term birth
+/0
Respiratory/allergic
outcomes
+/-
Infectious diseases
++/-
Malnutrition
++/-
Birth weight
+
Cardiometabolic
development
+/0
Table 3.1
Expert assessment (by authors) of the strength of the evidence
for associations between forests, trees and other types of green space and
different health outcomes in early life

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
86
3.3. Adulthood
The vast majority of research on nature-health
relationships, including those of forests, has in-
volved adults. In this section, we distinguish be-
tween mental and physical health outcomes with
a number of subsections for each category.
3.3.1 Mental health
Mental wellbeing and quality of life
This section focuses on general mental wellbeing
and quality of life in adulthood as outcomes, in-
cluding self-reported measures of overall mental
health. Mood and stress pathways are particular-
ly relevant when it comes to mental wellbeing.
Several mood and mental disorders are about ex-
periencing prolonged periods of negative moods
or stress (chronic stress) (e.g., burnout (Marin et
al., 2011)). Both social contacts and place attach-
ment pathways are relevant for mental wellbe-
ing (Holt-Lunstad et al., 2015). Physical activity
has also been shown to affect mental wellbeing
(Marquez et al., 2020). Physical health is con-
sidered a determinant of quality of life (see e.g.,
Suárez et al., 2018). In short, many of the path-
ways identied in chapter two may be relevant
when it comes to mental wellbeing and quality of
life, although the evidence on specic pathways
is limited (Zhang et al., 2021a).
Several reviews have shown benecial associa-
tions between the local availability of green space
and mental wellbeing of adults (Houlden et al.,
2018; Wendelboe-Nelson et al., 2019; Callaghan
et al., 2021; Lackey et al., 2021; Li et al., 2021).
Although there is less research on green spaces
and (overall) quality of life, the available evidence
points in the same direction (Houlden et al., 2018;
Giannico et al., 2021), at least for the residential
environment (Wu et al., 2022). When it comes to
mental wellbeing, the usual assumption is that di-
rect contact with green space is needed for such
benets to occur (Bratman et al., 2019) and that
more contact is better, at least up to a certain ex-
tent. There is also some empirical support for this
(see e.g., Coldwell and Evans (2018) and White et
al. (2019); however, see also Garrett et al. (2021)
who found associations between neighbourhood
green spaces and better subjective wellbeing, but
not via visits).
Before zooming in on forests, a distinction can
be made between short-term effects of contact
with nature and more long-term effects on men-
tal wellbeing and quality of life. When it comes
to short-term effects, mainly mood states, stress
levels and cognitive function have been studied,
and they in turn, have been identied as impor-
tant pathways leading to long-term effects (see
Chapter 2). Antonelli et al. (2021) looked at several
reviews of eld studies on the effects of spending
time in forests, specically in the form of ‘forest
bathing’ or Shinrin-yoku, as it is known in Japan.
They concluded that the programmed forest vis-
its could promote psychophysical wellbeing, from
heart rate variability and cortisol levels to self-re-
ported mood improvements. Meyer-Schulz and
Bürger-Arndt (2019) also looked at forest stays and
arrived at similar conclusions. Another type of re-
search is experience sampling, or ecological mo-
mentary assessments: upon receiving a message
in daily life (e.g., on their smartphone) people are
asked to report how they feel at that moment in
time. Studies in the UK (MacKerron and Mourato,
2013) and the Netherlands (de Vries et al., 2021)
show that people feel happier in forests than in
built-up areas (but feel even happier in another
type of natural environment, i.e., a natural coast-
line). More long-term, a Korean study showed that
the frequency of visits to forests was positively
associated with life satisfaction and that this fre-
quency was higher if it took less time to reach the
forest (Jang et al., 2019). A Finnish study reported
that restorative experiences were the strongest in
everyday favourite places located in outdoor ex-
ercise and activity areas, waterside environments
and extensively managed urban woodlands. Re-
storative experiences in urban parks and in built
urban indoor and outdoor places were signicant-
ly weaker by comparison (Korpela et al., 2010). A
French study showed that the presence of forests
within a 15-minute walk was positively associated
with one’s quality of life, and that association was
stronger than with the presence of urban parks
(Allard-Poesi et al., 2022). Jones (2021) looked at
a large-scale natural experiment – the New York
City (NYC) million trees programme – and found
that already after the rst years of the programme,
life satisfaction in NYC increased, compared to
neighbouring urban areas, but only when the trees
were in leaf.
All in all, having easy access to forests and
trees appears to be predominantly associated with
higher mental wellbeing in adults. Coming into
direct contact with these natural elements seems
relevant for wellbeing benets to materialise, al-
though they may also be benecial in ways that
do not necessitate direct contact. Contact may
also take place incidentally, outside the leisure do-
main of purposeful visits to forests, nature areas
or parks.

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
87
Mental health disorders
In the previous section, we looked into research
on mental wellbeing and (self-reported) overall
mental health. Here, we focus specically on the
association between nature contact and prev-
alence of mental health disorders and illness.
Following Bratman et al. (2019), mental health
disorders, in accordance with denitions from
the Diagnostic and Statistical Manual of Men-
tal Disorders (American Psychiatric Association,
2013) or the International Classication of Dis-
eases (WHO, 2017) are cognitive, affective and
behavioural disorders such as depression, schiz-
ophrenia, anxiety and bipolar disorders. Poten-
tially relevant pathways benecially linking na-
ture contact to mental disorders are the same as
mentioned for mental wellbeing in the previous
section, with the addition of immune function (or
gut regulation) which has been linked to depres-
sion and other psychological disorders via the
gut-brain axis (Rook, 2013).
There is mounting evidence that nature con-
tact buffers against the onset of mental health dis-
orders, in addition to decreasing symptomatology
in some cases. In a (large-scale) cross-sectional
study in Finland, Gonzales-Inca et al. (2022) found
that higher NDVI within 100m buffers of residen-
tial areas was associated with a decreased risk for
doctor-diagnosed depression, after controlling for
several individual-level characteristics. Anoth-
er study in the UK found an association between
NDVI greenness within 500m buffers of residenc-
es and decreased risk for major depressive dis-
order, especially for lower socio-economic status
and higher urbanicity areas (Sarkar et al., 2018).
Using land use data, de Vries et al. (2016) found
a relationship between green space (within 1km
of residence) and decreased rates of anxiety disor-
der (though not for mood disorders) in a nationally
representative survey in the general Dutch popu-
lation – replicating a similar nding by Maas et al.
(2009). Using land cover data, Belgian researchers
found that mood disorder medication sales for ur-
ban residents decreased 1-2% with a 10% increase
in various types of nature – most signicantly
woodland – though this association did not hold
for rural areas (Aerts et al., 2022). A similar asso-
ciation was observed in a Dutch study (Helbich et
al., 2018b). In a study across 18 countries, White et
al. (2021) found that visits to green spaces were as-
sociated with lower likelihood of using medication
for depression.
Recent studies have explored the association
between nearby green space and suicide. In the
Netherlands, Helbich et al. (2018a) looked at the
amount of green space at the municipal level and
suicide mortality, with level of urbanicity being
corrected for, to some extent (besides other covari-
ates). They observed a lower suicide risk in greener
municipalities. A similar association was observed
in Taiwan, using counties as units of observation
(Shen et al., 2022). A Japanese study, with munici-
palities as units of observation, paints a somewhat
more nuanced picture. In densely populated cities,
park density was inversely associated with suicide
mortality, while in small- and medium-sized cities,
it was park coverage (i.e., the proportion of the to-
tal park area to the municipal area), and only for
women aged 40 and above. Finally, in rural areas
it was not park coverage, but woodland coverage
that was inversely associated with suicide mortal-
ity, but only for men aged 40 and above (Jiang et al.,
2021b). However, a study conducted in Hong Kong
looking at rent-only public housing community
sites and the surrounding green space (in buffers
with sizes up to 800 metres from the site) did not
nd any association (Jiang et al., 2021a).
With respect to nature in general, including
urban green space, some evidence exists for the
association between access and usage and the de-
creased prevalence of mental illness, though this
evidence is mixed (Gascon et al., 2015). For exam-
ple, some studies employing a life-course approach
have found that early-life nature exposure may
help prevent later incidence of mental health dis-
orders, including schizophrenia, bipolar and mood
disorders, and depression (Engemann et al., 2019;
Li et al., 2021). Other evidence is less supportive of
this temporal aspect of the relationship through-
out the life course. A recent review of longitudinal
observational studies reported that no statistically
signicant association was found for depression in
six out of nine reviewed studies, while two showed
a reduction of the risk and one showed a small in-
crease in the risk with greater green space availa-
bility (Geneshka et al., 2021).
The evidence in support of a relationship of re-
duced incidence of mental health disorders with
higher exposure to forests specically is sparser.
In recent research, Bolton et al. (2021) character-
ised land cover in 207 countries to examine the
global change in forested areas from 2006 to 2016
at the country level. The authors found signicant
cross-sectional associations for the year 2016 (al-
though not for changes in the amount of forest
area): lower levels of forested areas were associat-
ed with higher levels of substance abuse and other
mental health disorders for lower-middle-income
countries, after adjusting for several confounders.
The evidence on the association between nearby
green space and medication shows that a higher
urban street tree density is associated with a lower

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
88
prescription of medication for depression (Taylor
et al., 2015), especially for individuals with lower
socio-economic status (Marselle et al., 2020; how-
ever, see Kardan et al. (2015) for a non-signicant
relationship).
In general, with regard to mental health dis-
orders the evidence is somewhat heterogeneous.
Most (published) studies thus far show a benecial
association between the amount of nearby green
space and the prevalence of mental disorders,
while some studies do not nd such an associa-
tion. However, detrimental associations are rarely
observed. Finally, in addition to these associations,
there is some evidence in support of decreased
symptomatology from mental health disorders
with nature contact. For example, individuals with
depression may experience greater short-term
affective benets from nature interventions than
nonclinical samples (Berman et al., 2012), and in
research specic to forests, reviews have found
support for the potential of Shinrin-yoku (forest
bathing) to reduce depressive symptoms (Rosa et
al., 2021; Stier-Jarmer et al., 2021; Yeon et al., 2021).
Spiritual wellbeing
Spiritual experiences in or with nature provide a
sense and purpose to people’s lives. These experi-
ences occur whenever individuals feel a connec-
tion with the larger, natural world (Gardner, 1999),
for example, through ‘magical moments’ during
which they realise that all creatures great and
small are intrinsically valuable (Talbot and Frost,
1989) or during moments of reminiscence, when
they nd comfort and support in feeling and re-
membering the connection with nature (Johansen
and Thorsen Gonzalez, 2018). The pathways that
lead to spiritual experiences are still largely un-
known, but it can be postulated that reduced
stress levels, increased attention and awareness,
and a positive mood are important preconditions
for experiencing nature as a source of spiritual
wellbeing. In addition, feeling attached to a place,
and absence of disturbing factors such as heat,
bad air quality and noise might also be relevant.
Endorsement of spirituality has consistently
been positively related to psychological health and
wellbeing (Labbé and Fobes, 2010). Research on
‘connectedness with nature’ (Kamitsis and Francis,
2013) has shown a positive relationship with many
outcomes, including psychological wellbeing,
quality of life and pro-environmental behaviour
(Cervinka et al., 2011; Nisbet et al., 2011; Capaldi et
al., 2015). These positive effects of feeling emotion-
ally and spiritually connected to nature have also
The Bongeunsa temple and park offer a pleasant and peaceful retreat in the middle of Seoul’s busy Gangnam district
Photo © Gerda Wolfrum

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
89
been found to moderate the relationship between
nature contact and wellbeing outcomes, with in-
dividuals who are more connected responding
more positively to contact with the natural world
(Martin et al., 2020). Another line of research has
demonstrated positive impacts of sublime experi-
ences with nature, as a mix of emotions – arous-
al, pleasure and vitality – together with feelings of
awe (Bethelmy and Corraliza, 2019). Spirituality
also emerges as a central theme in nature-based
therapy. Based on interviews with experienced na-
ture-based therapists, Naor and Mayseless (2020)
conclude that “signicant therapeutic effects are
linked to spiritual experiences, including the expe-
rience of nature’s immensity, which contributes to
an expansive perspective; experiencing intercon-
nectedness, which elicits a sense of belonging to
the vast web of life; and the reection of internal
nature and truth by external nature as an accept-
ing setting, which contributes to the discovery of
an authentic self.”
Within the spiritual domain, forests and trees
are imbued with special meanings and values. In
general, four types of spiritual values as they re-
late to forests can be distinguished (Clark, 2011):
intrinsic sacredness (e.g., ceremonial forests in
Thai villages as places for the souls of the dead
to rest); sacredness associated with rituals or local
traditions (e.g., the Celtic tradition to hang rags in
trees near holy wells to ask for a cure); forests as a
reection of divine glory (e.g., Buddha’s enlighten-
ment under the Bodha tree); and forests as places
to experience transcendence (e.g., individual ex-
periences of forests of non-religious individuals
as places for spiritual renewal and healing). These
spiritual values of forests may be especially help-
ful in times of crises, to make people more resilient
to negative impacts of pandemics and war (Tidball
and Krasny, 2013). To summarise, there are many
indications that natural environments, and forests
in particular, could benet different aspects of
spiritual wellbeing.
3.3.2 Physical health
Communicable diseases
Infectious diseases
As already discussed in the section on children,
ecosystem condition (including that of forests)
might drive the change in the prevalence of infec-
tious diseases. With regard to forests, vegetation
cover, temperature and humidity might create
conditions that are favourable to specic vector
species (e.g., mosquitoes, ticks, ies) transmitting
infectious disease (Kar et al., 2014; MacDonald
and Mordecai, 2019; Guégan et al., 2020). As a
consequence, loss of forest cover might create
conditions unsuitable for certain vector species
(e.g., Anopheles dirus in Thailand and Anopheles u-
viatilis in India). However, it may also lead to con-
ditions that enable development of new vectors
(e.g., Anopheles gambiae and Anopheles arabiensis in
the Sahara region) (Kar et al., 2014 and referen-
ces therein). This highlights the need to unders-
tand site specic dynamic interactions between
forest ecosystems and infectious diseases before
adequate health relevant forest management can
be carried out. Moreover, the regulatory service
of forests, for watershed quality for instance, can
be essential for reducing the prevalence of infec-
tious diseases in communities living in the sur-
roundings (also see Section 3.2.2).
On an individual plant level, ethnopharmaco-
logical studies have reported on plants being wide-
ly used against human infectious diseases across
the world (Raal et al., 2013; Chinsembu, 2015;
Ozkan et al., 2016). A recent study revealed that
the well-known African Baobab (Adansonia digitata)
has multiple medicinal benets in the treatment
of infectious diseases and the bark’s extract has
been found to be useful against malaria and fever
(Asogwa et al., 2021). With regards to diarrhoea,
there are reports on plant species used in tradi-
tional medicine in Mexico (Calzada and Bautista,
2020) and in Benin (Dougnon et al., 2021). Some
plants are suggested for utilisation against respira-
tory infections in general (Rigat et al. (2013) in the
Iberian Peninsula) or particular diseases such as
tuberculosis (Madikizela et al. (2013) for examples
in South Africa and Shari-Rad et al. (2020) for ex-
amples covering Africa, the South Pacic, America
and Asia) and coronavirus diseases (Keyaerts et
al., 2007; Adhikari et al., 2020; Mehmood et al.,
2021). Many studies seeking to provide the scien-
tic basis for the use of selected plants have also
documented the biological activities of plant ex-
tracts on pathogens responsible for diseases (Zuo
et al., 2012; Madikizela et al., 2013; Maggi et al.,
2013; Rehman et al., 2017; Debalke et al., 2018;
Owusu et al., 2021). However, it should be noted
that some curative/preventive medicinal plants
might have potentially serious side effects as re-
ported in a systematic review by Alebie et al. (2017)
and appropriate dosage needs to be identied for
any medicinal plant.
In conclusion, the interaction with forests
could be associated with infectious diseases, but
the direction can be positive or negative depending
on the context and dosage. Proper understanding
of these complex relationships is needed to allow
site-tailored forest management that optimises
health benets.

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
90
Chronic noncommunicable diseases (NCDs)
Cardiometabolic health
Physiological and lifestyle factors, including psy-
chosocial stress and physical activity and en-
vironmental factors such as air pollution, noise
and heat are closely linked with cardiometabolic
health (also see Section 3.2.2). Forests, trees and
green spaces in general have been shown to re-
duce stress, increase physical activity, strengthen
immune function and mitigate exposure to air
pollution, noise and heat, and thus could exert
benecial impacts on cardiometabolic health.
Land use change through forest res and de-
forestation may also impact cardiometabolic
health through reduced place attachment.
The potential effect of natural environments
on the cardiometabolic system is one of the most
commonly studied topics in nature and health re-
search. Several such studies have been performed
worldwide, especially in western high-income
countries and Asian countries like China. A recent
systematic review by Liu and colleagues pooled
epidemiological studies on green space (assessed
by NDVI, percentage of green space, distance to
the nearest green space, proximity to public parks,
etc.) and cardiovascular disease (CVD) incidence/
prevalence. The pooled evidence generally sup-
ports that exposure to areas with more vegetation
was associated with reduced odds of CVD events
(Liu, 2022).
Overweight and obesity are among the most
important cardiometabolic risk factors. A sys-
tematic review by Luo et al. summarised studies
on the association between green space exposure
(assessed using various metrics including NDVI,
distance to the nearest green space, proportion of
green space and the number of parks) and over-
weight and obesity. They found that most of the
included studies reported benecial associations
between green space exposure metrics and over-
weight/obesity prevalence and adiposity metrics
such as body mass index (BMI) and waist circum-
ference (Luo et al., 2020).
Hypertension is another important cardiomet-
abolic risk factor. Zhao (2022) summarised studies
on green space exposure and blood pressure and
hypertension and found that the evidence sup-
ported benecial associations between greater
NDVI and proportion of green space (but not dis-
tance to nearest green space) and reduced blood
pressure levels and lower odds of hypertension.
Diabetes is one of the major cardiometabolic
conditions and a major contributor to the global
burden of the disease. A total of 19 studies were
included in the review by De la Fuente et al. (2021)
and these studies consistently showed that living
near green space, having higher residential green
space levels, or having more parks near home,
were associated with reduced risk of type 2 dia-
betes. Another study performed in northeastern
China, which was not covered by the systematic
review by De la Fuente et al. (2021), also report-
ed that higher greenness levels were benecially
associated with glucose metabolism (Yang, 2019).
Several studies have also investigated the as-
sociations between green space exposure and
blood lipids. A retrospective cohort study of about
250,000 Americans aged over 65 found that high-
er levels of residential NDVI were associated with
lower blood lipid levels (Brown, 2016). Kim et al.
(2016) found similar benecial associations of
higher density of nearby parks and green areas
with lower blood lipid levels. In a cross-sectional
study of Chinese adults, Yang (2019) found that
living in neighbourhoods with higher green space
was consistently associated with improved blood
lipid proles. However, another retrospective co-
hort study of 3,205 Australian adults did not nd
any signicant association between public open
green space and occurrence of abnormal blood li-
pid levels (Paquet, 2014).
As summarised in the review by Wolf et al.
(2020), the impact of urban trees on cardiovascu-
lar health has also been explored adopting exper-
imental designs. They found that forest bathing
(Shinrin-yoku) could improve cardiovascular func-
tion and related health outcomes among healthy
participants, including lower blood pressure, heart
rate and sympathetic activity. In addition, forest
bathing could also lower blood pressure and ho-
mocysteine (a biological marker of cardiovascular
disease) levels among CVD patients (Wolf et al.,
2020). Forest bathing and forest therapy are report-
ed to be associated with positive cardiac health,
specically stress reduction, reduction of inam-
mation, better immune functions, blood pressure
and cardiac rhythm regulation (Logan et al., 2018).
Moreover, a potential link between forest loss and
the double burden of malnutrition and its links to
cardiometabolic diseases has been reported from
sub-Saharan Africa (Zeba et al., 2012; Acharya et
al., 2020). Forest res, resultant heat and air pol-
lution have complex negative consequences in-
cluding on cardiometabolic health (Frumkin et al.,
2017; Münzel et al., 2021). Land use change and de-
forestation in Indonesia and Malaysia for oil palm
cultivation have been linked in complex ways to
NCDs in general and potentially to cardiometabol-
ic syndrome (Kadandale et al., 2019). With respect
to forest proximate Indigenous communities, there
is emerging evidence of the association between
displacement or migration of forest-dependent

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
91
communities from Southeast Asia and their rapid
socio-economic change, and the deterioration of
their cardiometabolic health (Phipps et al., 2015;
Ashari et al., 2016).
In summary, studies show benecial effects of
green spaces on multiple aspects related to car-
diometabolic health especially from high income
countries and to some extent from emerging econ-
omies like China. There is limited research on for-
est dwelling communities and their lifestyles on
cardiometabolic health or the recent lifestyle tran-
sition in the context of out migration.
Respiratory and allergic conditions
Natural environments in general, and forests in
particular, may affect respiratory health through
different pathways including a reduction of stress,
the promotion of physical activity, enriching mi-
crobiota, and mitigating exposure to air pollution
on the one hand, and producing pollens on the
other hand (also see subsection 3.2.2).
The most frequently studied adult respirato-
ry outcomes in association with natural environ-
ments are chronic obstructive pulmonary disease
(COPD) (Sarkar et al., 2019; Fan et al., 2020; Xiao et
al., 2022), asthma (Alcock et al., 2017; Donovan et
al., 2021) and allergic rhinitis (Kwon et al., 2019).
The most commonly used exposure metric is the
NDVI (Kwon et al., 2019; Sarkar et al., 2019; Fan et
al., 2020; Donovan et al., 2021; Xiao et al., 2022), al-
though some studies used plant-diversity metrics
(Liddicoat et al., 2018; Donovan et al., 2021) or ur-
ban-landcover metrics that include forests (Alcock
et al., 2017; Kim and Ahn, 2021).
Several studies have found that higher residen-
tial green space is associated with a reduced risk
of suffering from COPD (Maas et al., 2009; Sarkar
et al., 2019; Xiao et al., 2022). In China, Xiao et al.
(2022) further found that higher residential green
space was associated with improved lung function,
although all associations were limited to women,
people younger than 65 and non-smokers. In con-
trast, Fan et al. (2020) found that higher residential
green space was associated with an increased risk
of COPD among men in China. Local differences in
plant species and air pollution may be important
reasons for these inconsistent results, because air
pollution can potentiate the allergic potential of
plant pollen (Janssen et al., 2003). The inconsistent
pattern between green space exposure and COPD
is also seen in studies of short-term lung function,
with improvements in lung function from walk-
ing in a park observed in both younger Austrians
(Moshammer et al., 2019) and older British adults
(Sinharay et al., 2018), whereas other studies have
found associations with decreased lung function
in Scandinavian adults (Nordeide Kuiper et al.,
2021).
Several studies have found that exposure to
green space is associated with reduced asthma risk
(Maas et al., 2009; Alcock et al., 2017; Douglas et al.,
2019; Kim and Ahn, 2021; Wu et al., 2021), where-
as others have found that green space exposure
is associated with increased asthma risk (Khan et
al., 2010; Lai and Kontokosta, 2019; Donovan et al.,
2021). Within these contradictory results, consist-
ent patterns can be seen with regards to the criti-
cal role of the composition and structure of green
space in the observed heterogeneities. Several
studies have found that exposure to more diverse
green space is associated with lower asthma risk
(Donovan et al., 2021; Wu et al., 2021). In the USA,
Kim et al. (2021) found that exposure to clusters of
trees and small areas of private green space was
associated with lower asthma risk, whereas there
was no association with exposure to large areas
of green space such as parks and golf courses. A
handful of studies have found that exposure to
green space is associated with a decreased risk
of allergic rhinitis (Stas et al., 2021; Zhang et al.,
2021b). Consistent with the asthma literature, the
composition of the exposure matters. For example,
Zhang et al. (2021a) found that exposure to more
diverse greenness was associated with lower rates
of self-reported allergic disease in China. Howev-
er, exposure to more diverse plants with airborne
pollen was associated with higher rates of allergic
disease.
A small number of studies in the green space
and adult respiratory health literature has specif-
ically used trees or forests as an exposure metric.
Alcock et al. (2017) found that urban areas in the
UK with more tree cover had lower rates of asth-
ma hospitalisation, although this relationship was
only seen in areas with higher levels of air pollu-
tion. In contrast, Lai and Kontokosta (2019) found
tree cover was associated with increased asthma
risk in New York City. Finally, in Belgium, Stas et
al. (2021) found that exposure to birch trees (Betula
spp.) was associated with an increased risk of al-
lergic rhinitis, whereas exposure to alder trees
(Alnus spp.) was associated with a decreased risk.
In conclusion, although there is some evidence
that exposure to the natural environment includ-
ing forests may protect against respiratory and
allergic diseases in adults, the overall evidence is
contradictory. A systematic review published in
2022 concluded that the extant literature was sug-
gestive of a potentially causal link between green
space and respiratory health, with the evidence
being stronger for mortality rather than morbid-
ity (Mueller et al., 2022). The inconsistency of the

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
92
literature may be because exposure to the natural
environment is protective of respiratory and al-
lergic outcomes such as asthma, atopy and aller-
gic rhinoconjunctivitis, while it also exacerbates
symptoms in susceptible individuals.
Cancers
Urbanisation, and the consequent reduction of
contact with the natural environment, can in-
crease exposure to anthropogenic contaminants
and lead to changes in lifestyle and social behavi-
ours that have been associated with cancer risk.
Based on that, a number of environmental and
socio-behavioural mechanisms could explain the
potential association between natural environ-
ments and cancer incidence and/or prevalence.
This association could be partly explained by the
ability of natural environments to mitigate expo-
sure to air pollution, which is an important cause
of cancer (Loomis et al., 2013), and increase physi-
cal activity, which is a protective factor for cancer
incidence and mortality (McTiernan et al., 2019).
Similarly, the ability of natural environments to
reduce stress, strengthen social contacts and
improve immune function might constitute pro-
tective factors that may reduce cancer incidence
and mortality.
There are still relatively few studies exploring
the association between green space and cancer
incidence and/or prevalence. A recent systematic
review (Zare Sakhvidi et al., 2022) and a scoping re-
view (Porcherie et al., 2021) have summarised the
existing evidence on the topic.
Studies have mainly assessed green space
availability based on measurement on surround-
ing greenness and land cover around home (As-
tell-Burt et al., 2014; Carles et al., 2017; Demoury et
al., 2017; Datzmann et al., 2018; O’Callaghan-Gor-
do et al., 2018; Shao et al., 2019; Iyer et al., 2020;
Harrigan, 2021; Zare Sakhvidi et al., 2021). Addi-
tionally, some of these studies have also included
measurements of green space accessibility (Carles
et al., 2017; Zare Sakhvidi et al., 2022).
Most of the evidence of the association be-
tween green space and cancer comes from stud-
ies on skin, prostate and breast cancer. There are
three major studies available on skin cancer. Res-
idential surrounding green space was associated
with lower risk of non-melanoma skin cancer in
a study conducted in Germany (Datzmann et al.,
2018), but with increased risk of melanoma skin
cancer in a study in France (Zare Sakhvidi et al.,
2021) and with increased prevalence of skin can-
cer overall (melanoma and non-melanoma) in an-
other study in Australia (Astell-Burt et al., 2014).
From four studies on prostate cancer, three stud-
ies conducted in Canada, Germany and the USA
found reduced risk of prostate cancer associated
with the increase in residential surrounding green
space (Datzmann et al., 2018; Demoury et al., 2017;
Iyer et al., 2020). However, one study carried out in
France suggested the opposite results (Zare Sakh-
vidi et al., 2021). There are also four major studies
on breast cancer, of which two conducted in France
and Germany reported that residential surround-
ing greenness was a protective factor (Datzmann et
al., 2018; Zare Sakhvidi et al., 2021), one carried out
in Canada reported no association (Harrigan, 2021)
and one based on participants from Spain report-
ed that surrounding greenness was a risk factor
(O’Callaghan-Gordo et al., 2018). However, this last
study showed different results when land use was
taken into account: urban green areas were asso-
ciated with reduced risk of breast cancer, whereas
agricultural areas were associated with increased
risk. These ndings could at least partially explain
the heterogeneity of results observed in studies
on green spaces and cancer that only take into
account the amount of surrounding green space
without considering the type of green space or
the activities conducted in such areas. There are
a few other studies on the association between
green space and other cancer sites including lung
cancer, colorectal cancer, brain cancer, mouth and
throat and all-sites cancers (Carles et al., 2017;
Datzmann et al., 2018; Shao et al., 2019; Zare Sakh-
vidi et al., 2021). The evidence from these studies is
mainly mixed and inconclusive. One early ecologi-
cal study looked specically at forest coverage and
mortality due to different types of cancer. Using
Japanese prefectures as units of observation, Li et
al. (2008) observed inverse associations between
the percentage of forest cover and the standard-
ised mortality rate for several types of cancer.
In conclusion, the available evidence on the
association between green space and cancer is
still evolving. However, it suggests a benecial
association for some of the cancers, particularly
hormone-dependent cancers such as breast can-
cer. To our knowledge, only one study to date has
explored specically the association between ex-
posure to forests and/or trees and cancer.
3.2.3 Summary
Table 3.2 provides an overview of the strength
of the evidence for associations between forests,
trees and green spaces on the one hand, and health
and wellbeing in the adult life stage on the other,
based on the expert judgement of the authors.
The evidence for most of the included health do-
mains is generally positive, with the strongest and

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
93
most consistent evidence for mental and spiritual
wellbeing and quality of life, and cardiometabolic
health. Although somewhat more mixed, there is
also mostly positive evidence for the contribution
of natural environment and forests to the preven-
tion and reduction of (symptoms of) mental disor-
ders. In the other domains, including infectious
diseases, respiratory and allergic outcomes, and
cancers, the evidence is more mixed, with positive
as well as negative impacts being reported.
ADULTHOOD: STRENGTH OF THE EVIDENCE
MENTAL HEALTH
PHYSICAL HEALTH
Mental wellbeing
and quality of life
++
Infectious diseases
+/-
Spiritual wellbeing
++
Respiratory/allergic
outcomes
+/-
Cancers
+/-
Mental disorders
+/0
Cardiometabolic
health
++
Table 3.2
Expert assessment (by authors) of the strength of the evidence for forests,
trees and other types of green space being associated
with different health outcomes among adults
Note: Sign indicates type of association: + benecial association, 0 no association, - detrimental (harmful) association. Number of
same signs indicates strength of evidence for a particular type of association.
3.4 The Elderly
In this third stage of life, we distinguish between
studies focusing on healthy ageing, mental health
and longevity.
3.4.1 Healthy ageing
Cognitive decline and dementia
Natural environments may affect cognitive decli-
ne and dementia through alleviating risk factors
such as physical inactivity, loneliness, depression,
obesity, cardiovascular diseases and air pollution,
and by buffering negative impacts of major life
events such as hospitalisation and institutionali-
sation (Livingston et al., 2020).
A systematic review of 13 studies available
up to 2016 on the link between exposure to green
space and cognitive functioning indicates low
quality evidence (e.g., cross-sectional self-report-
ed data) (de Keijzer et al., 2016). In particular, the
four studies with elderly people showed incon-
sistent results regarding the association between
green space and cognitive functioning. Since 2016,
at least 30 studies including analyses of longitu-
dinal data have been published. These include
Australian cohort studies that have isolated tree
canopy from other types of green space (e.g., grass
and shrub), indicating reduced risks of subjective
memory complaints (Astell-Burt and Feng, 2020b)
and dementia risk over 11 years (Astell-Burt et al.,
2020). These ndings on the potential benets of
urban tree canopy cover are complemented by
cohort studies assessing associations with NDVI-
based measure of residential green space, report-
ing lower 10-year risks of cognitive decline in the
UK (de Keijzer et al., 2018) and dementia over a
13-year period in Canada (Paul et al., 2020). How-
ever, such protective effects of green space are not
always observed for all people (Jin et al., 2021).
Current research is assessing different types
of dementia, such as a USA-based cohort study
(Slawsky et al., 2022) reporting a lower risk of
all-cause dementia with more NDVI-based green
space, but not with dementia sub-types such
as Alzheimer’s disease (AD). Studies are also ex-
amining associations between nature and brain
measurements. For example, Falcón et al. (2021)
observed an association between residential sur-
rounding green space and specic brain areas
known to be affected in AD, indicating a lower vul-
nerability in a large sample of cognitively unim-

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
94
paired individuals at risk for AD. This result aligns
with that reported by Crous-Bou et al. (2020),
wherein more exposure to green space was associ-
ated with greater thickness in brain regions known
to be affected by AD, thus indicating a benecial
effect on vulnerability in brain areas involved in
AD. A recent experimental study in South Korea re-
ported that repeated forest therapy sessions could
mitigate the physical, psychological, and cognitive
risk factors of dementia among at-risk elderly (Lim
et al., 2021). Another recent trial on dementia pa-
tients in four French nursing homes reported that
visits to gardens improved cognitive function and
ability to carry out daily activities independently
(Bourdon and Belmin, 2021).
To summarise, the evidence on the benecial
impacts of natural environments, including forest,
on decelerating cognitive ageing and reducing the
risk of dementia, is accumulating and indicative
for such an impact.
Physical functioning and frailty
Physical functioning is dened as the ability to
perform daily activities unassisted (Covinsky,
2006). A poor physical functioning is associated,
among others, with a higher risk of age-related
frailty (Rodríguez-Gómez et al., 2021). Frailty is a
multidimensional syndrome, including a number
of physical, cognitive, psychological and social
problems (Levers et al., 2006), which has been as-
sociated with a higher risk of disability, hospita-
lisation and mortality and lower quality of life in
later life (Kojima, 2017; Chu et al., 2021). Pathways
through which natural environments, including
forests, could inuence physical functioning and
frailty are mostly similar to those for cognitive
decline, as described in the preceding section.
Physical functioning and its decline in older
adults have been extensively investigated, also in
relation to lifestyle factors (e.g., van Assen et al.,
2022). Regarding contact with green space, Vogt et
al. (2015) found in a sample of older German adults
that certain features of a residential environment,
including proximity to green space, were not as-
sociated with self-rated physical constitution, dis-
ability and health-related quality of life. Howev-
er, the authors attributed this nding to the fact
that the city under consideration, i.e., Augsburg,
has many green spaces, thus making it difcult to
isolate its effect on citizens. A later longitudinal
study that investigated the effect of exposure to
natural environments (i.e., green and blue spaces)
on physical functioning among nearly 6,000 mid-
dle-aged and older healthy adults in the UK found
that higher residential surrounding green space
was associated with a slower 10-year decline in
walking speed, an indicator of lower body physi-
cal functioning (de Keijzer et al., 2019). They also
observed indications for a similar association for
grip strength, an indicator of upper body physical
functioning. In another study in China, more res-
idential green space was found to be associated
with lower odds of developing disabilities related
to basic and instrumental activities of daily living
in the elderly (Zhu et al., 2019). Consistent with
this, another longitudinal study found a negative
association between the amount of residential
green space and the likelihood of frailty among
over 16,000 Chinese older adults (Zhu et al., 2020).
A recent study reported an association between
residential surrounding green space and bone min-
eral density (BMD) change and incident fracture in
a sample of Hong Kong Chinese older adults (Lin
et al., 2021). BMD loss is correlated with osteopo-
rosis, both of which are among common indicators
of physical frailty in the elderly. This study found
that residential surrounding green space was as-
sociated with slower 14-year increase in lumbar
spine BMD. Mixed ndings were instead found in
whole body BMD, which showed to be associated
with greenness measured in a 300m buffer, but
not a 500m buffer. However, green space was also
found to be associated with a higher risk of frac-
ture incidence in the same sample. The authors
posit that it is highly likely that the association
between higher green space level and bone health
is mediated by physical activity. Another possible
mediator could be through mitigation of exposure
to air pollution (Weuve et al., 2016), which is sup-
ported by recent ndings reporting associations
between exposure to long-term air pollution and
risk of osteoporosis-related fracture in the elderly
(Heo et al., 2022). However, air pollution was not
signicantly associated with decline in physical
functioning in other studies (e.g., de Keijzer et al.,
2019).
Summarising, although the available evidence
on the association between exposure to natu-
ral environments, including forests, and physical
functioning and frailty is still limited with some
inconsistencies in their ndings, it is suggestive of
a benecial relationship.
3.4.2 Mental health
With regard to mental health, psychological path-
ways (i.e., stress reduction, mood improvement)
are of key importance although physical activity
may also be a relevant pathway (Kadariya et al.,
2019). Specically for the elderly, the social con-
tacts pathway is deemed relevant for their men-
tal health and wellbeing, since social isolation

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
95
is a more common risk factor for this age group
(Choi and Matz-Costa, 2018; Urzua et al., 2019;
Domènech-Abella et al., 2021).
In their review, Kabisch et al. (2017) reported
on the effects of (mainly urban) green space on
elderly people (and children). They conclude that,
although a universal protective health effect of ur-
ban green space has not been established due to
the relatively limited available studies, the trend is
positive. A study by Ode Sang et al. (2016) in Swe-
den reported that higher perceived naturalness in
the neighbourhood was associated with more ac-
tivities and higher self-reported wellbeing. Similar
results were found in Japan by Soga et al. (2017)
with regard to urban allotment gardens. Moreover,
in China, Zhou et al. (2020) found that neighbour-
hood green space was positively associated with
older adults' mental wellbeing via social interac-
tions. A eld study in Finland on urban parks and
woodlands found that both had restorative effects,
but nature (versus city) orientedness and noise
sensitivity modied the effects (Ojala et al., 2019).
For example, in the high nature-oriented group,
the highest restorative effects (observed based on
psychological measures only) were found in urban
woodlands. Other studies report on the importance
of physical activities. In a cross-sectional study in
Germany, 272 adults aged 65 answered questions
regarding health-related quality of life, physi-
cal activity and exposure to urban green spaces
(Petersen et al., 2018). The analysis showed sig-
nicant positive associations between weekly
duration of exposure to urban green space and
health-related quality of life. Similarly, a study
conducted in six European countries showed the
importance of urban green spaces for the quality
of life of seniors residing in care facilities, as well
as for the staff and visitors (Artmanna et al., 2017).
A review by Oh et al. (2017) in China and Korea
focused on articles analysing the effect of different
forest therapy interventions on physical and psy-
chological health outcomes. Two of the three stud-
ies with elderly participants measured psycho-
logical responses with the prole and mood state
questionnaire which is used to measure current
affect (Mao et al., 2012; Jia et al., 2016). They re-
ported that the forest therapy intervention group
had signicantly lower scores in the negative sub-
scales (tension-anxiety, depression, anger-hostili-
ty, fatigue and confusion) and increased vigour. A
similar study in Korea compared different health
outcomes of a forest therapy group versus a con-
trol group of elderly hypertensive patients and
found a signicant decrease in cortisol level and
improvement in quality of life measures (Sung et
al., 2012).
Some work supports a benecial association
between availability of and/or proximity to nature
and risk for mental disorders in elderly popula-
tions, especially depression. A USA-based study
found that the elderly living in greener neighbour-
hoods had a reduced risk of depression (Brown et
al., 2018). The reduction was larger in low-income
neighbourhoods. A study among older women
(mean age 70) in the USA Nurses’ Health Study
who lived in the highest quintile of green space
Forests and green spaces are essential for physical and mental wellbeing
Photo © Nelson Grima

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
96
(using average NDVI) within 250m buffers had a
reduced risk for the onset of depression over 10
years of the study period (Banay et al., 2019). In
China, the middle-aged and elderly living in a city
district with a green space coverage above 38%
had lower odds of having depressive symptoms
than those living in districts with a coverage below
38% (Zhou et al., 2022). Specically with regard to
forests and trees, Nishigaki et al. (2020) assessed
depression rates (using the Geriatric Depression
Score) in 126,878 adults 65 and over, and found
that greater amounts of trees within district areas
were associated with lower odds for depression.
With respect to symptomatology, Wu et al.
(2015) found that the amount of neighbourhood
green space was inversely associated with sub-
threshold levels of depression and anxiety symp-
toms among a sample of elderly adults (age 74 and
over) in the UK. Other work from the USA found
that depressive symptoms were inversely relat-
ed to tree canopy coverage (especially for buffer
sizes between 0-250m and 250m-500m) around
9,186 nursing homes (Browning et al., 2019). A Ko-
rean study on the effect of a 10-week urban forest
therapy programme for low-income elderly living
alone showed that the elderly had fewer depres-
sive symptoms after the programme and also few-
er than a control group (Lee and Son, 2018; also see
Lim et al. (2021) for a similar Korean study, with
a similar result). We are not aware of any other
studies looking specically at forests and trees in
relation to mental health disorders and symptom-
atology among the elderly.
In short, it can be concluded that there is sug-
gestive evidence that urban green spaces contrib-
ute positively to mental wellbeing and quality of
life for the elderly, resulting in a lower prevalence
of mental disorders and sub-clinical levels of re-
lated symptoms. This pertains especially to de-
pression, which appears to be the most frequently
researched disorder in connection to green space.
The few studies looking specically at the effect of
forests on wellbeing of elderly people indicate pos-
itive impacts on both wellbeing and quality of life.
3.4.3 Longevity and mortality
Exposure to natural environments, including for-
ests, has been associated with reduced risk of
mortality and improved life expectancy. These ef-
fects would seem to be the ultimate result of all
relevant pathways.
A systematic review and meta-analysis of lon-
gitudinal epidemiological studies found that incre-
ments in green space surrounding the residential
address – especially in a buffer of 500m – were sig-
nicantly associated with reducing all-cause mor-
tality (Rojas-Rueda et al., 2019). This review includ-
ed 13 studies with more than 8 million individuals
across seven countries: Australia; Canada; China;
Italy; Spain; Switzerland; and the USA. Although
the review could not conclude which mechanisms
underlay the reduction in mortality, many bio-
logical, lifestyle, and environmental mechanisms
and pathways (e.g., physical activity, stress, mi-
crobiome, air quality and heat) could mediate the
association between green space exposure and
mortality. Moreover, exposure to green space has
been associated with longer telomere length (Mar-
tens and Nawrot, 2018; Miri et al., 2020). Shortened
telomere length is an indicator of cellular ageing,
therefore a positive association between exposure
to nature and telomere length could indicate a de-
celeration of cellular ageing.
The evidence between exposure to nature and
mortality is robust enough to allow modelling the
future impacts of urban greening strategies on
mortality. A number of studies have been able to
quantify the mortality impacts of future greening
strategies (Mueller et al., 2018; Kondo et al., 2020).
In such a study in Philadelphia, USA, researchers
assessed the health impacts of 2025 tree canopy
goals (Kondo et al., 2020). In this study, the most
ambitious tree canopy goal (achieving 30% of the
city land covered by tree canopy) was estimated to
prevent 403 premature annual deaths among the
adult population. This study also quantied the
health-related economic benets, estimating that
the increase in the tree canopy to cover 30% of the
city land will result in health economic benets of
USD 3.8 billion annually.
To summarise, the available evidence is indica-
tive for the capability of natural environments to
reduce mortality, decelerate cellular ageing and
promote longevity.
3.4.4 Summary
Table 3.3 below gives an overview of the strength
of the evidence for associations of natural envi-
ronments and forests with health and wellbeing in
later stages of life, based on the expert judgment
of the authors. The evidence for the four included
health domains is generally positive, with strong
and consistent evidence for three out of four do-
mains: cognitive decline and dementia; mental
health and wellbeing; and longevity and mortality.
The evidence for an impact of contact with nature
and forests on physical functioning and frailty is
somewhat more mixed, mostly because the phy-
sical activity pathway underlying these benets
may also lead to accidents and bone fractures.

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
97
3.5 Other Health and Wellbeing Effects
3.5.1 Sleep quality and duration
Studies on the potential of forests, trees and
green spaces to support population-wide im-
provements in sleep are emerging. Stress relief,
physical and social activities, and protection
from chronic noise, excess heat and air pollution
are all plausible and likely intertwined mecha-
nisms (Astell-Burt and Feng, 2020), though evi-
dence is still in its infancy. A systematic review
on green space exposure and sleep (Shin et al.,
2020) identied 13 studies up to 31 December
2018, including seven epidemiological studies
with a cross-sectional design (Astell-Burt et al.,
2013; Singh and Kenney, 2013; Bodin et al., 2015;
Chum et al., 2015; Grigsby-Toussaint et al., 2015;
Triguero-Mas et al., 2017; Johnson et al., 2018),
one case report (Rappe and Kivelä, 2005), three
uncontrolled pre/post trials (Lee and Kim, 2008;
Morita et al., 2011; López-Pousa et al., 2015) and
two randomised controlled trials (Gladwell et al.,
2016; Dolling et al., 2017). Findings indicating that
contact with green space may support healthier
sleep durations and/or quality were reported in
all ve of the trials (Dolling et al., 2017; Gladwell
et al., 2016; Lee and Kim, 2008; López-Pousa et al.,
2015; Morita et al., 2011) and in six of the seven
epidemiological studies (Astell-Burt et al., 2013;
Bodin et al., 2015; Grigsby-Toussaint et al., 2015;
Johnson et al., 2018; Singh and Kenney, 2013;
Triguero-Mas et al., 2017).
Since the aforementioned review, six cross-sec-
tional studies (Feng et al., 2020; Xie et al., 2020;
Yang et al., 2020; Li et al., 2021; Williams et al.,
2021; Zhong et al., 2021) and three longitudinal
studies (Astell-Burt and Feng, 2020a; Mayne et
al., 2021; Putra et al., 2022) have been published.
Six focussed on adults and three on children
and adolescents. Results from six out of eight of
these more recent studies indicate that contact
with green space may support sleep-related out-
comes (Astell-Burt and Feng, 2020a; Li et al., 2021;
Mayne et al., 2021; Xie et al., 2020; Yang et al., 2020;
Zhong et al., 2021). Two longitudinal studies found
evidence of benets from nearby tree canopy
(Astell-Burt and Feng, 2020a; Mayne et al., 2021). In
a study of adolescents, Mayne et al. (2021) report
that an increase in neighbourhood tree canopy
was associated with earlier sleep onset and ear-
lier sleep offset. In a study of adults, Astell-Burt
and Feng (2020) reported 13% reduced odds of
insufcient sleep (<6 hours) among participants
with >30% tree canopy within a 1.6km buffer in
contrast with peers with <10% tree canopy, while
there were no associations for other types of green
space (e.g., open grasslands).
3.5.2 Other physical health benets
In addition to the aforementioned health outcomes,
exposure to nature has been associated with re-
duced risk of other morbidities. For example, a
study by Maas et al. (2009) based on data from over
345,000 participants in the Netherlands reported
that a higher percentage of green spaces in buffers
of 1km and 3 km around the residential address
of participants was associated with lower risks of
medical visits for musculoskeletal problems (e.g.,
severe neck, back and shoulder complaints), neu-
rological problems (e.g., migraine/severe headaches
Table 3.3
Expert assessment (by authors) of the strength of the evidence for forests, trees and
other types of green space being associated with different health outcomes
among the elderly
ELDERLY: STRENGTH OF THE EVIDENCE
Cognitive decline
and dementia
++
Mental health and
wellbeing
++
Longevity and
mortality
++
Physical functioning
and frailty
+/0
Note: Sign indicates type of association: + benecial association, 0 no association, - detrimental (harmful) association. Number of
same signs indicates strength of evidence for a particular type of association.
Source: MEA, 2005

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
98
and vertigo), gastrointestinal infections and acute
urinary tract infections. Other studies have also
suggested a protective association between expo-
sure to natural environments and refractive errors
of eyes such as myopia and astigmatism among
children (Dadvand et al., 2017; Huang et al., 2021).
3.5.3 Potential adverse health effects
Natural environment could also be a source of a
number of adverse health effects. For example, the
pesticides applied to maintain green spaces could
expose individuals who use these spaces or live in
their vicinity to these chemicals. Exposure to pes-
ticides, in turn, has been associated with a wide
range of health effects including cancers as well
as adverse conditions in reproductive, nervous,
immune and endocrine systems (Blair et al., 2015).
Moreover, users of natural environments, particu-
larly children, could experience accidental injuries
such as drowning or falls when they are in these
environments. However, such injuries occurring
in natural environments account for a very small
proportion of accidental injuries at the population
level (WHO regional Ofce for Europe, 2016).
3.6 Modiers of Forest Potentials
to Improve Health
The health and wellbeing effects of green spaces
and forest can vary across the strata of socio-eco-
nomic status, sex/gender, ethnicity and degree of
urbanicity. These potential moderators are dis-
cussed in this section. Typology and quality char-
acteristics of natural environments may also af-
fect the amount and type of interaction between
people and these environments, and hence could
inuence their potential to exert health benets.
For example, in their systematic review Nguyen et
al. (2021) concluded that trees are more effective
than grass in exerting benets for mental wellbe-
ing, allergic respiratory conditions and cardiovas-
cular conditions. An in-depth discussion of the rel-
evance of the typology and quality characteristics
of the natural environment to human health can
be found in Chapter 4 of this report.
3.6.1 Socio-economic status
Evidence is growing about the differential health
effects of exposure to outdoor nature by socio-
economic status (SES). A review of 122 analyses
across 85 articles found moderate evidence that
those with lower-SES show more benecial asso-
ciations across seven physical health outcomes
from outdoor nature exposure than higher-SES
populations (Rigolon et al., 2021). These differen-
tial benets were more prominent in analyses of
public parks than generalised measures of na-
ture/vegetative cover. Differential benets were
also more prevalent in European studies than in
North American studies. Lower SES populations
benetted more from outdoor nature among se-
veral of the reviewed studies in LMICs, including
China (i.e., Huang et al., 2020) and Brazil (Rossi et
al., 2019). Studies on mental and socio-emotional
health outcomes also suggest stronger benecial
effects of nature exposure for those in lower SES
strata (McEachan et al., 2016; van den Berg et al.,
2016; Triguero-Mas et al., 2017; Pearce et al., 2018;
McCrorie et al., 2021; Browning et al., 2022a).
Beyond evidence on SES as an effect modier
on the health benets of outdoor nature, some
studies have explored interactions between SES
and other potential modiers such as urbanicity
or gentrication (Maas et al., 2006; Mitchell and
Popham, 2007; Cole et al., 2019; Zayas-Costa et al.,
2021). For example, Cole et al. (2019) focused on
adults’ self-perceived general health in New York,
USA, and found only those living in gentried
neighbourhoods with higher education or income
levels benetted from green space. A review of 15
studies on gentrication following urban greening
found long-time, marginalised residents felt ex-
cluded from and used, new green spaces less than
newcomers (Jelks et al., 2021).
Lower SES populations may benet more from
nature than privileged groups for multiple rea-
sons. Populations with limited nancial resources
could be more dependent on their neighbourhoods
because of lower rates of vehicle ownership than
more privileged populations (de Vries et al., 2003;
Maas et al., 2008; McEachan et al., 2016; Rigolon
et al., 2021). Limited resources could also increase
reliance on freely available health-promoting fa-
cilities such as green spaces rather than cost-pro-
hibitive services (de Vries et al., 2003; Triguero-Mas
et al., 2017). Additionally, people with lower SES
are vulnerable to poor health outcomes resulting
from environmental and social stressors across
the lifespan, resulting in suppressed baselines and
having more to gain from outdoor nature regard-
ing improvements in health (Braveman et al., 2010;
Ursache and Noble, 2015; Robinette et al., 2017;
Rigolon et al., 2021). A notable exception to low-
er-SES populations benetting more from nature
than their privileged counterparts are residents of
neighbourhoods witnessing green gentrication
(Rigolon and Collins, 2022). In these cases, studies
in both higher income countries and lower income
countries show only higher-SES populations may
benet from exposure due to changes in senses of

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
99
Shorea roxburghii, a plant mostly found in Asia, is commonly used for medicinal purposes
Photo © Arun Kumar
community and belonging, perceived safety, phys-
ical activity levels and nancial pressures, among
other factors (Cole et al., 2019; Jelks et al., 2021).
There is little evidence on differential impacts
of forests specically on health by SES. One not-
able exception is a study of sedentary behaviour,
obesity, asthma and allergic rhinoconjunctivitis
amongst Spanish children (Dadvand et al., 2014a).
The authors found stronger benecial associations
between residential proximity to forests and lower
sedentary behaviour (screen time) for children of
parents with higher education levels. Another rel-
evant exception is an exploration of associations
between street tree density and species richness
with antidepressant prescriptions amongst Ger-
man adults; in this study, lower prescriptions were
associated with street tree density and species
richness only amongst respondents with low SES
(Marselle et al., 2020).
Collectively, the available evidence, along with
reasons to expect that outdoor nature benets low
SES residents more than other populations, sup-
ports the likelihood of forests and trees having
‘equigenic effects’, i.e., narrowing socio-economic
inequalities in health (Mitchell et al., 2015). Indi-
viduals in the greatest need may receive the great-
est health benets from living in or visiting areas
with abundant canopy cover.
3.6.2 Gender
Women and men may perceive and experience
nature differently. In some cultures, women tend
to express greater safety concerns in urban parks
and densely vegetated areas, such as forests, than
men (Sreetheran and van den Bosch, 2014). This
could result in less optimal use of these spaces
for health and wellbeing benets among women.
At the same time, women tend to be more con-
nected to nature and supportive of the idea that
contact with nature can be benecial for health,
as evidenced by a large survey among a represen-
tative sample of Dutch residents (van den Berg,
2012). However, direct evidence for differences
between men and women in the nature-health
relationship is mixed and inconclusive. In discus-
sing the available evidence, we considered gender
as a binary construct, because all studies that are
available treat gender as such. However, we ac-
knowledge that the research falls short in recog-
nising that many individuals identify as non-bi-
nary, bigender, agender or other (Springer et al.,
2012).
Systematic reviews of self-rated health (Bolte
et al., 2019), physical health (Sillman et al., 2022)
and cardiovascular health (Núñez et al., 2022)
have examined how gender impacts the health
benets of green space but provide little guidance
on differential benets of trees/forests. Bolte et al.
(2019) identied seven studies on self-rated health
and green space, natural land cover, or perceived
green space amount/quality. Four studies showed
no difference between men and women while the
remainder showed associations for one group or
the other. A more extensive review by Sillman et al.
(2022) identied 81 analyses of gender differences
across 62 articles on associations between cardio-
vascular disease, cancer, diabetes, general physical
health, non-malignant respiratory disease, mor-
tality and obesity-related outcomes with differ-
ent types of green space measures. Some of these
measures (e.g., green land cover) included forested
land, but this was not distinguished as a separate
category. Results of this review were again mixed

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
100
and inconclusive, with 42% of the analyses report-
ing stronger associations for women, 35% showing
no differences between women and men, and 23%
showing stronger associations for men. Protective
associations for women were most prominent in
obesity-related and mortality outcomes, when
green space was measured very close to home,
and for green land cover estimates that included
forests. In no case did men show more prominent
protective associations among specic health out-
comes or types of nature. Núñez et al. (2022) found
women tended to benet more than men from
exposure to nature when measured with NDVI
values but not when using other exposure assess-
ments across the 22 reviewed studies. Another
recent study among Chinese adults that was not
included in the review found some evidence that
street view green space was negatively associat-
ed with hypertension among women but not men
(Wang et al., 2022). No gender differences were
found for the relationship between total vegetative
cover using overhead estimates (i.e., NDVI). These
results suggest the location and type of vegetation
– including trees – denes when gender differenc-
es are present in associations between nature and
human health.
Taken together, research points to a small
but potentially signicant role of gender in how
people relate to nature and forests and the health
benets they derive from interacting with forests,
trees and green spaces. Contrary to the nding
that women tend to feel more unsafe in parks and
forests, and thus might avoid visiting these spaces
for health purposes, the benets seem to be slight-
ly more in favour of women. This might be relat-
ed to women's stronger connection to nature and
how this inspires them to engage in nature-based
activities such as gardening, taking walks in (safe)
natural areas, and other activities that allow them
to reap the health benets of nature.
3.6.3 Ethnicity and culture
The evidence on ethnicity and culture as effect
modiers in relationships between nature and
health is scarce and contradictory. Dening such
group identities remains complex and challeng-
ing. For a start, culture and ethnicity are distinct;
a shared system of symbols (i.e., language) and
values can dene cultural groups whereas social
boundaries restricting ‘in’ and ‘out’ group mem-
bers can dene ethnic groups (Ordóñez-Barona,
2017; Kaufman and Hajat, 2021). However, in
American contexts, such divisions are histori-
cally dominated by ethnoracial differentiations
(i.e., Hispanic, Black and Asian), whereas in many
European countries, divisions are often made be-
tween locally- versus foreign-born individuals
(Gentin, 2011). In LMICs, broad and multifaceted
denitions have been used alongside population
sizes to identify potential minorities. Here we use
‘ethnicity’ to describe how groups of minority and
majority populations beyond their SES might de-
rive benets differently from nature and forests
(Victora et al., 2020).
McEachan et al. (2016) found no role of ethnic-
ity as an effect modier in associations between
residential green space exposure and depressive
symptoms among pregnant women in a UK birth
cohort. In contrast, another study of the same co-
hort reported positive associations between sur-
rounding green space and birth weight for White
British but not for Pakistani newborns (Dadvand et
al., 2014b). However, in the review by Rigolon et al.
(2021), the collective ndings of 25 articles showed
no notable differences between White and other
racial/ethnic groups across seven physical health
outcomes. Another review of the use and percep-
tions of urban natural environments by ethnic mi-
norities found that passive, social activities, larger
group sizes and manicured landscapes with fewer
trees tended to be most preferred (Ordóñez-Barona
et al., 2017).
Individual characteristics such as ethnicity and
race are frequently used as surrogates of the expe-
riences of racism and social discrimination. Cer-
tain ethnic or racial population groups such as mi-
norities and immigrants may not enjoy the same
economic, political and health status as more priv-
ileged groups (Mohai et al., 2009; Chen and Miller,
2013). Green space quality, programming and safe
access are often lower among non-Whites, even
where there is equal green space proximity. Such
patterns could perpetuate lower exposure to these
health-promoting amenities (Frumkin et al., 2017).
New or improved green spaces may also be intim-
idating and fear-inducing for some minority and
immigrant groups because of memories or nar-
ratives of discrimination, violence, lynching and
crime (Rigolon and Németh, 2018; Anguelovski et
al., 2020). Some authors have suggested that mi-
nority and immigrant groups may also lack the
condence to visit green spaces; for example, some
populations fear getting lost in urban green spac-
es (Cronin-de-Chavez et al., 2019). Inadequate un-
derstanding of the needs (e.g., route nding), lan-
guages, identities and preferred uses of green spac-
es of different racial and ethnic groups may result
in inequitable health benets of these spaces.
Inclusive participation in the design and mainte-
nance of green spaces may help overcome ethno-
racial disparities in the health benets of forests,
trees and green spaces (Anguelovski et al., 2020).

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
101
3.6.4 Urbanicity and rurality
The health-promoting benets of forests, trees
and green spaces can span the urban-rural con-
tinuum. Whether these benets are more promi-
nent in cities, suburbs or countrysides is poorly
understood. Forests are heralded for their array
of ecosystem services (Roeland et al., 2019) inclu-
ding cultural services related to human health,
economic development and tourism (Nesbitt et
al., 2017). These services may be particularly va-
luable in urban contexts where environmental
stressors are concentrated, including air pollu-
tion, heat and noise (Boehmer et al., 2013). Trees
thus provide health benets by ltering air pollu-
tion, mitigating the urban heat island effect and
diffusing trafc noise (Markevych et al., 2017).
Trees and forests can also support physical ac-
tivity, social interaction and sleep quality, while
restoring attention and aiding in stress recovery
(Nilsson et al., 2010).
Dozens of studies have been conducted on the
health benets of trees and forests in exclusively
urban settings without rural comparisons (Wolf
et al., 2020). In turn, dozens of other studies have
determined the therapeutic benets of forests in
larger tracts of forested land without examining
their urban counterparts (Yau and Loke, 2020;
Cheng et al., 2021). Scant research has attempted
to answer the question of how trees may impact
health differently across the urban-rural spec-
trum. Some insight is available from a review on
how urbanicity impacts relationships between
physical health and green space (in all its forms),
which found stronger protective effects for urban
than less urban areas (Browning et al., 2022b).
Across 57 analyses in 37 reviewed articles, around
50% showed no differences, 40% showed higher
benets for more urban areas and 10% showed
higher benets for less urban areas. Prior narra-
tive summaries support such ndings (Kabisch et
al., 2017; Markevych et al., 2017; Fong et al., 2018).
These differential effects were present across both
higher-income and low-to-middle-income coun-
tries, such as China (Huang et al., 2021).
Conicting evidence on where forests and trees
matter most persists in many nationwide stud-
ies. Annual healthcare expenditures (an outcome
of healthcare utilisation, presumably linked to
poor health status) among older adults was lower
in American counties with more forest coverage.
Contrary to the reviewed literature above, these as-
sociations were strongest in rural counties (Becker
et al., 2019). Meanwhile, the same authors found
opioid-related mortality was positively associat-
ed with tree canopy cover in American counties.
Sensitivity analyses uncovered that these effects
persisted only in rural counties and in fringe areas
around major cities (Becker et al., 2022). Carrus et
al. (2020) revealed rural Italian residents exhibited
higher connectedness to nature scores (CNS) than
urban residents. CNS scores were in turn positively
correlated with the perceived importance of for-
ests for sports, relaxation, illness prevention, so-
cial cohesion and community identity, suggesting
urbanicity might differentially affect perceptions
of forest health benets.
3.7 Global Health Challenges
3.7.1 The potential of forests
to tackle major global health challenges
Over the past decades, economic development to-
gether with advances in healthcare and food secu-
rity have resulted in changes in population growth
trajectories and composition (e.g., ageing popula-
tions) and in patterns (e.g., increased life expec-
tancy) and causes of mortality which, together,
are considered as the ‘epidemiological transition’
(McKeown, 2009). The pace of this transition has
been different across different countries, main-
ly depending on the developmental level of each
country, with high-income countries being gen-
erally more advanced in this transition. A con-
sequence of the epidemiological transition has
been a shift from communicable diseases (CDs)
to chronic noncommunicable diseases (NCDs) as
major contributors to the global burden of disease
(GBD). As presented in Table 3.4, while in 1990 (the
year for which the rst GBD was systematically es-
timated) CDs dominated the top 25 contributors
to the GBD (calculated as Disability-Adjusted Life
Years or DALYs), this list was mainly dominated by
NCDs in 2019 (GBD 2019 Diseases and Injuries Col-
laborators, 2020). Natural environments, including
forests, have a potential role in preventing many
of the NCDs and some of the CDs in this list. More
specically, the available evidence is suggestive for
a protective association of contact with natural
environments and ischaemic heart disease, stroke,
lower respiratory infections, diarrhoeal diseases,
diabetes, lower back pain, depressive disorders,
headache disorders, musculoskeletal disease, self-
harm and anxiety disorders. Moreover, in the case
of a number of mental health conditions such as
anxiety and depressive disorders, natural environ-
ments could also provide therapeutic effects. For
malaria and some other vector-based infectious
diseases, however, poor management and unsus-
tainable use of forests can increase the risk of
transmission and the burden associated with dis-
ease (Kar et al., 2014; Ranjha and Sharma, 2021).

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
102
The potential of forests and natural environ-
ment to tackle global health challenges also in-
cludes their ability to moderate some of the lead-
ing risk factors contributing to the GBD. Based on
the available evidence, forests and trees outside
forests as key components of urban and rural eco-
systems could contribute to the mitigation of most
of the 10 leading risk factors for global DALYs (Ta-
ble 3.5), including hypertension, high fasting plas-
ma glucose (i.e., hyperglycaemia), low birth weight,
high body-mass index (i.e., overweight and obesi-
ty), short gestation (i.e., pre-term birth), ambient
air pollution and high cholesterol level (GBD 2019
Risk Factors Collaborators, 2020). In addition to re-
ducing the risk of major disease and mitigating the
major risk factors contributing to the GBD, natural
Source: Adopted from (GBD 2019 Diseases and Injuries Collaborators, 2020)
Table 3.4
Top 25 causes of global burden of disease
in terms of disability-adjusted life years (DALYs) in 1990 and 2019
Leading causes of DALYs (1990) Leading causes of DALYs (2019)
1. Neonatal disorders 1. Neonatal disorders
2. Lower respiratory infections 2. Ischaemic heart disease
3. Diarrhoeal diseases 3. Stroke
4. Ischaemic heart disease 4. Lower respiratory infections
5. Stroke 5. Diarrhoeal diseases
6. Congenital birth defects 6. COPD
7. Tuberculosis 7. Road injuries
8. Road injuries 8. Diabetes
9. Measles 9. Lower back pain
10. Malaria 10. Congenital birth defects
11. COPD 11. HIV/AIDS
12. Protein-energy malnutrition 12. Tuberculosis
13. Lower back pain 13. Depressive disorders
14. Self-harm 14. Malaria
15. Cirrhosis 15. Headache disorders
16. Meningitis 16. Cirrhosis
17. Drowning 17. Lung cancer
18. Headache disorders 18. Chronic kidney disease
19. Depressive disorders 19. Other musculoskeletal disease
20. Diabetes 20. Age-related hearing loss
21. Lung cancer 21. Falls
22. Falls 22. Self-harm
23. Dietary iron deficiency 23. Gynaecological diseases
24. Interpersonal violence 24. Anxiety disorders
25. Whooping cough 25. Dietary iron deficiency

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
103
environments, including forests, could also reduce
the GBD through the co-benets that they provide
including enhancing the mitigation, adaptation
and resilience to ongoing climate change, which in
turn has direct and indirect health and wellbeing
effects.
Source: Adopted from GBD 2019 Risk Factors Collaborators (2020).
*LDL: low-density lipoproteins.
Table 3.5
Top 10 risk factors for the global burden of disease in terms of
disability-adjusted life years (DALYs) in 1990 and 2019
Leading causes of DALYs (1990) Leading causes of DALYs (2019)
1. Child wasting 1. High systolic blood pressure
2. Low birth weight 2. Smoking
3. Short gestation 3. High fasting plasma glucose
4. Household air pollution 4. Low birth weight
5. Smoking 5. High body-mass index
6. Unsafe water 6. Short gestation
7. High systolic blood pressure 7. Ambient particulate matter
8. Child underweight 8. High LDL* cholesterol
9. Unsafe sanitation 9. Alcohol use
10. Lack of handwashing 10. Household air pollution
3.7.2 Differences between high-, middle- and
low-income countries
Forests and other natural environments may
have varied effects on human health in diverse
regions across low-, middle- and high-income
countries due to (i) the different stages of the epi-
demiological transition of these countries, and
(ii) some differences in the nature of interactions
with, and reliance on, forests and forest products,
especially for spiritual and cultural services and
traditional medicines. While high-income coun-
tries mainly face the challenge of NCDs, mid-
dle-income countries exhibit a mix of commu-
nicable and non-communicable diseases burden
with a higher proportion of NCDs. Low-income
countries continue to have a disproportionately
higher burden of communicable diseases while
NCDs are also rising rapidly. Low- and middle-in-
come countries (LMICs) also face a higher burden
of nutritional deciencies, pollution and related
morbidities in general, which makes them poten-
tially more sensitive to forest loss or degradation
(FAO et al., 2021). Moreover, LMICs are in greater
danger of forest loss and degradation because of
local and foreign economic interests, corruption
and poor enforcement capacity (Robinson et al.,
2010). Nutritional deciency and vector-based
infectious diseases continue to be a challenge in
many LMICs. Consequently, many studies from
LMICs have focused on how forests can contrib-
ute to reducing malnutrition and related health
challenges such as vector-based infectious dis-
eases (Vira et al., 2015; Fungo et al., 2016; Rowland
et al., 2017; Rasolofoson et al., 2018; Vinceti et al.,
2018). Rasolofoson et al. (2018) indicate that for-
est exposure can improve dietary diversity by up
to 25% thus preventing micronutrient deciency
(vitamin A and iron) in LMICs. Similarly, there is a
stronger focus on non-wood forest products and
their direct and indirect health benets in LMICs,
including contributions to nutrition and dietary
diversity, (Ahenkan and Boon, 2011; Boulom et
al., 2020), direct treatment of communicable and
non-communicable ailments (Ahenkan and Boon
2011) and spiritual health based on biocultural
cosmologies, and associations with forests and
forest products (e.g., Caluwe et al., 2009; Cocks et
al., 2012).

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
104
Consequently, there appear to be differences
in the way research priorities on forests and hu-
man health are established in these contexts. A
major difference in terms of research evidence is
that much of the data on the direct impact of nat-
ural environments on health, is from high-income
countries and typically urban contexts. Available
evidence on the effects of natural environments
on health in LMICs is limited but growing (Labib
et al., 2020; Shuvo et al., 2020). Such evidence may
be constrained by other priorities related to devel-
opment planning, limitations of resources and re-
search capacities. In Dhaka, Bangladesh, Labib et
al. (2020) report that there is an inadequate sup-
ply of, poor access to, and low attractiveness of,
green spaces in the city. Likewise, Hong et al. (2021)
based on a study from Cali, Colombia, report that
a challenging health disparity within LMICs is bet-
ter access to green spaces for wealthier as com-
pared to lower income populations. Another sys-
tematic review of 46 studies by Rigolon et al. (2018)
found inequities in quantity and proximity to ur-
ban green spaces based on socio-economic status
and race-ethnicity across Asian, African and Latin
American cities. Globally, estimates indicate that
only 13% of urban residents live in neighbourhoods
with higher than 20% forest cover to experience
its mental health benets (McDonald et al., 2018)
with urban development generally reinforcing pri-
vatisation and exclusion (Byrne and Wolch, 2009).
A review of 22 studies from LMICs illustrates the
challenge of generalising ndings from 125 LMICs
due to methodological constraints of available evi-
dence (Shuvo et al., 2020). Most studies use sub-
jective and cross-sectional designs, lacking robust,
objective and longitudinal data.
In summary, the majority of available stud-
ies on the health effects of natural environments
have been conducted in high-income countries
while their ndings are not necessarily general-
isable to LMICs, given the differences in cultures,
climates and types of interactions with these envi-
ronments, in particular with forests.
3.8 Conclusions
This chapter provided an overview of the best
available evidence regarding the association be-
tween green spaces in general, and forests and
trees in particular, and human health and well-
Aesthetics, spirituality, sense of place and educational experiences enhance the recreational effects of green spaces
Photo © Alexander Buck

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
105
being across all life stages. For most health out-
comes, the observed associations were predom-
inantly benecial and in a smaller number of
cases were mixed. Evidence of benecial associ-
ations was stronger for some outcomes, such as
mental health and wellbeing or longevity, than
for others (e.g., cancers) due to fewer studies hav-
ing been conducted on the latter. For some health
outcomes, the evidence is more mixed, with both
positive and detrimental associations being ob-
served. This was especially the case for allergic
and respiratory conditions, such as asthma, and
for infectious diseases such as malaria. Relatively
little research has been done specically on for-
ests and trees versus green space more broadly.
Regarding the focus on adults, there is a case to
be made that for many health outcomes the un-
derlying processes and mechanisms are likely
to be the same for children and the elderly, with
similar outcomes. This is especially the case when
more basic physical and physiological processes
are involved (e.g., air pollution and heat stress
reduction). Thus, results for adults may to some
extent be generalisable to other life stages (and
vice versa). Regarding the focus on residential
surrounding green space, here we want to point
at the importance of the proximity, the exposure
and the amount of direct contact with the green
space. Results on nearby green space are unlikely
to be generalisable to green space that is located
further away, or that is only rarely approached.
In this chapter we focused on empirical re-
search often looking at spatial differences in the
local availability of and/or access to green spaces,
forests and trees or at changes herein over time,
and how these are associated with human health
and wellbeing. Effects of large-scale biodiversity
loss over decades, or large-scale changes in eco-
systems due to climate change, were not includ-
ed. Given a wider and longer time perspective, the
presence and state of nature elsewhere may have
local health consequences. Chapter 4 in this re-
port focuses more specically on forests and their
characteristics.
Besides fewer studies being conducted in LMICs
thus far, the focus of studies on forests and health
differs to some extent between LMICs and high-in-
come countries, largely due to differences in main
health problems (e.g., CDs versus NCDs and un-
dernutrition versus malnutrition or overnutrition)
and contextual differences in the use of green
space and forests. With regard to generalisability
of ndings from studies conducted in high-income
countries to a LMIC context, to some extent also
here underlying processes and mechanisms may
in principle also apply in LMICs, but may be less
prominent or relevant due to different starting sit-
uations and baseline values. Also, generalisability
is more likely for basic physical and physiological
processes than for ‘higher order’ culturally-de-
ned processes.
Most of the studies conducted thus far had a
cross-sectional design, which has limited the abil-
ity to draw rm conclusions regarding the causal-
ity of the observed associations. Besides longitu-
dinal studies, intervention studies, looking at the
impact of substantial changes in the local natural
environment could help, although their gener-
alisability is often also limited (Woolcock, 2022).
Furthermore, knowledge on underlying processes
and mechanisms may also help to determine the
causality of observed associations between na-
ture and human health and wellbeing. Although
several plausible mechanisms have been identi-
ed, research on which process contributes how
much to the association, thereby establishing its
causality, is still scarce. To some extent, the most
relevant processes are likely to differ by health
outcome. Knowledge on processes is also likely
to give indications of which type of green space,
with which characteristics is likely to facilitate the
process, and thereby yield the best positive health
outcome. The importance of the type of vegeta-
tion is still very much an open question, which
calls for future investigation. Moreover, research
is warranted into unintended side effects, such as
gentrication, that diminish the health returns of
green space interventions.
In summary, the body of evidence on the health
and wellbeing effects of green spaces in general,
and forests and trees in particular, is accumulating.
The available evidence already strongly supports
a wide range of benecial associations including
neurodevelopment in children, mental health and
wellbeing, spiritual wellbeing, and cardiometabolic
health in adults and mental health and wellbeing,
cognitive ageing, and longevity in the elderly. More-
over, the current evidence is suggestive for such a
benecial association for pregnancy outcomes and
complications, cardiometabolic health in children
and mental disorders in adults. These associations
could vary across the strata of gender, ethnicity,
culture, socio-economic status, urbanicity, and
types and quality of green spaces and forests. Giv-
en that many of the aforementioned outcomes are
among the major contributors of the global burden
of disease, forests, trees and green spaces have a
great potential for improving health and wellbeing
of humans across all life stages in our rapidly ur-
banising world. This potential adds to the co-bene-
ts that these spaces could exert through their
other ecosystem services.

3. THE HEALTH AND WELLBEING EFFECTS OF FORESTS, TREES AND GREEN SPACE
106
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4

125
Chapter 4
Forests for Human Health – Understanding the Contexts,
Characteristics, Links to Other Benefits and Drivers of Change
Coordinating Lead Authors: Liisa Tyrväinen and Cecil Konijnendijk
Lead Authors: Nicole Bauer, Djibril S. Dayamba, Serge Morand, Unnikrishnan Payyappallimana,
Roseline Remans, Charlie Shackleton and Patricia Shanley
Contributing Authors: Victoria Bugni and Sarah Laird
TABLE OF CONTENTS
4.1 Introduction ............................................................................................................................................... 126
4.2 Health Impacts of Forests in Different Contexts ................................................................................... 127
4.3 Valuation of Health Benets of Forests ................................................................................................... 135
4.4 Synergies and Trade-Offs Between Health and Other Forest Ecosystem Services ............................. 137
4.5 Threats and Drivers Causing Deforestation, Tree Cover Loss and
Forest Degradation, with Implications for Human Health .................................................................. 142
4.6 Conclusions ............................................................................................................................................... 148
4.7 References .................................................................................................................................................. 150

4. FORESTS FOR HUMAN HEALTH – UNDERSTANDING THE CONTEXTS,
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126
Abstract
This chapter presents the key relations between people and communities in different local and
global contexts and different types of forests, trees and green spaces. The focus is on the inter-
actions between forests and urban, rural and forest-dependent communities. Health outcomes
related to forests, both at the individual and community level, can considerably differ between
different types of forest contexts and communities, along a gradient of human landscape trans-
formation that includes urban, rural, and forest-dependent settings. The chapter also discusses
synergies and trade-offs between health outcomes of forests on the one hand, and other ecosys-
tem services on the other. Synergies exist, for example, between regulation or cultural services
(such as outdoor recreation or biodiversity targets, and health and wellbeing benets of forests).
However, there can also be important trade-offs leading to negative changes in health outcomes,
such as those related to closing off forests to local communities or visitors for specic purposes
or to changing forest type and structure for biomass production. Where synergies need to be en-
hanced and trade-offs limited, it is also important to understand direct and indirect threats, as
well as drivers causing forest loss and degradation, as these impact the availability and capacity
of forests to meet human health demands. Direct threats relate to, for example, economic threats
such as agriculture and energy production and biophysical threats such as climate change and
res. Indirect threats such as cultural ones related to technology and increased consumption,
need to be addressed as well, while governance and political drivers also have to be understood.
4.1 Introduction
The direct and indirect links between forest
5
eco-
systems and human health and wellbeing are in-
creasingly being understood. Health outcomes are
provided by urban, peri-urban, rural and periph-
eral forests that may be preserved or managed
in various ways to meet local and more distant
needs. Forests are exposed to increasingly unfa-
vourable environmental and climatic changes
worldwide, as well as to anthropogenic pressures
that affect both the capacity of forest ecosystems
to sustain their complexity and resilience, and
their capacity to provide for material and imma-
terial human needs. Although decision-makers at
different levels acknowledge the role that forests
play in contributing to the sustainable develop-
ment goals (SDGs), the importance of forests for
achieving health and wellbeing goals (SDG 3) are
not yet sufciently understood (Katila et al., 2019).
This chapter rst explores the key relations
that people and communities have with different
types of forests and specic forest characteristics,
as well as the human health impacts of forests in
different local and global contexts. We focus on the
interactions between forests and urban, rural and
forest-dependent communities (see also Beatty
et al., 2022). Whereas Chapter 3 focused on the
5 All terms that are dened in the glossary of this report (Appendix 1) appear in italics the rst time they are mentioned.
impacts of forests on human health, this chapter
explores the forest characteristics that contribute
to health outcomes.
Forests globally develop under a variety of envi-
ronmental and socio-economic conditions leading
to very diverse forest ecosystem characteristics.
This chapter includes a wider view of human-for-
est interactions in a global context, understanding
that mechanisms and channels to deliver and per-
ceive health and wellbeing benets may vary sig-
nicantly depending on where one is in the world.
The chapter also discusses synergies and trade-
offs between the health outcomes of forests and
a range of other benets and ecosystem services
that are not yet comprehensively understood. In
particular, the links between health benets and
various cultural, provisioning and regulating eco-
system services, as well as with biodiversity, are
explored.
The nal section of this chapter looks at key
drivers that affect the loss and degradation of for-
ests and forests’ abilities to deliver human health
outcomes. It discusses and describes the key land
and forest use threats impacting human health
including political, cultural and economic drivers
impacting on forest management and transfor-
mation.

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4.2 Health Impacts of Forests
in Different Contexts
4.2.1 Forest-health relations in urban, rural
and forest-dependent contexts
Whilst all forests deliver a common suite of es-
sential ecosystem services, they vary signifcantly
in the diversity of species that they host and the
relative magnitude of the different ecosystem ser-
vices provided. In this section, the forest-human
health relationships for three broad contexts will
be explored along a gradient of human landscape
transformation, namely from high transformation
typical of urban contexts, intermediate in rural
contexts and relatively low transformation for
many (albeit not all) forest-dependent or proxi-
mate contexts (Figure 4.1). For each of these three
contexts we broadly consider the forest and user
attributes relevant to the nature and strength of
the human health outcomes.
Urban Forests
Forest attributes
Urban forests may comprise only a few species
and strata or be extremely species- and struc-
turally-rich. Irrespective, the urban context often
means that most, albeit not all, forests are subject
to greater degrees of management and higher use
pressures than those in protected areas or remote
rural locations with limited human impact.
Increasingly, cities are seeking to secure or es-
tablish more urban forests as nature-based solu-
tions to mitigate climate change and to improve
microclimates, air quality and stormwater inl-
tration. Recent studies have shown that urban
forests managed for recreational purposes can be
structurally close to natural forests and may pro-
vide habitat features, such as dead wood, that are
scarce in intensively managed forest landscapes
(e.g., Korhonen et al., 2021). In addition to green
urbanisation, the conservation of forests and agro-
forestry systems in peri-urban landscapes is stra-
tegic to achieving more sustainable cities. Peri-ur-
ban green areas regulate temperature, improve
air quality, offer recreational space and, critically,
promote landscape connectivity (Von Thaden et
al., 2021).
In an urban context, management goals may
include recreational use or shade provision, and
are measured using different metrics such as can-
opy cover, species richness, area of green space, to
mention a few (Ordonez et al., 2019), although in
resource poor settings there is generally little or
no monitoring against goals (Chishalshale et al.,
2015). Urban forests may be managed to enhance
biodiversity, landscape values and forest vitality.
They may also be managed to create and maintain
attractive outdoor recreation environments and to
improve urban areas, for example inuencing mi-
croclimates and water inltration (Tyrväinen et al.,
2005). Other urban forests may receive relatively
little active management, either by design or due
to resource constraints. In contexts where use and
management of rural forests for wood production
is intensive, urban forests may act as biodiversi-
ty hotspots for some groups of species (Ives et al.,
2016; Korhonen et al., 2021). Management goals
and approaches also vary according to contextual
factors such as tenure, governance, stewardship
and available skills and resources.
In urban areas the growth conditions for for-
ests and trees are often challenging. Most urban
and peri-urban forests are subject to some degree
to negative inuences associated with the urban
context leading to a decrease in forest or single
tree vitality. These threats include heavy metal
pollution, reduced populations of pollinators or
dispersers, urban heat island effects as well as
opening of the subcanopy for human access. In
rapidly urbanising contexts, the danger of land
transformation leading to forest loss or forest frag-
mentation can be more pronounced both in high-
and low- income countries.
Studies have demonstrated that mental, social
and physical health, and economic and ecological
sustainability, correlate with the amount of green
space in an urban neighbourhood. The ow of
health benets from urban forests is likely to be
unevenly distributed within cities due to the un-
even distribution of forest area, tree cover, species
richness and even forest quality. The wealth sta-
tus of households also inuences the distribution
and quality of, and access to, green space and for-
est, and consequently the benets that they pro-
vide (Nero, 2017; Wüstemann et al., 2017; Riglon
et al., 2018; Nesbitt et al., 2019; Venter et al., 2022).
As green space benets are reected in property
prices, high-income households are more likely
to live in a green environment than low-income
families, unless city planning takes these inequal-
ities into account by providing adequate amounts
of good quality green areas for all income class-
es (Tyrväinen et al., 2005; Escobedo et al., 2015).
In wealthier countries efforts have been made to
expand green space, and make its access more
equitable (Loures et al., 2007; Marušáková and
Sallmannshofer, 2019). In low- and middle-income
countries, calls have been made for urban plan-
ners to better understand the diversity of ways

4. FORESTS FOR HUMAN HEALTH – UNDERSTANDING THE CONTEXTS,
CHARACTERISTICS, LINKS TO OTHER BENEFITS AND DRIVERS OF CHANGE
128
residents interact with natural areas, which in-
cludes recognising that people view themselves
as part of, not separate from, nature (Cocks et al.,
2016; Cocks et al., 2020).
Furthermore, with the increasing frequency of
severe heat, drought, ooding and storms, urban
areas designed with adequate green space play
critically important roles in mitigating negative
environmental impacts and supporting human
health (Russo and Cirella, 2018). Cities such as
Copenhagen, use ‘green fingers’, that reach out
from the city to the suburbs, allowing for broad
access to green spaces (Brüel, 2012). In Singapore,
urban planners are working to ensure that 80% of
Singapore’s residents live within 400 metres of a
green space (Tng and Tan, 2012) and in China, an
ambitious afforestation plan resulted in over 50
million trees being planted in Beijing and a 10%
increase in overall forest cover (Yao et al., 2019).
User attributes
Urban forests cater to the needs of a diverse group
of urban dwellers in terms of ages, genders, educa-
tion, local knowledge, cultures, length of residency
in urban settings and relationships with forests
(Janowsky and Bekker, 2003; Shackleton and Blair,
2013; Aasetre et al., 2016). Most groups use urban
forests for cultural ecosystem services, mainly
for diverse recreation activities (such as exercise,
relaxation, picnicking, family occasions, nature
watching, etc.), although in some contexts there
may be a high dependence on provisioning bene-
ts (such as wild foods, traditional medicines, fuel-
wood) (McLain et al., 2013; Shackleton et al., 2017).
Extent or frequency of use of public urban forests
is mediated by relative ease of access, either phys-
ically or nancially, as well as the quality of the
green areas. Within private spaces, urban citizens
may themselves maintain a diversity of elements
associated with green spaces, ranging from a few
plants in containers to structurally- and spe-
cies-rich gardens (Loram et al., 2008; Bigirimana et
al., 2012; Heezik et al., 2013).
Previous studies suggest that lower socio-eco-
nomic status groups are more dependent on pub-
lic green areas and therefore, may benet more
Figure 4.1
Interdependencies of forest-human health relationships
in three human-forest contexts
Forest attributes
• Access
• Governance
• Management
• Quality
• Diversity
• Maturity
• Size/extent
• Rural/urban
• Etc.
User attributes
• Location
• Childhood
• Age
• Gender
• Income
• Livelihood
• Vulnerability
• Local knowledge
• Etc.
• Climate change
• Deforestation
• Etc.
Drivers/pressures of change through time
FOREST PROXIMATE
RURAL
URBAN
Forest functions, services &
disservices
• Cultural change
• Urbanisation
• Etc.
(a) Individual/personal scale
• Consumptive
• Recreation
• Spiritual
• Psychological
• Regulating • Air quality
• Water quality
• Climate regulation
• Soil fertility
• Storm protection
• Biodiversity habitat
• Gene pools
• Etc.
Health use
Trade/income
Socialisation/bonding
Exercise
Culture
Sense of being
Mental health
Sense of place
(b) Community/societal
HUMAN FOREST
CONTEXTS
(EXAMPLES)
MEDIATING CONDITIONS
& PROCESSES HEALTH OUTCOMES

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from them than high income class residents (Ward
Thompson et al., 2016; Triguero-Mas et al., 2017;
Rigolon et al., 2021). In spite of efforts to offer eq-
uitable access to urban forests for different user
groups, access is lower among minorities and
poorer communities leading to lower exposure to
these health-promoting environments (Rigolon et
al., 2021). Women and men experience urban na-
ture spaces differently as women often appreciate
green areas more but also express greater safety
concerns than men (e.g., Sreetheran and van den
Bosch, 2014) that call for specic management ac-
tions such as maintaining good visibility and good
lighting conditions in forests. There is also some
evidence that women use nature more frequently
than men, and seem to better appreciate the avail-
ability of, and possibility to connect with, nature
(e.g. van den Berg, 2012; Neuvonen et al., 2022).
Urban forest attributes that contribute
to health outcomes
There is a growing focus on understanding the
ways in which specic elements of biodiversity
itself matters for human health (Marselle et al.,
2021b). The benets of nature views, immersion
and experiences, including of urban forests and
trees on a range of mental health and wellbeing
conditions and indicators – such as reduced anxi-
ety, depression, fatigue, stress and tension result-
ing in improved mood and sense of restoration,
wellbeing and happiness – may relate to specic
forest attributes (Shanahan et al., 2015; Honold
et al., 2016; Pataki et al., 2021). For example,
there is some evidence of positive relationships
between health outcomes and tree number (e.g.,
Townsend et al., 2016), tree cover (e.g., Egorov et
al., 2017), and evergreen, as opposed to broadleaf,
species (Gonçalves et al., 2021). A study in an ur-
ban setting in Italy found that self-rated wellbe-
ing was greater in more biodiverse sites than less
biodiverse ones (Carrus et al., 2015). Research in
a low-income country context (in South Africa)
found a positive relationship between tree spe-
cies richness in school grounds and the pupils’
rating of their ability to concentrate whilst at
school (Shackleton et al., 2018).
Other important features of urban forests that
impacts on health include their size (Lin et al.,
2015) and connectivity, orientation and nature
of the surrounding urban matrix (Lindén et al.,
2016). All of these have an impact on the cooling
effect of urban forests. Allied to this is the reduc-
tion in ill-effects from ultraviolet (UV) light radia-
tion, with denser canopies having a greater effect
in reducing UV radiation (Heisler et al., 2003).
Rural Forests
Forest attributes
Forests that rural communities benet from, can
be of different types, including savannah, dry for-
est, humid forest, mangrove, etc., depending on
their geographical location and nature of trans-
formation (e.g., agroforests). Different ownership
and governance types will determine manage-
ment objectives and practices, and access by ru-
ral communities. Management will also impact
the structural and species diversity of the stand.
Communities may enjoy the benets from a single
tree (e.g., when plant parts are used for medicinal
purposes) or from many hectares of forests, when
the health benets are derived from the whole
forest ecosystem as is the case for example, with
recreational or spiritual uses of forests.
An important consideration inuencing the
health (and other) benets from forests in rural
landscapes is the extent of transformation and
intensity of landscape management. In general,
whilst there are many reasonably intact forests
in rural locations, there are also many manifes-
tations of managed trees in elds, agroforests and
as boundary or perimeter markers between elds
or parcels of land. Frequently, trees in such con-
texts have been planted or retained because of
particular services that they provide to landown-
ers and users. Some agroforests host numerous
species and are structurally rich, although rare-
ly as rich as intact forests (Scales and Marsden,
2008), providing multiple nutritional, medicinal,
cultural and regulating services. Many agrofor-
estry designs and practices are deeply embedded
in local cultures and ecological knowledge and
have ancient roots, such as the Satoyama forests
in Japan (Katoh et al., 2009; Nishi et al., 2022), the
home-gardens in Kerala, India (Mohan et al., 2007;
George and Christopher, 2020), or the cultural
parklands of West Africa (Assogbadjo et al., 2012).
User attributes
Rural forests cater mostly to the needs of rural
households that extract a wide variety of pro-
ducts (wood and non-wood forest products) from
nearby forests for their health, food, energy and
other aspects of rural welfare (Mahapatra et al.,
2005), as well as maintaining trees in elds and
homesteads. In many rural settings, especial-
ly in low- and middle-income countries, use of
wild and cultivated plant species underpins the
health of all family members irrespective of gen-
der and life cycle stage, including babies, chil-
dren, mothers and adults (de Souza Silva et al.,
2014; Torres-Avilez et al., 2016; Randrianarivony
et al., 2017; Shaheen et al., 2017; Ahmed et al.,

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2018). Use of edible insects and their by-products
for nutritional, health and livelihood benets has
been reported across different regions (Gahukar,
2020).
Rural households’ reliance on forests and for-
est products is substantial because of their less di-
versied income (Wei et al., 2016; Sheppard et al.,
2020) which makes them more vulnerable than
urban households. Forest use is also inuenced by
remoteness from markets, government services,
and other urban amenities, with correspondingly
lower income and employment opportunities and
with higher levels of poverty, and social and politi-
cal marginalisation (Sunderlin et al., 2005; Belcher
et al., 2015). Research also shows that, even with-
in a group of rural households, local wealth con-
ditions determine the demand for, and perceived
importance of, forest ecosystem services (Aham-
mad et al., 2019). The role of rural women in the
forests and health nexus as primary collectors and
users of forest produce, and the need for integrat-
ing conservation and human health objectives
have also been highlighted (Wan et al., 2011). The
use of forests and forest products is positively
linked to the traditional knowledge and cultural tra-
ditions that communities possess and this has a
signicant impact on forest conservation and sus-
tainability. Indeed, the loss of local and indigenous
knowledge (notably on the benets and uses of
forest products) is likely to reduce the motivation
to manage these resources sustainably, thereby
leading on the one hand, to a reduction in effec-
tive conservation of biodiversity, particularly in
community-based conservation efforts, (Aswani et
al., 2018; Fernández-Llamazares et al., 2021), and
on the other hand, to negative impacts on health
outcomes.
Rural forests may also be visited and used by
urban people for recreation and tourism, provid-
ing income to rural enterprises both in low- and
high-income countries while bringing direct well-
being outcomes to urban visitors. In northern Eu-
rope, outdoor recreation surveys show that 76%
to 91% of the adult population visit forests (both
urban and rural) each year (Edwards et al., 2013).
Regular visits to forests are shown to maintain and
support human wellbeing (Tyrväinen et al., 2019).
Furthermore, nature-based tourism is an impor-
tant business sector, for example, in central and
northern Europe and in the Americas. It has high
potential globally in forest-rich countries where
natural features of forests and forested land-
scapes have been well maintained (e.g., Tyrväinen
et al., 2017a). Nature-based tourism rms are typ-
ically located in rural regions and provide a com-
plement to more traditional resource uses such as
farming and forestry, contributing to diversifying
rural livelihoods and maintaining rural popula-
tions (Fredman et al., 2021). In addition to rural
and urban forests, peri-urban forests, an ‘interme-
diate’ category, have also been shown to provide
key ecosystem services (Livesley et al., 2016).
Rural forest attributes that contribute
to health outcomes
Forests and trees that provide a source of food
and medicine are both highly important in rural
contexts. For instance, Tata et al. (2019) reported
that plant foods from the forest may make im-
portant contributions to iron intake and reduce
the risk of anaemia in women. A study under-
taken in 35 countries found that forest cover is
associated with reduced anaemia, stunting and
diarrhoeal diseases in children, particularly for
the poorest (Fisher et al., 2019; Beatty et al., 2022).
Dependence on medicinal plants may be very
high in rural contexts. In India, for the years 2014-
2015 for instance, of the total national demand for
medicinal plants of 512,000 metric tonnes (MT),
an estimated 167,500 MT was consumed by rural
households, 90% of which was sourced from the
wild (Goraya and Ved, 2017).
In rural settings, the location of forest cover
may also determine the regulating services it can
provide to rural households. For instance, forests
in upper watersheds regulate water quality down-
stream with direct effects on health. Indeed, high-
er upstream tree cover was found to be associated
with lower probability of diarrhoeal disease down-
stream (Herrera et al., 2017). Rural communities
are more likely to be dependent on such regulat-
ing services for improved health outcomes than
are urban populations, as healthcare facilities are
often more readily available for the latter. Certain
types of trees also regulate to a greater extent
soil fertility (Hong et al., 2018; Bayala et al., 2019;
Dierks et al., 2021) which is relevant to popula-
tions in rural contexts for agro-pastoral produc-
tion which can represent a substantial part of ru-
ral livelihoods.
Forest-Dependent Communities
In this report we address forest-dependent com-
munities separately from rural communities. Ac-
cording to Newton et al. (2016), the term ‘forest-de-
pendent people’ is widely used to describe human
populations that gain some form of benets from
forests. These authors call for users of the term
‘forest-dependent people’ to dene their popula-
tion of interest with reference to the context and
purpose of their forest- and people-related objec-
tives. In this section, we refer to forest-dependent

4. FORESTS FOR HUMAN HEALTH – UNDERSTANDING THE CONTEXTS,
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131
communities or people as communities who ‘rely
more’ (pronounced dependence) on forests than
rural communities. This includes people living
within or very close to the forest (‘forest peoples’)
and, who are heavily dependent on forests, pri-
marily for subsistence, for their livelihoods.
Forest attributes
The forest-dependent context is typically characte-
rised by human interactions with forests and trees
in a variety of settings, ranging from large expan-
ses of forests, through to trees in elds and home-
steads. In some cases, forests might be in their
natural state. However, many expansive patches
of forest are increasingly experiencing various
local and external pressures that affect their ex-
tent, quality and the services they provide. Be-
cause forests in these contexts are larger and of-
ten less transformed than most urban or rural fo-
rests, they can be structurally and compositionally
more diverse for the climatic region in which they
are located, but this is locally variable. While in
many cases forests for both forest-dependent and
rural communities might be similar, their cultural
uses differentiate them.
User attributes
Forest-dependent communities derive a substan-
tial proportion of their livelihood needs from the
forests in which they live or reside. This ‘depen-
dence’ means reliance on forests in a manner
that is either difcult or impossible to replace, for
a portion of environmental services, subsistence
needs, safety net and gap ller functions, and op-
portunities for poverty elimination (Sunderlin et
al., 2005). It also fulls the literal sense of ‘depen-
dence’, that their condition would worsen if they
no longer had access to the forest outputs that
form an integral part of their livelihood systems
(Somorin, 2010). They exist around the world but
are mostly found in low-income countries. Their
needs may be directly consumptive or for income,
as well as for culture and identity (Scherr et al.,
2003; Newton et al., 2016). For instance, approxi-
mately 1.6 billion people globally are estimated
to be dependent on forests or non-timber forest pro-
ducts (NTFPs) for their livelihoods (FAO, 2001).
Numerous factors inuence the extent of re-
liance on forests and consequently associated
health impacts, including biocultural diversi-
ty, tradition, gender, socio-economic status, age,
family size, indigeneity, longevity in a region and
proximity to forest (Laird et al., 2011; Aung et al.,
2014; Shanley et al., 2015; Nguyen et al., 2019). For
example, in Viet Nam, Nguyen et al. (2019) found
that NTFP use increased with household size and
age of household heads, and decreased with ed-
ucation level and land area, and that Indigenous
people in the area consumed a larger number and
diversity of NTFPs than immigrants to the region.
A study in the mountainous areas of Cameroon
also found that, while both migrant and Indige-
nous households rely on forest as a complement
to farm income, Indigenous forest-dependent
households do this to a far greater extent and de-
rive roughly four times the income from wild and
native species compared to migrants (Laird et al.,
2007; Laird et al., 2011).
Attributes of forests that contribute to health
outcomes among forest-dependent communities
Forests are a source of many important medici-
nal plants, which are the foundation of primary
healthcare for the majority of people in many
low- and middle-income countries (WHO, 2002),
especially in forest-dependent communities due
to their lifestyles (Rahman et al., 2022).
Forest-dependent communities recognise
many individual species as well as sites within the
forest as having cultural or spiritual signicance.
Specic species are required for particular tradi-
tions or rituals and non-adherence or observance
of taboos and rituals typically results in ‘misfor-
tune’ and hence negative mental wellbeing (Posey,
1999; Cocks et al., 2012). The same negative effects
may result from degradation of the forest or loss
of certain species.
4.2.2 Forest attributes and characteristics in
delivering health benets
A vast diversity of factors affect the health and
wellbeing outcomes of forests, including accessi-
bility, size and density, diversity, forest type, age,
species composition and biodiversity (Tyrväinen et
al., 2007). The wide range of forest ecosystem ser-
vices that support human health directly and indi-
rectly, their relative importance for human health
and the key pathways for delivery can vary sub-
stantially in different global (and local) contexts.
Accessibility
In high income and urbanised areas, access to
forests is often linked to proximity and usabili-
ty of forests for recreational purposes. Access in
different countries and regions is regulated by
different policies and practices varying from free
access to all undeveloped land such as in Nordic
and Baltic countries, to restricted access to for-
ests, as is the case in the United States (Pröbstl
et al., 2008). In rural and peripheral areas, forest
access may be largely linked to ownership that

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132
also regulates use of various forest products (e.g.,
timber, NWFPs, forest foods etc.).
Urban users often appreciate recreational in-
frastructure such as trails and signposts or other
on-site facilities, as well as maps and other infor-
mation about the forest. Planned forest access and
use also help to prevent negative ecological effects
from use or conicts between user groups (Bell et
al., 2008).
Although in theory people may have access to
many forests, often a range of barriers may pre-
vent them from visiting or using these spaces
(Weldon et al., 2007). These include, for example,
lack of suitable public transport, poorly main-
tained and signposted footpaths making it dif-
cult for people to nd their way, and the percep-
tion of risks or safety.
Size and density
The larger the size of the forested area the more
benecial it is on wellbeing and cognitive perfor-
mance. Research demonstrates that generally
larger green spaces, either parks or urban wood-
lands, have stronger positive impacts on these
measures than small parks (e.g., Tyrväinen et al.,
2014b; Akpinar, 2016). In Philadelphia, an increase
in urban tree canopy to 30% was found to prevent
403 premature deaths annually while the imple-
mentation of Barcelona’s Superblock programme –
which converts streets to green walking areas –
could prevent 667 premature deaths annually
(Kondo et al., 2020; Mueller et al., 2020). Schäffer
et al. (2020) conclude in their study in Switzer-
land that more vegetation is associated with low-
er sensitivity to noise from road and rail trafc.
The size of the urban park/forest has a con-
siderable impact on cooling and buffering of the
urban heat island effect. Whilst the general ef-
fects might be an average of only 1–3oC difference,
the benets are starkly evident during heatwaves
when the risks of heat stress and stroke are severe-
ly heightened. The distance to which any cooling
effect is felt is proportional to the size of the urban
forest patch (Lin et al., 2015) and several other fac-
tors such as connectivity, orientation and nature of
the surrounding urban matrix (Lindén et al., 2016).
Allied to this is the reduction in ill-effects in
UV radiation, probably most marked in the trop-
ics, but there is little research from those regions.
Denser canopies have a greater effect in reducing
UV radiation (Heisler et al., 2003).
Diversity
A number of recent studies have stressed the im-
portance of a highly ecologically diverse environ-
ment for the optimal functioning of the human
immune system. One of the most prominent theo-
ries related to this is the biodiversity hypothesis
stating that “contact with natural environments
enriches the human microbiome, promotes im-
mune balance and protects from allergy and in-
ammatory disorders” (Haahtela, 2019). Previous
studies report that a more diverse environment is
correlated with a rich human microbiome (Hanski
et al., 2012), and lower risk of allergies (Haahtela
et al., 2013).
Perceived environmental qualities, such as the
attractiveness of the landscape, natural sound-
scapes, species richness and cultural features
have been positively associated with increased
use of forests for physical activity (Björk et al.,
2008). Moreover, soundscapes and auditive char-
acteristics of forests, together with visual aspects,
inuence the health promoting ability of forests.
Natural sounds have limited potential to mask
disturbing sounds, however, birdsong, for exam-
ple, is perceived as relaxing in itself and acts as an
indicator of intact, nearby nature (Ratcliffe et al.,
2013; Renterghem, 2019).
Types of forests
There is limited evidence based on eld experi-
ments or other studies examining how different
types of forests or green spaces support mental
health, although some studies are available (see
Tyrväinen et al., 2014b; Ojala et al., 2019) and even
less eld studies have compared the wellbeing ef-
fects of different forests (see Martens et al., 2011;
Sonntag-Öström et al., 2014; Takayama et al., 2017).
Nevertheless, the variation in the effects on psy-
chological wellbeing and restorativeness between
different forest types (e.g., pine forest versus mixed
forest, large urban parks versus extensively man-
aged urban woodland) has been supported by some
studies (Sonntag-Öström et al., 2014; Tyrväinen
et al., 2014a). Care must be taken when comparing
the study results, as the understanding of the level
of naturalness may vary signicantly in different
contexts.
Age
Age of forests is also a factor affecting the perceived
or real health benets of forests. A recent study in
Finland showed that older forests have stronger
restorative effects compared with younger forests
(Simkin et al., 2020). In the above-mentioned study,
the three older forests were natural spruce stands
managed for recreation, wood production or bio-
diversity conservation. Edwards et al. (2010) found
that mature forests contribute to the wellbeing
of visitors as long as they show a certain degree
of openness. This is consistent with the recently

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planned network of old growth forests for human
health in Spain, the recreational effects occurring
in nature reserves and the idea of wilderness ther-
apy (Menton-Enderlin and Schraml, 2017). The de-
mand for a wide view and large crowns is usually
satised in older forest stands without dense un-
dergrowth.
Species
Tree species vary in their absorptive capacity for
air pollutants (e.g., Nowak et al., 2014), with conif-
erous species rating higher than broad-leafed
species (Zhang et al., 2017). A more specic feature
of forests with effect on the immune function is
the role of phytoncides. These are volatile organic
compounds that have been studied most exten-
sively in Asian and Mediterranean forests and,
that have been found to positively inuence the
activity and percentage of natural killer cells (Li
et al., 2009; Albert Bach et al., 2021). The concen-
tration of phytoncides in the forest air depends on
tree species and differs largely between countries
and regions of the world. The false cypress, for ex-
ample is found to emit a comparably high concen-
tration of phytoncides.
Biodiversity
Biodiversity includes a myriad of pollinators that
are vital to global agriculture, fruit trees, forests
and all food systems (CBD and WHO, 2015). It is the
basis of adaptation and resilience in all species,
which is critical in light of climate change. Bio-
diversity is also the source of a wide diversity of
medicinal plants and fungi, hundreds of nutri-
ent-dense forest and traditional smallholder foods
and, linked with cultural diversity, is the founda-
tion of our unique relationships with place, and
spiritual and mental health (Posey, 1999; Cocks et
al., 2016). For example, forest-derived medicines
are prominent in Indigenous health care systems.
Many of the drugs upon which Western medicine
depends are derived from forest plants and were
discovered as part of the traditional health sys-
tems of forest peoples (Fabricant and Farnsworth,
2001).
Research has demonstrated some positive rela-
tions between biodiversity and human health, but
the research evidence is still somewhat limited. An
inuential report by the Harvard Medical School
highlighted the overall importance of biodiversity
to human health (Chivian, 2002), mentioning for
example, the importance of medicinal plant pro-
Timber from the surrounding forests ready to be transported away in Para, Brazil
Photo © Nelson Grima

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vision, ecosystem disturbance and the potential
spread of human infectious diseases and food
production. In a joint report, the Convention on
Biological Diversity (CBD) and the World Health
Organization (WHO) also stressed the important
inter-linkages between biodiversity, ecosystem
stability and epidemic infectious diseases such as
the Ebola virus; and the connection between bio-
diversity, nutritional diversity and health (CBD and
WHO, 2015).
At a forest site level, there can also be impor-
tant synergies between biodiversity and human
health. The presence of a diverse vegetation and of
wildlife can enhance the recreational experience
and serve as an attraction. In their review, Aerts et
al. (2018) found evidence for positive associations
between species diversity and wellbeing (psycho-
logical and physical) and between ecosystem di-
versity and immune system regulation. Marselle
et al. (2021a) also mentions these positive associ-
ations, outlining different pathways that link bio-
diversity to health. As an example of individual
studies that looked into this, Hedblom et al. (2014)
concluded that the presence of (diverse) birdsong
inuences young people’s appreciation of urban
landscapes. Curtin’s (2009) ethnographic study of
wildlife tourism shows the health benets of wild-
life encounters, inspiring positive feelings of con-
nection with other beings, awe and contemplation.
Furthermore, several studies demonstrate that
forest attributes and characteristics, for example,
habitat diversity and the biodiversity, multi-struc-
ture and multi-functionality of forests inuence
the abundance and value creation of NTFPs. A
study in the Brazilian Amazon showed that recre-
ational ecosystem services are helping to comple-
ment the benets from NTFP extraction, and thus
maintain biodiverse forests (Ribeiro et al., 2018). A
study in the northern periphery of the Boumba-
Bek National Park in Southeast Cameroon, demon-
strated that habitat fragmentation driven by hu-
man activities such as industrial logging and shift-
ing cultivation, destroys the forest ecosystem and
has a strong inuence on the sustainability of the
major NTFPs in the locality (Ngansop et al., 2019).
On the other hand, a study in Burkina Faso found
that the local oil tree occurrence showed signi-
cant differences between land cover types and
sites, but the oil tree seemed fairly resilient to hu-
man pressure and tended to recolonise disturbed
lands (Lankoandé et al., 2017).
In spite of substantial knowledge gaps, it is
clear that forest loss and degradation, and associ-
ated biodiversity loss, can be a major threat to hu-
man health, for example because of proliferation
of zoonotic diseases (with COVID-19 as a recent
example), loss of food sources and reduced eco-
system stability. Smith (2022) calls for close inte-
gration of biosecurity concerns into conservation
policies, which requires greater acknowledgment
of the unique challenges for human communities.
4.2.3 Forest management and health outcomes
Forest management targets are often dominated
by timber production and intensive management
may decrease forests’ qualities for health and
wellbeing. Poor management and logging practic-
es can undermine biodiversity and environmen-
tal services upon which human health depends.
The health impacts of different forest manage-
ment activities such as thinning may vary, al-
though there are few studies in different settings
and cultural contexts. Chiang et al. (2017) found
that a dense forest is better suited for attention
restoration effects while Martens et al. (2011) re-
ported on more positive impacts of tended forest
compared to a wild forest with denser vegetation.
Similarly, increased stand density and shrubs in-
uenced negatively the perception of the psycho-
logical benets from forest visits (Tomao et al.,
2018; Kim et al., 2021).
As studies on health effects related to the dif-
ferent management regimes are limited, useful in-
formation can be obtained from forest landscape
preference studies that have explored which types
of forest environment people appreciate and pre-
fer to visit. These studies conclude that people ap-
preciate mature forests with good visibility, some
undergrowth and a green eld layer with no signs
of soil preparation (Stoltz et al., 2016; Tyrväinen
et al., 2017b). A forest after clear-felling is the
least preferred environment (e.g., Gundersen and
Frivold, 2008; Kearney and Bradley, 2011). The rel-
atively low tolerance by recreational forest users
of unmanaged understories, or dead or decaying
wood, can also be the result of decreased feel-
ings of safety, visibility and walkability of forests
(Tyrväinen et al., 2003; Gundersen et al., 2017). For-
ests that are thought to be in their natural state, or
that look natural and bear no visible trace of hu-
man activity, are usually preferred as long as there
is little dead wood.
Some forest management activities are often
needed to improve visibility, walkability and bring
light to forest scenery as well as to reduce the
amount of dead wood. Once visitors understand
the value of dead wood for nature conservation,
they are better able to appreciate it and it can even
improve their nature experience (Bröderbauer,
2015).

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It is challenging to manage highly-used forests
to ensure safety, at least along paths, whilst mak-
ing them look well-tended but still close-to-nature
(Bell et al., 2008). Preference studies suggest that
often light silvicultural management of forests
increases their recreational value and also their
health benets. Amenity values may, however, of-
ten be understated in forest management, even in
urban and peri-urban forests where use intensi-
ties are the highest. Moreover, rural forests deliver
signicant wellbeing effects through nature-based
tourism or provision of NTFPs.
In rural areas logging can provide many ben-
ets to people, including construction materials,
shelter, fuelwood, and household items of critical
importance around the world. In Europe, for ex-
ample, the goals and motivations of forest own-
ers to manage their forests vary substantially, de-
pending on forest size, their connection to their
property, preferences regarding economic, envi-
ronmental and social values, and their exibility
to respond to market trends (Weiss et al., 2019). In
some countries, such as those of central Europe,
forests are often managed for multiple purposes,
including the provision of environmental services,
including erosion control and water management,
together with landscape and recreational values,
while in southern Europe an important manage-
ment goal is forest re prevention (Weiss et al.,
2021). Natural, or well-managed, forests mitigate
risks from ooding, storms, drought, extreme
temperatures, landslides and wildres (Beatty et
al., 2022).
4.2.4 Disservices of Forests for Human Health
The ecosystem disservice concept has been in-
troduced recently reecting negative effects
of ecosystems on human wellbeing or health
(Shackleton et al., 2016). Although criticised
(Schaubroeck, 2017), the concept of ecosystem
disservices is useful to highlight the trade-off be-
tween an ecosystem service and one component of
human health (Dunn, 2010), for example the pol-
lination service and the allergic reaction to pollen.
An ecosystem disservice for health can be the cli-
mate regulation service of afforested and reforest-
ed areas that may also enhance disease outbreaks.
A global study has found an association between
conversion mostly to monoculture plantations of
commodities such as oil palm, and the increase of
both zoonotic and vector-borne diseases (Morand
and Lajaunie, 2021).
Biodiversity can also conict with the health
benets of forests. Some studies have indicated
that high diversity (understood as dense forests)
can negatively impact wellbeing (e.g., Kim et al.,
2021). For example, pests and pathogens that in-
habit forests represent the ecosystem health dis-
services related to biodiversity. Aerts et al. (2018)
found high species diversity to be associated with
both reduced and increased vector-borne disease
risk. Tick-borne diseases such as Lyme’s disease
and tick-borne encephalitis (Tomalak et al., 2010),
but also mosquito-borne diseases such as dengue
fever, are increasingly seen as a barrier to forest
recreation across the world (e.g., van Gestel et
al., 2021). The rise in numbers of these diseases
is partly linked to climate change and partly to
disturbance of forest ecosystems that boost the
multiplication of some species. Other forest-as-
sociated diseases include malaria, Chagas dis-
ease, African trypanosomiasis (sleeping sickness),
leishmaniasis and lymphatic lariasis (FAO, 2020).
Some outbreaks of infectious diseases are as-
sumed to be linked to biodiversity loss (Smith et
al., 2014) which is related to forest loss and deg-
radation. Moro et al. (2009) discuss the potential
risks of nature recreation pertaining to especial-
ly snake bites. Limited understanding of citizens
regarding the importance of biodiversity may de-
crease acceptability of management actions that
enhance biodiversity.
4.3 Valuation of Health Benets of Forests
The previous sections have linked forests in dif-
ferent contexts, as well as a range of forest at-
tributes and characteristics, to health outcomes.
Valuation is another important aspect of under-
standing and promoting the health benets of
forests. While market values exist in certain areas
for some NTFPs that contribute to health, such
as wild meat, plants or medicines, many other
health-specic ecosystem services of forests have
no tradeable market, such as water purication,
disease regulation and various cultural benets.
Cultural services such as traditional importance
to native groups, cognitive development, and
spiritual enrichment are less common in the lit-
erature than, for example, provisioning or regu-
lating services (Mandle et al., 2020). Due to this,
these ecosystem services have often been exclud-
ed from cost-benet calculations, for example,
around conservation, which can lead to underes-
timation of forests’ values.
In recent years, more studies have attempted to
estimate these values through stated and revealed
preference methods which can be costly and time
consuming. Some valuation methods have been
found to be better suited to certain ecosystem ser-
vices than others (Ferraro et al., 2012; Taye et al.,

4. FORESTS FOR HUMAN HEALTH – UNDERSTANDING THE CONTEXTS,
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2021). Water regulation and provisioning are often
considered outside of the NTFP category and rela-
tively few valuation studies have focused solely on
these services (Lele, 2009; Ojea et al., 2012). Air im-
provement and carbon sequestration have seen an
increase in the valuation literature in recent years
due to public discussions of carbon emissions’ im-
plications for climate change and human health.
In one study on the contiguous USA, health ben-
ets from removed air pollution by trees and for-
ests were valued at around USD 6.8 billion in 2010,
while another study on Canadian national parks
found that they sequester 4.43 gigatonnes of car-
bon with an annual value of approximately USD
107-116 billion (Kulshreshtha et al., 2000; Nowak
et al., 2014).
Disease regulation, another less frequently
mentioned ecosystem service, is typically dis-
cussed within the context of land use change and
water purication for forests (Pattanayak and
Wendland, 2007; Pattanayak and Yasuoka, 2008).
One study in Indonesia estimated that there would
be approximately 2,600 less cases of diarrhoea a
year due to ecosystem services from Ruteng Park
in Indonesia, for a total cost decrease of USD 5,900
(in 1985 terms) (Lerman et al., 1985; Pattanayak
and Wendland, 2007).
Several studies examine the value of trail use
and recognise the physical health benets of green
spaces, yet signicantly less studies have explic-
itly examined the valuation of health and well-
being benets (Wolf et al., 2015; Wolf and Robbins,
2015; Moseley et al., 2018). Two recent studies that
controlled for socio-economic factors found that
health care spending is lower for people living in
greener spaces. A study in northern California
found health spending to be USD 374 lower in the
greenest versus least green areas, while another
study in the USA found spending was USD 632 less
in areas for each 0.1 Normalised Difference Vege-
tation Index (NDVI) increase (Becker and Browning,
2021; Eeden et al., 2022).
Forest recreation values have been studied
both in Europe and the USA. Studies valuing the
recreational use of forests, for example, in Fin-
land, include both revealed preference (travel cost
The recreational values and physcial health benets of forests are increasingly recognised, particularly in high income countries
Photo © Sital Uprety

4. FORESTS FOR HUMAN HEALTH – UNDERSTANDING THE CONTEXTS,
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137
and property value methods) and stated prefer-
ence (contingent valuation and choice experi-
ment methods). Studies have focused on the val-
uation of urban recreational areas (Ovaskainen et
al., 2012), national parks or national hiking areas
(Huhtala and Pouta, 2009), and recreational ben-
ets at a national level (Lankia et al., 2015). Re-
search has also been carried out on valuing forest
attributes such as scenery and species richness
in municipal recreation sites (Horne et al., 2005)
and measuring tourists’ willingness to pay for im-
proved landscape and biodiversity characteristics
in nature-based tourism areas through payments
for ecosystem services (PES) (Tyrväinen et al., 2014a).
In general, economic valuations of public
health interventions can aid decision-making on
the efcient allocation of resources aimed at im-
proving public health in the face of xed budgets.
4.4 Synergies and Trade-Offs Between
Health and Other Forest Ecosystem
Services
4.4.1 Synergies and trade-offs between forest
health benets and cultural ecosystem services
Many health benets of forests relate to forest
recreation and tourism. Urban forests provide op-
portunities for everyday recreation, physical ac-
tivity, mental restoration and social meeting pla-
ces. Rural forests can be important destinations
for both day recreation and for tourism. Forests
also provide other cultural ecosystem services
including spirituality, aesthetic and educational
services (MEA, 2005; Figure 4.2.).
In many cases, health and cultural services
go together. Aesthetics, spirituality, sense of place
and educational experiences can all be related to,
and promote, forest recreation and tourism, and
enhance the recreational experience of forests. Al-
though synergies between health outcomes and
cultural ecosystem services provided by forests
and trees are common, there can also be trade-
offs that need to be understood and managed (e.g.,
Dobbs et al., 2014). It may also be that the demand
for the range of cultural services is not adequately
known and therefore, not included as a key for-
est management target (Tyrväinen et al., 2017a;
Cheng et al., 2021). As these services are often
regional- and individual-specic as well as inu-
enced by local human – ecosystem relationships,
demand surveys and other social science tools are
needed to ensure that these services are incorpo-
rated into planning and management objectives
(Riechers et al., 2016; Hegetschweiler et al., 2017).
In some European countries, NTFPs such as herbs
and medicinal plants have important cultural and
socio-economic meanings (e.g., Guarrera and Savo,
2016; Sisak et al., 2016). Forests and other wooded
lands are of outstanding importance for a range
of non-wood and cultural ecosystem services, but
use regulations are common features in many
countries thereby limiting access (Tyrväinen et
al., 2017a). The prevalence of self-treatment with
medicinal plants in rural populations can also be
inuenced by other attributes, including tradition-
al knowledge, cultural traditions and education
(Thorsen and Pouliot, 2016; Aswani et al., 2018).
A rst area of (potential) trade-offs is within
the recreational use of forests, as different types
of forest recreation conict with and even exclude
one another. This can result in some people ob-
taining health benets through recreational ac-
tivities associated with forests, trees and green
spaces, at the expense of other users. Confer et al.
(2005) offer an overview and typology of outdoor
recreation conicts. They mention that conicts
often arise between local populations (with their
own recreational or other landscape uses) and vis-
itors. Often conicts emerge between more active
forms of recreation that have a high ‘footprint’
(e.g., mountain biking, or motorised activities that
create noise and nuisances) with recreation that is
more centred on for example, nature experience
(e.g., hiking, wildlife viewing). In their European re-
port, Bell et al. (2007) found that conicts between
different types of forest recreation are most like-
ly to occur in more densely populated areas with
limited forest areas (e.g., in urban areas, but also in
densely populated countries).
Problems within forest recreation and tourism
also relate to groups being (or feeling) excluded
from forests. This can relate to lack of availabil-
ity or proximity of forests, lack of access, exclu-
sion and fear for example in relation to other user
groups, but also lack of knowledge, adequate skills
and awareness (e.g., Sreetheran and Konijnendijk
van den Bosch, 2014). Byrne (2012) studied the case
of an urban national park in the Los Angeles, USA,
area. Many urban dwellers of Latin American her-
itage refrained from recreation in the park because
of the “predominantly White clientele of parks; (..)
a lack of Spanish-language signs, fears of perse-
cution; and direct experiences of discrimination”.
White et al. (2013) highlight that relations between
Indigenous communities and ecotourism are very
complex. Although these communities can benet
from ecotourism, there are also risks of exclusion.
Some forms of health benets (e.g., related to
mental health) will benet more from silent and
serene environments, as well as opportunities for
solitude or activities performed in small groups.

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These include, for example, hiking, bird watching
and other activities in which nding peace and
nature experiences are valued (Haukeland et al.,
2021). The experience of the serene can be closely
linked to spirituality, as for example reected in
the Japanese ‘Shinrin-yoku’ (forest bathing) con-
cept (Hansen and Jones, 2020). More active and
noisy forms of recreation (e.g., motorised sports
or activities in larger groups) can negatively affect
spiritual experiences, which results in trade-offs
between users seeking recreational and health
benets, and those seeking more spiritual and
health benets.
Spiritual values, sense of place and religious
values of forests can also be connected to forest
groves. These can have high cultural values for
local communities, including rural and forest-de-
pendent ones. In some cases, these groves are
closed off for other people, implying that their
recreational and health benets are not fully re-
alised. On the other hand, opening up these groves
for wider use can threaten the benets to the local
community. Sacred natural sites are primarily pro-
tected by communities for their spiritual or cultur-
al value, but may be additionally valued and used
for other social, economic and ecological reasons,
resulting in different forms and intensities of so-
cial conict and unfavourable human impact on
sacred sites (Rutte, 2011; Cogging and Chen, 2022).
The recreational and touristic use of forests,
which can be pathways towards better health, can
have a negative impact on biodiversity, for exam-
ple through disturbance of wildlife, trampling of
vegetation and the like (e.g., Marzano and Dandy,
2012). Although urban and peri-urban forests
served as a critical infrastructure for adaptation
and stress relief during the COVID-19 pandemic,
in many instances the overcrowding of most popu-
lar sites surpassed in their social carrying capacity
and may have had negative impacts on ecological
values (Geng et al., 2021; Neuvonen et al., 2022).
The lessons learnt from the COVID-19 pandemic
suggest that areas that provide multiple ecosys-
tem services for people are at the same time of
ecological importance. These multifunctional sites
enable simultaneous biodiversity conservation
and wellbeing outcomes (Andersson et al., 2014;
Fagerholm et al., 2021).
Where biodiversity conservation is prioritised,
for example by means of establishing protected
areas such as nature reserves, this can lead to the
(partial) closing off of forest areas to recreation
and tourism, but also to other health-promoting
forest uses (e.g., gathering of food and medicinal
plants, spiritual use; Thomas and Reed, 2019).
Where the demand for recreational opportunities
is the highest, for example in urban areas, this can
lead to a major loss in terms of health benets, es-
pecially as available forests and green spaces are
often more limited.
4.4.2 Synergies and trade-offs between health
benets and provisioning services
Provisioning services are the tangible resources or
goods that people obtain from ecosystems. These
services can be grouped into ve types: food;
fodder; timber and bre (for construction and
energy); chemical and medicinal products; and
fresh water (MEA, 2005). Biodiverse forests pro-
vide a vast range of plants and animals with nu-
tritional and medicinal values. They are of local
importance and also commercialised on nation-
al and international markets. In Europe, NTFPs
such as game, mushrooms or berries provide val-
ues – beyond supplying food – that are related to
recreation benets, sense of place, culture, edu-
cation and traditional knowledge. A large varie-
ty of game (38 species), mushrooms (27 species)
and vascular plants (81 species) is collected and
consumed in member states of the European
Union (EU). Overall, more than 100 million EU citi-
zens consume wild food (Schulp et al., 2014). Wild
foods, particularly wild game and other forest
products, are also commonly consumed in North
America (Chamberlain et al., 2018). Use regula-
tions and limited access are, however, common
features in many countries (Schulp et al., 2014).
The provisioning services of biomass and tim-
ber production can have positive health impacts
(e.g., contributing to livelihoods) but also negative
impacts when forests become less attractive for
recreation or are closed off to local communities.
In particular, intensive wood (biomass) production
and forest management (e.g., clear cuts, shortened
rotation cycles and large management units) neg-
atively inuence the recreational quality of forests
(and the associated health-related impacts of na-
ture visitation) and the business opportunities of
nature-based tourism companies.
Peri-urban areas can also be a source of nutri-
tious wild and semi-domesticated forest products
including fruits, fungi, nuts and game (Russo and
Escobedo, 2022). Due to their proximity to urban
markets, peri-urban areas offer market opportuni-
ties and can catalyse smallholders to experiment
with innovative management strategies, increas-
ing the density of nutritious fruits and valuable
forest goods, offering critical sources of income to
smallholders, while facilitating the transmission
of traditional knowledge linked with culturally
valued forest goods (Brondízio et al., 2021).

4. FORESTS FOR HUMAN HEALTH – UNDERSTANDING THE CONTEXTS,
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139
4.4.3 Synergies and trade-offs between health
benets and regulating ecosystem services
Disease regulation appears in the classication of
ecosystem services as a regulating ecosystem ser-
vice (MEA, 2005). Conicting results emerge from
studies on disease regulation (Cardinale et al.,
2012), which can be explained by the few studies
focusing on human diseases compared to studies
on other regulating services such as climate. The
protective role of biodiversity against infectious
diseases has been put into question (Lafferty and
Wood, 2013) by the fact that the diversity of hu-
man pathogens is linked to the species diversity
of birds and mammals, and that species-rich and
forested countries host high diversities of human
pathogens (Dunn et al., 2010). On the other hand,
the role of biodiversity in protecting from dis-
eases via the ‘dilution effect’ has been acknowl-
edged. The dilution effect, or the ‘negative diver-
sity-disease’, postulates that biodiversity losses
may promote disease transmission (Keesing et
al., 2006). A recent meta-analysis (Magnusson et
al., 2020) gives support to the dilution effect by
showing a signicant negative diversity–disease
relationship across spatial scales from global to
small sites.
Figure 4.2
Ecosystem services and links to human wellbeing
Security
• Personal safety
• Secure resource access
• Security from disasters
Freedom of choice
and action
Opportunity to be able to
achieve what an individual
values doing and being
ARROW´S COLOR
Potential for mediation by
socioeconomic factors
Low
Medium
High
Weak
Medium
Strong
ARROW´S WIDTH
Intensity of linkages between ecosystem
services and human wellbeing
Basic material
for good life
• Adequate livelihoods
• Sufficient nutritious food
• Shelter
• Access to goods
Health
• Strength
• Feeling well
• Access to clean air
and water
Good social relations
• Social cohesion
• Mutual respect
• Ability to help others
CONSTITUENTS OF WELLBEING
Supporting
• Nutrient cycling
• Soil formation
• Primary production
• ...
Provisioning
• Food
• Fresh water
• Wood and fiber
• Fuel
• ...
Regulating
• Climate regulation
• Flood regulation
• Disease regulation
• Water purification
• ...
Cultural
• Aesthetic
• Spiritual
• Educational
• Recreational
• ...
ECOSYSTEM SERVICES
LIFE ON EARTH – BIODIVERSITY
Source: MEA, 2005

4. FORESTS FOR HUMAN HEALTH – UNDERSTANDING THE CONTEXTS,
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140
Analyses done at country level show that the
number of outbreaks of infectious diseases, tak-
ing into account the diversity of known diseases,
appears to be linked with biodiversity loss (Smith
et al., 2014; Morand, 2020). For example, defor-
estation in Cambodia was found to be associat-
ed with an increased incidence of diarrhoea, fever
and acute respiratory infection in children, while
protected area coverage was associated with de-
creased incidences of these diseases (Pienkowski
et al., 2017). Suggested mechanisms underlying
the association between forest destruction and
childhood diseases include reduced ability of
degraded forests to regulate microbial contami-
nation of surface and ground waters, leading to
increases in diarrhoeal diseases, and smoke from
biomass burning (which accompanies deforesta-
tion) exacerbating respiratory illnesses.
Figure 4.3
Examples of potential links between protected areas, forest cover,
deforestation and health
PROTECTED AREA
DEFORESTATION
INTACT FOREST
PROTECTED AREA
+) Safeguarding hydrological
services that regulate microbial
load, reduce flooding, and
increase groundwater recharge,
suppressing diarrhoea risk
+) Restriction of human-wildlife
contact, reducing risk of zoonotic
disease transmission
+) Amelioration of air pollution,
restriction of access to domestic
biomass fuel, and management
of fire occurrence, reducing risk of
acute respiratory infection
+) Formalisation of sustainable
access to natural resources within
multiuse protected areas, which
could stabilize access to forest
products important for health
INTACT FOREST
+) Diverse host communities
mitigate disease risk in individual
species (the dilution effect)
+) Provision of products, such as
food and medicine, important for
health
+) Provision of social and cultural
functions, such as recreation,
that support mental, social, and
physiological health
+) Predator populations might
suppress vector abundance,
regulating disease risk
DEFORESTATION
+) Income from extractive activities,
new employment opportunities,
and agriculture, which can
improve diets, and access to
health care, and buffer against
environmental risks
+) Increase in dietary quality from
agriculture in some cases
+) Can be associated with the
expansion of other industrial
activities, which might reduce
some disease risks

4. FORESTS FOR HUMAN HEALTH – UNDERSTANDING THE CONTEXTS,
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141
Defaunation is the global or local extinction of
animal populations from ecological communities
that can negatively affect ecosystem services (e.g.,
soil functioning, pollination, pest control, water
quality) (Dirzo et al., 2014). The resulting ‘empty
forest’ (Redford, 1992; Benitez-Lopez et al., 2019)
may enhance the loss of disease-regulating ser-
vices. Defaunation contributes to the loss of eco-
logical regulation of small mammals, which are
the main reservoirs of several zoonotic diseases
(Johnson et al., 2020). Gibb et al. (2020) demon-
strate how global land use changes, including for-
est conversion, may favour zoonotic reservoirs and
the risks of zoonotic diseases.
Forests full other regulatory ecosystem ser-
vices that are strongly related to health, such as
providing or protecting sources of clean drinking
water (e.g., Dudley and Stolton, 2003). Many of the
world’s cities derive their drinking water from for-
ests and other protected areas, and in some cases,
cities have even owned and managed more remote
forests to ensure a safe supply of drinking water,
as in the case of the Vienna water source protec-
tion forests (Dudley and Stolton, 2003; Richards
et al., 2012). Drinking water protection and provi-
sion thus should be an important consideration in
land use planning, and it can perhaps inspire the
wider consideration of health benets of forests.
Although clean water is essential to health, the
closing off of reservoir and watershed forests can
limit other health benets obtained through for
example, forest recreation or the livelihood uses
by forest-dependent populations.
Carbon sequestration and air ltration repre-
sent important ecosystem services that may lead
to synergies and trade-offs with health outcomes.
Increasing forest and forest canopy cover can
be benecial for carbon storage, air pollution re-
duction and human health (e.g., Lave and Seskin
(2011) and Nowak et al. (2014) specically for ur-
ban (forest) contexts). However, focusing on for
example, specic tree species that optimise car-
bon storage and/or air pollution reduction could
potentially result in negative impacts on other
aspects of human health (e.g., monocultures with
lower recreational values (Filyushkina et al., 2017)
or selection of trees that produce more pollen
(Sousa-Silva et al., 2021).
Source: Pienkowski et al., 2017
-) Restriction of access to forest
products from strict protected
areas, such as food and
medicine, important for health
-) Crop raiding by wild animals
could potentially reduce
agricultural yields, exacerbating
malnutrition, and increasing
disease risk
-) Zoonosis from high populations
of wild animals transgressing park
boundaries
-) Increased exposure to zoonotic
diseases among protected area
staff and
visitors+)
-) Supporting forest-dependent
hosts and vectors, harbouring
emerging infectious diseases, or
maintaining disease reservoirs
-) Zoonoses from human wildlife
contact during forest product
harvesting and processing
-) Forests can be associated with
socioeconomic contexts, such as
restricted access to health care
and economic opportunities that
perpetuate poverty – a strong
predictor of health outcomes
-) Smoke from fires containing fire
particulate matter increases the
risk of acute respiratory infection
-) Loss of dietary diversity and
quality of forest foods, impairing
the immune system and
increasing disease vulnerability
-) Increased run-off, increasing
microbial load and diarrhoea risk
from surface water
-) New biophysical conditions
suitable for some vector and
disease species
-) Changing human behaviour,
such as guarding crops at night,
increasing disease exposure
-) Might be associated with the
expansion of other industrial
activities posing novel health risks
-) Habitat encroachment and
stressed host populations might
increase emerging infectious
diseases risk

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4.5 Threats and Drivers Causing
Deforestation, Tree Cover Loss and
Forest Degradation, with Implications
For Human Health
4.5.1 Rate and extent of deforestation,
tree cover loss and forest degradation
More than 40% of the earth’s forest has been
lost, with 10 million hectares of forest lost each
year between 2015 and 2020, and much of what
remains being signicantly degraded (Lovejoy
and Nobre, 2019; FAO, 2020). Loss of forests can
be temporary or permanent and, in this context
two main terms are used: tree cover loss and de-
forestation (see Box 4.1.). Permanent forest cover
loss can be caused by commodity agriculture and
urbanisation, while temporary loss can be caused
by intensive logging, shifting cultivation and re.
Deforestation refers to human-caused perma-
nent land use change from natural forest to an-
other land use (Curtis et al., 2018; WRI, 2022a).
It is estimated that one-third (1/3) of forest loss
since 2000 is permanent deforestation, and two-
thirds (2/3) is temporary tree cover loss (WRI,
2022a). Section 1.3 in this report summarises re-
cent information on permanent deforestation.
Temperate and boreal forests have lost 158
Mha of gross tree cover since 2000, with 95%
mainly due to potentially temporary drivers like
forestry and wildre, primarily in Canada, Russia
and the USA (WRI, 2022a) (Figure 4.4.). In this case,
forests will often recover naturally or the sites are
reforested by planting which is required by forest
legislation, for example, in Finland, Sweden and in
most EU countries. Tropical forests, led by Brazil
and Indonesia, account for 204Mha – half of global
tree cover loss - since 2000, but 96% of deforesta-
tion, with the rate almost doubling in the last 20
years (WRI, 2022a) (Figure 4.4.).
Biodiversity loss, which accompanies forest
loss, is often paired with climate change as a glob-
al tragedy impacting our planet. Despite the CBD
entering into force in 1993, subsequent decades
have seen little increase in awareness of the im-
portance of biodiversity for human health, forests
and our environment. Like climate, however, in re-
cent years the pace and extent of change has made
it difcult to ignore the environmental, economic
and health implications of biodiversity loss. The
report by the Intergovernmental Science-Policy
Platform on Biodiversity and Ecosystem Services
(IPBES) published in 2019 highlighted some stark
trends: around 1 million animal and plant species
are now threatened with extinction, many within
decades; average abundance of native terrestrial
species dropped by at least 20% since 1900; and
more than 40% of amphibian, 33% of reef form-
ing corals, and a third of all marine mammals are
threatened (IPBES, 2019).
Figure 4.4
Annual rates of global tree cover loss have risen since 2000
2001
Tree cover loss (millions hectares)
Boreal
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
20022003 20042005 20062007 2008 2009 2010 2011 2012 2013 2 014 2015 2016 2017 2018 2019 2020
Gross tree cover loss by ecozone
Temperate Tropical Subtropical
Source: WRI, 2022

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The loss and degradation of forest are due to
a range of direct and indirect threats, which are
reviewed in this section along with the human
health impacts and trade-offs. Economic drivers
include massive expansion of commodity and
shifting agriculture; illegal and unsustainable
logging; energy expansion in oil and gas, biofuels
and biomass; destructive and poorly planned in-
frastructure; and urban sprawl (Figure 4.5.). Bio-
physical drivers include climate change, re and
invasive species. Indirect threats to forests in-
clude cultural and political drivers like urbanisa-
tion, technology, consumption, loss of biocultural
diversity and governance. Figure 4.5. highlights
the signicant regional variation in the drivers of
deforestation and tree loss.
4.5.2 Direct threats to forests and
human health
Economic drivers
The most signicant economic drivers of forest
loss and degradation include large-scale com-
modity and shifting agriculture, illegal and unsus-
tainable logging, energy expansion, infrastructure
development and urban sprawl (Figure 4.5). Curtis
et al. (2018) identied the primary drivers of tree
cover loss from 2001-2015 as 26% from forestry;
27% from permanent land use change for com-
modity production; 24% from shifting agriculture;
and 23% from wildre.
Agriculture
Large-scale commodity agriculture, including
cattle ranching, is the most signicant contribu-
tor to deforestation and to greenhouse gas emis-
sions. Food crop production has increased 300%
since 1970 (IPBES, 2019) and around 47% since
2001, with 63% of this rise taking place in tropical
regions, which now represent around half of all
global output (WEF, 2021). Since 2002, more than
60 million hectares of primary forest have been
lost in the tropics, with more than 80% of this in
areas in which agriculture is the dominant driver,
and the cause of half to three- quarters of total
deforestation (WRI, 2022b). Cattle pastures oc-
cupy 36% of all areas deforested for agriculture
from 2001-2015, followed by oil palm, soy, cocoa,
plantation rubber, coffee and plantation wood -
bre – which together account for 57% of all tree
cover loss associated with agriculture between
2001 and 2015 (WRI, 2022b). Commodity-driven
permanent conversion of forests from 2001-2020
Box 4.1
Defining and measuring deforestation and forest loss
According to the denition used by FAO’s
Global Forest Resources Assessment (FRA),
deforestation is “the conversion of forest
to other land use independently of wheth-
er human-induced or not” (FAO, 2020). That
is, deforestation is essentially referring to a
change in land use, not in tree cover. Den-
ing deforestation thus implies a denition of
forest, which, in the FRA, combines physical
criteria (minimum thresholds of 10% canopy
cover, 0.5 ha in area and 5 m in height) and
a notion of the predominant land use, ex-
cluding tree-covered areas where the pre-
dominant use is agriculture or urban; hence,
the denition excludes plantations of agri-
cultural tree crops (such as oil-palm planta-
tions and orchards) as well as urban parks
but includes various types of planted forests
(including rubber plantations) (FAO, 2022).
Furthermore, the data used in the FRA are
provided by countries and there may be sig-
nicant divergences in interpretations and
methodologies applied.
Many technical and scientic studies do
not use FAO’s denition but rather equate
forest loss with tree-cover loss without tak-
ing land-use criteria into account. These
datasets use remote-sensing-based method-
ologies. They consider both all tree cover (in-
cluding tree-covered areas not meeting FAO’s
forest denition) and instances of non-per-
manent tree-cover loss (e.g., the clear-felling
of a natural or planted forest that will later
regrow, and the temporary consequences of
a forest re) as loss of forest. When interpret-
ing gures on forest loss in different studies,
therefore, users should be aware of the im-
pacts of the denitions and tools used.

4. FORESTS FOR HUMAN HEALTH – UNDERSTANDING THE CONTEXTS,
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144
is associated with 103 Mha of tree cover loss.
Shifting agriculture, which includes many differ-
ent smallholder agriculture systems around the
world in which forests are cleared for agriculture,
but then temporarily abandoned to allow trees to
regrow and soil fertility to return, is associated
with 87Mha of tree cover loss during the same
period (WRI, 2022a).
The global food system was found to be respon-
sible for at least 16 billion tonnes of greenhouse gas
emissions in 2018, a third of total global anthro-
pogenic emissions, with net forest conversion be-
ing the single largest emission source estimated on
agricultural land in the period 1990-2018 (Crippa et
al., 2021; Tubiello et al., 2021). As a result, at the Con-
ference of the Parties to the United Nations Frame-
work Convention on Climate Change (UNFCCC)
in Glasgow in 2021, world leaders issued a declara-
tion on forests and land use that called for halting
and reversing forest loss and degradation by 2030,
including “implement and, if necessary, redesign
agricultural policies and programmes to incentiv-
ise sustainable agriculture, promote food security
and benet the environment” (UNFCCC, 2021).
Intensive agriculture degrades wildlife habi-
tat, soils and biodiversity, including pollinators
upon which 75% of global food crop types depend
(IPBES, 2019), and impacts on surface tempera-
tures, rainfall patterns and energy uxes to a far
greater extent than rural smallholder agriculture,
which retains greater vegetation cover (Maeda et
al., 2021). Large-scale commodity agriculture also
wastefully uses scarce water resources, pollutes
and mines for nutrients, while undermining the
biodiversity and pollinators upon which natural
systems and proximate smallholder agriculture
Figure 4.5
Drivers of forest and tree cover loss by region (2001-20)
Source: WRI, 2022a

4. FORESTS FOR HUMAN HEALTH – UNDERSTANDING THE CONTEXTS,
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145
depend. Intensive agriculture can lead to reduced
crop yields and food insecurity, loss of agrobio-
diversity, and can lock small farmers into hunger,
malnutrition and poverty (Leakey et al., 2021). It
can undermine nutrition by producing cheap, pro-
cessed low quality foods that lead to poor health
outcomes and obesity (CBD and WHO, 2015),
eroding local cuisines, nutrition, and leading to
economic dependence (Ladio and Lozada, 2004;
Dounias and Aumeeruddy-Thomas, 2018). These
systems also present socio-economic challenges,
including underpaid workers, sometimes exposed
to chemical inputs which cause signicant health
impacts (CBD and WHO, 2015).
Forestry
Logging can coexist with healthy forests if done sus-
tainably and at long enough rotations, but 10-15%
of global timber supplies are provided illegal-
ly, and in some regions, this is as high as 50%
(Kleinschmit et al., 2016; IPBES, 2019). Since 1970,
raw timber production has increased 45%, and
from 2000-2013 intact forests were reduced 7%
(IPBES, 2019). Forestry accounted for 119 Mha of
tree cover loss between 2001 and 2020. However,
most of this loss can be considered temporary, as
long as natural forests are allowed to regenerate
or trees are planted, although this depends upon
the nature of logging, length of rotations and con-
dition of the forest (WRI, 2022a).
Forests are among the most signicant climate
change mitigation strategies proposed in global
policy today (Lewis et al., 2019; Moomaw et al.,
2019; UNFCCC, 2021). Research in the last decade
has identied natural, old-growth forests as sig-
nicant carbon sinks (Anderson, 2019), and found
that the rate of carbon capture and storage in-
creases with the age and size of trees (Luyssaert et
al., 2008; Stephenson et al., 2014). Accumulation of
carbon in forest soils also increases with time, and
levels can be very high (Morriën et al., 2017). Plan-
tations established on logged land cannot fully
replace the loss of biodiversity, environmental ser-
vices and carbon sink values of forests, and those
in biodiverse tropical regions are disproportionate-
ly planted with non-native species (Axelsson and
Grady, 2022), including 98% of South American
plantations (Jong et al., 2021).
In addition, in many tropical and subtropical
countries, large-scale logging, particularly where
it is carried out illegally, can threaten sources of
important NTFPs for subsistence; local and glob-
al trade; and local sources of fuelwood and tim-
ber (Laird, 1999; Angelsen et al., 2014; Aung et al.,
2014). Important NTFPs include a wide range of
nutritious foods, as well as medicinal plants which
make up the primary health care of the majority
of the world’s population (WHO, 2002; Shanley
and Luz, 2003; Cunningham et al., 2008; Laird et
al., 2011; Shanley et al., 2015). An estimated 2.77
billion rural people use NTFPs in the low- and
middle-income countries and 0.79 billion users
in the high income countries, with a global total
in rural and urban areas of 5.8 billion NTFP users
(Shackleton and Vos, 2021). Forest plants, micro-
organisms, insects and genetic resources also pro-
vide important starting points or foundations for
natural product pharmaceuticals, with almost a
quarter of all new drugs from 1981-2019 derived
from nature, and another 20% mimicking nature
(Chivian, 2002; CBD and WHO, 2015; Newman and
Cragg, 2020). Logging and forest degradation and
Figure 4.6
Forestry, commodity-driven deforestation, wildfire, and shifting agriculture are
the leading causes of tree cover loss
Tree cover loss (million hectares)
Wildfire
Urbanization
Shifting agriculture
Forestry
Commodity-driven deforestation
010 20 30 40 50 60 70 80 90 100
Commodity-driven deforestation Forestry Shifting agriculture Urbanization Wildfire
Global tree cover loss by dominant driver (2001–20)
Source: WRI, 2022a

4. FORESTS FOR HUMAN HEALTH – UNDERSTANDING THE CONTEXTS,
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fragmentation associated with agriculture, also
create a launch pad for novel human viruses, im-
proving and altering the biology of disease vector’s
habitats (Dobson et al., 2021; Beatty et al., 2022).
Energy
Energy expansion impacts forests and human
health on several fronts. Global subsidies for fos-
sil fuels of USD 345 billion result in USD 5 trillion
in overall costs, including nature deterioration ex-
ternalities, with coal accounting for 52% of post-
tax subsidies, petroleum for 33% and natural gas
for around 10% (IPBES, 2019). Pollution and the
by-products from fossil fuel combustion cause a
wide range of health problems, including respira-
tory disorders, asthma and heart attacks, and are
considered the world’s most signicant threats to
children’s health, and major contributors to en-
vironmental injustice (Perera, 2017). Biofuels and
biomass, once viewed as alternatives to fossil fu-
els, are now understood to create signicant en-
vironmental, social and health challenges of their
own, and contribute less than anticipated to com-
batting climate change (Stephenson et al., 2014).
Both rely on raw material and biomass which can
be agricultural feedstocks produced on land that
was previously forest (WRI, 2022b), or wood from
natural or planted forests, and ‘woody debris’ that
removes important nutrients from forests. Addi-
tionally, arable land is often planted with crops
and plantations for biofuel and biomass energy
and can result in land conicts with Indigenous
peoples and local communities (IPLCs) and other
local groups. At the same time, forests – left intact
– contain more carbon than exploitable fossil fu-
els, and absorb a quarter of the carbon generated
by humans (Dunne, 2018).
Urbanisation
Urbanisation, and associated infrastructure, can
result in encroachment and fragmentation of for-
ests; loss of green corridors and relatively small
reservoirs of biodiversity and wildlife in peri-ur-
ban areas; loss of genetic pools for restoration
of forests; reduction in carbon sink capacity and
pollution control; depletion of groundwater and
water management capacity; and loss of biodi-
versity, wildlife, and other environmental servic-
es provided by forests (Beatty et al., 2022). Urban
areas have grown more than 100% since 1992
(IPBES, 2019) and account for 3 Mha of forest loss
between 2001 and 2020, with the majority in tem-
perate forest (WRI, 2022a). Uncontrolled urban
sprawl can remove scarce forest areas which pro-
vide recreation, forest bathing and tourism bene-
ts for physical and mental health (Marušáková
and Sallmannshofer, 2019), and may reduce the
private amenity benets of owning forests and
living in the countryside. Redevelopment of ur-
ban areas can involve removal of trees, particu-
larly when tree protection ordinances do not exist
or are weak. Planting of monocultures of street
trees throughout cities can also expose the entire
city’s canopy to pests and diseases.
Uncontrolled urbanisation coupled with forest
fragmentation is leading to degradation of ecosys-
tem and human health, with infectious disease on
the rise. Recent estimates reveal that globally, only
13% of urbanites live close enough to nature to ex-
perience its mental health benets (McDonald et
al., 2018).
In response to forest fragmentation, urban
sprawl, and the numerous environmental hazards
impacting the wellbeing and livelihoods of city
dwellers worldwide, there is a growing trend to de-
sign compact cities, with high density, mixed-use
patterns, leaving green space, planting trees and
improving resilience (Pataki et al., 2021).
Biophysical drivers
The following sub-sections review some of the in-
terlinked biophysical drivers with direct impacts
on forests, and their impact on human health, in-
cluding climate change, re and invasive species.
Climate change
Climate change is referred to as the “existential
crisis of our time” and is interwoven with all oth-
er drivers of deforestation. It negatively impacts
forests in a myriad of ways, with impacts on hu-
man health, such as: reducing species diversity
(including species with medicinal, food and oth-
er qualities for local and global communities;
Applequist et al., 2020); facilitating the spread of
tree pests and diseases (Linnakoski et al., 2019);
increasing drought and ooding (Beatty et al.,
2022); and creating conditions for wildres and
the spread of diseases (Dobson et al., 2021). The
World Economic Forum (WEF) found that climate
change has already adversely impacted food se-
curity, and that tropical and subtropical regions
are likely to be the most vulnerable to crop yield
declines (WEF, 2021).
The socio-economic impacts of these changes
disproportionately affect the poor and marginal-
ised around the world. For example, ooding im-
pacts poorer countries more than wealthy ones,
and within wealthy countries the poorest commu-
nities bear the brunt of climate induced ooding
or other extreme climate events (Gourevitch et al.,
2022). Climate change multiplies existing risks to
human health and generates conict, water scar-

4. FORESTS FOR HUMAN HEALTH – UNDERSTANDING THE CONTEXTS,
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Forested landscape and green spaces are essential elements of residential areas in Thimphu, Bhutan
Photo © Dikshya Devkota

4. FORESTS FOR HUMAN HEALTH – UNDERSTANDING THE CONTEXTS,
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city, land degradation and res. From 1996 to 2015,
an estimated 1.3 million people died as a direct
result of so-called natural hazards like ooding,
hurricanes, drought, wildres, landslides and ex-
treme temperatures, and these are increasing due
to climate change. Forest cover can help provide
protection from these hazards, including buffering
and absorbing oodwater, stabilising soils and re-
ducing ambient temperatures (CRED and UNISDR,
2016).
Medicinal plants, which provide primary
healthcare to 70% of the world’s population (WHO,
2002) and are threatened by overharvesting and
habitat destruction, are also negatively impacted
by climate change, including changes in temper-
ature and precipitation, disruptions in commen-
sal relationships, increased pests and pathogens,
and impacts on species’ productivity and quality
(potency and chemical composition). In addition,
concerns have also been raised about climate
change-induced alterations in the nutritional
quality of food crops (Applequist et al., 2020).
Fire
Fire as a by-product of climate change, as well as
a tool for forest clearance, has signicant impacts
on human health. Wildres accounted for 89Mha
of tree cover loss between 2001 and 2020 (WRI,
2022a). Climate change, which produces drier and
warmer conditions, and forest degradation and
fragmentation, has led to more res globally, over
larger areas and burning at higher temperatures
as a result of the hotter and drier conditions pro-
duced by climate change (WRI, 2022b). Fires lead to
loss of human life, and the associated smoke cre-
ates signicant and prolonged illness. For exam-
ple, in the Brazilian Amazon, re was the primary
method used to clear 15% of the forest between
1976 and 2010, and researchers have estimated
an average of 2,906 premature deaths annually
due to deforestation res (Reddington et al., 2015;
Beatty et al., 2022). Fires also affect human health
by leading to the loss of important environmental
services including clean air and water, and carbon
sequestration.
Invasive species
Invasive species are a by-product of the massive
increase in global trade, as well as climate change
which allows species to spread to areas previously
deemed inhospitable. They can elbow out impor-
tant food, medicinal and other forest species, and
profoundly change forest composition and suc-
cession, which in turn undermines the provision
of important environmental services critical for
human health (Trumbore et al., 2015). For exam-
ple, invasive plants degrade and undermine for-
est health and natural regeneration processes by
overwhelming native species, aggressively absorb-
ing water and nutrients, light and space (Trumbore
et al., 2015). Invasive insect vectors of disease can
also directly impact human health (Juliano and
Lounibos, 2005).
4.5.3 Governance and political drivers
Approximately 75% of global forests are con-
trolled by governments, with higher percentages
in many countries (Barr et al., 2014; Sunderlin
et al., 2021). Governance and political power sig-
nicantly impact forests and associated human
health benets. Ineffective, poorly designed laws
and policies contribute to forest loss and degra-
dation, and in many countries corruption, weak
law enforcement and patronage politics under-
mine forest governance (Laird et al., 2010; Barr et
al., 2014; Sunderlin, 2021).
Land rights represent some of the greatest
challenges to forests around the world, with prop-
erty rights historically contested by the state, pri-
vate-sector and IPLCs (Barr et al., 2014). The land
rights of many IPLCs in highly forested countries
remain unrecognised under statutory law, in-
cluding around 8.8% in Asia, 7.4% Latin America,
and 49.9% in Africa (Rights and Resources Initia-
tive, 2020). When land tenure and resource rights
are secure, forests and the food and medicinal
species within them are more likely to be sus-
tainably managed, communities can access wild
nutritious plants from a range of habitats, includ-
ing forests and fallow, and food security, nutri-
tion, wellbeing and human health are enhanced
(Cunningham et al., 2008; Laird et al., 2010).
In some countries, governments might subsi-
dise or create perverse incentives in related sec-
tors that lead to forest loss, while in other sectors
they might work to conserve forests. Governance
and political issues associated with forests and
human health are explored in greater detail in
Chapter 5.
4.6 Conclusions
This chapter has shown that the health outcomes
related to forests, trees and green spaces, both at
the individual and community level, can consid-
erably differ between different types of forest
contexts and communities (i.e., rural, urban, for-
est-dependent). It is important to have insight in
this complexity of forest-human health relations,
also in terms of response options as presented in
Chapter 5. Moreover, response options related to

4. FORESTS FOR HUMAN HEALTH – UNDERSTANDING THE CONTEXTS,
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149
planning, design, and management for instance,
need to be based on an understanding of the at-
tributes and characteristics of forests that affect
their health impacts. These relate, notably, to
structure, species composition and development
phase of the forest.
Synergies exist between the health outcomes
of forests and many of the ecosystem services pro-
vided. Often there are synergies between regula-
tion and biodiversity targets and health and well-
being benets of forests. However, there can also
be important trade-offs, for example related to
closing off forests to local communities or visitors
for specic purposes or to changing forest type
and structure for biomass production and carbon
storage.
In the future, it will be important to maintain
and strengthen those human-forest interactions
and practices that locally support human health
and wellbeing the best and integrate these prac-
tices, if possible, with other locally or regionally
important forest ecosystem services to nd ade-
quate support and justication for the necessary
land-use and forest management changes.
When developing governance, planning, man-
agement, and other solutions, these synergies and
especially also trade-offs need to be considered
and reconciled in forest management. It is also
important to consider different forest users and
user groups, from local communities to visitors
from further aeld, and from urban to rural and
forest-dependent communities. Use of the for-
est for health reasons by one user group can also
hamper other uses by other groups, as seen in the
case of spiritual forests and recreational versus
livelihood uses of forests.
Finally, it is also essential to understand the
many threats and drivers of deforestation, tree
cover loss and forest degradation, as these will
impact the availability and capacity of forests
to meet human health demands. Part of the re-
sponse option for promoting positive forest-hu-
man health relationships while minimising those
relationships that can threaten health, will be di-
rectly linked to these threats and drivers.

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Chapter 5
Response Options:
Access, Spatial Dimensions, Design, Communications and Economics
Coordinating Lead Authors: Agnes van den Berg and Cecil Konijnendijk
Lead Authors: Shureen Faris Adbul Shukor, Ranaivo Rasolofson and Patricia Shanley
Contributing Authors: Victoria Bugni and Nelson Grima
TABLE OF CONTENTS
5.1 Introduction ............................................................................................................................................... 164
5.2 Response Options Related to the Management of Forest Access: Property Rights and Capitals ..... 164
5.3 Response Options Related to the Management of Spatial Dimensions of Forests ............................ 170
5.4 Response Options Related to the Design of Forests, Trees and Green Spaces .................................... 174
5.5 Response Options Related to Communications and Education ........................................................... 179
5.6 Response Options Related to Governance and Economics ................................................................... 184
5.7 Conclusions ............................................................................................................................................... 189
5.8 References .................................................................................................................................................. 190

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
164
Abstract
This chapter gives an overview of ve categories of response options available to secure health
benets of forests, trees and green spaces: the management of access; spatial dimensions; de-
sign, communications and education; and governance and economics. Across these areas, some
common solutions emerge, although response options differ between settings and regions of the
world. In general, there is a need to explicitly include and acknowledge human health as an
important value (or ecosystem service) in the development of visions, plans and other strategic
policy documents pertaining to forests. Initiatives aimed at improving access to health benets
of forests and reducing inequity need to consider a wide range of interconnected factors in-
cluding property rights and natural, physical, human, social and nancial capitals. The spatial
dimensions of providing health-promoting forests revolve essentially around the current location
of forests in different settings as well as nding optimal spatial congurations. Key factors are
proximity and accessibility, visibility and developing well-connected networks of forests and oth-
er green spaces. From a design perspective health needs to become a guiding principle in master
plans and more detailed designs for forest areas, focusing on enhanced safety, accessibility and
usability and promotion of positive experiences. Communication and education have to shift
their focus from informing people about the evidence for health benets to building understand-
ing of why forests are benecial for health and wellbeing, using for example informal learning
through hands-on experiences. Governance related to health benets of forests requires a change
in the forest conservation and land-use discourse, as well as new alliances between governments,
markets and civil society actors, mobilisation of resources and changes in governance rules of the
game. Economic and other assessment methods and payments for ecosystem service schemes
need to include health outcomes.
5.1 Introduction
This report has so far presented the current the-
ories and evidence on the multiple relations be-
tween forests, trees and green spaces6, and human
health outcomes. It has also discussed some of the
relations between different types of forests and
forest characteristics on the one hand, and spe-
cic health benets or risks on the other. Moreo-
ver, synergies and trade-offs between the health
impacts of forests and other ecosystem services
(and disservices) have been highlighted, as well as
many key drivers that can either strengthen for-
est-health relations or serve as barriers to these.
Based on this analysis, and as a foundation for fu-
ture policies and interventions, this chapter pre-
sents ve response options towards optimising
the positive impacts of forests on human health,
while also managing potential negative impacts.
These response options are categorised under the
themes of: 1. management of access; 2. spatial di-
mensions; 3. design; 4. communications and edu-
cation; and 5. governance and economics.
The relevance of the response options differs
between different regions of the world. In many
countries, property rights for example, will affect
the forests-health relationship. To ensure a wide
6 All terms that are dened in the glossary of this report (Appendix 1) appear in italics the rst time they are mentioned.
applicability, each response option is illustrated
with examples and evidence from a variety of re-
gions and countries.
Each response option is rst briey intro-
duced, followed by a discussion of relevant fac-
tors that may shape the relation between forests
and health, and some key associated issues that
need to be addressed to enhance this relationship.
These insights are then used to highlight response
options and solutions for forest managers, policy-
makers and other stakeholders.
5.2 Response Options Related to
the Management of Forest Access:
Property Rights and Capitals
5.2.1 Introduction
An important precondition for individuals to reap
the health benets from forests is that they have
access to those forests. With access being dened
as the “ability to derive benets from things”
(Ribot and Peluso, 2003). The ability to derive
health benets from forests is to a large extent
ensured by public ownership of forested areas in
many countries, and by these forests being ac-

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
165
cessible for recreational and other health-related
activities (e.g., wild foods). In many low-income
countries, largely due to historical legacies, ac-
cess of local communities and other forest-de-
pendent groups is often limited by unclear or
conicting property rights. In addition, natural,
physical, human, social and nancial capitals can
either constrain or enable people to benet from
forests (Peluso and Ribot, 2020).
This section introduces property rights and
capitals as key factors that shape people’s access
to forest health benets, along with a discussion of
the issue of inequity in access to forest health ben-
ets and the pathways that may lead to inequity.
The section focuses mostly on low-income coun-
tries where access, and other property rights, are
a major issue.
5.2.2 Factors relevant to access to
forest health benets
Property rights
Rights are claims to benets that are acknowl-
edged and supported by society through law, cus-
tom or convention (White and Martin, 2002). In
the context of forests, property rights are impor-
tant means for local communities to gain access
to health-related forest products, such as forest
foods, medicinal plants, as well as timber and
non-timber products that are sources of income
that people can then use for health care. Moreover,
securing the property rights of local communities
to forest resources matters for ethical reasons, as
these communities have often customarily owned
these resources for many generations and their
wellbeing and way of life depend on access to them
(Mollett and Kepe, 2018). In general, four cate-
gories of forest tenure can be distinguished (Rights
and Resources Initiative, 2018): (1) government ad-
ministered; (2) designated for Indigenous peoples
and local communities (IPLCs); (3) owned by IPLCs;
and (4) privately owned by individuals and rms. As
illustrated in Figure 5.1, these four categories clas-
sify forest tenure according to the rightsholder and
can be plotted against the specic property rights
(or legal entitlements) recognised by national-
level laws and regulations.
Figure 5.1
Spectrum of the bundle of rights
Note: Alienation rights
(to sell, lease, or use their lands
as collateral) are not required
under this category.
Communities do
not hold rights
under this
category.this
category.
Communities hold all of
the following:
Individuals and firms hold all
of the following:
Unlimited
duration of
rights
Right to
process and
compensation
Communities hold both:
Access
rights
Withdrawal
rights
Plus at least 1 of the following:
Management
rights
Exclusion
rights
Forests are
administered by
governments,
but communities
may hold:
Access rights
Withdrawal
rights
Category 1
Government
Administered
Category 2
Designated for Indigenous
Peoples and Local Communities
Category 3
Owned by Indigenous Peoples
and Local Communities
Category 4
Privately Owned by
Individuals and Firms
SPECTRUM OF THE BUNDLE OF RIGHTS
Access
rights
Withdrawal
rights
Management
rights
Exclusion
rights
Unlimited
duration of
rights
Alienation
rights
Right to
process and
compensation
Access
rights
Withdrawal
rights
Management
rights
Exclusion
rights
Source: Rights and Resources Initiative, 2018

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
166
Community ownership: Legal and customary
Legal ownership provides IPLCs with the highest
level of control and therefore, the best ability to
derive health benets from forests, i.e., they can
mediate or exclude others to forest resources.
Local forest owners also have rights to due pro-
cess and compensation in case of conicts. Yet,
an analysis across 58 countries showed that, as
of 2017, local communities were legally recogni-
sed as owning only 12.2% of global forest area,
with an additional 2.2% having legally designated
rights. By comparison, governments have legal-
ly-enshrined administrative authority over more
than two-thirds of global forest area (Rights and
Resources Initiative, 2018, see Figure 5.2).
Where local communities do not have legal
ownership of forests, national laws often recognise
the customary ownership of local communities
without requiring formal registration of custom-
arily owned lands. In countries with such laws
(e.g., Kenya, Mali, Mozambique) the percentage of
community ownership is higher than the ofcial
data. However, overlap between legal and custom-
ary ownership can result in access ambiguity that,
in turn, may lead to conicts. Moreover, whenever
local communities have no legal ownership, their
legal rights and their access to forest resources,
including those associated with health benets,
remain insecure as the government, which legally
owns the forests, is the ultimate access mediator,
adjudicator and power holder.
Private ownership
As shown in Figure 5.2, in the 58 countries re-
viewed, an estimated 11.4% of forestlands are
owned by private individuals or rms. These pri-
vate forest owners are often smallholder farmers
whose vulnerability and dependence on forest
resources may be like that of local communities.
However, there is no global data on the proportion
of private forestlands owned by smallholders com-
pared to rms, corporations or families with large
holdings. The lack of data reects inadequate at-
tention to laws that are needed to secure the abil-
ity of smallholders to access benets, including
health benets, from forest resources.
Figure 5.2
Global status of statutory forest tenure in 58 countries as of 2017 by percent
Government Administered
67.7%
Designated for Indigenous Peoples
and Local Communities
2.2%
Owned by Indigenous Peoples
and Local Communities
12.2%
Privately Owned by
Individuals and Firms
11.4%
Unknown Tenure
6.5%
Source: Rights and Resources Initiative, 2018

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
167
Conservation areas
Of particular interest is the continuing expan-
sion of protected areas for biodiversity conserva-
tion that are often administered by governments.
About 18% of the world’s forests are currently
within the boundaries of legally established pro-
tected areas (FAO and UNEP, 2020). While the ma-
jority of protected areas established during recent
decades allow multiple uses of forest resources
(International Union for Conservation of Nature
(IUCN) categories V – VI), access to resources with-
in many of these protected areas is still contested
by local communities (Sunderland and Vasquez,
2020). Furthermore, there are still many protect-
ed areas where access to forest resources is more
strictly regulated (IUCN categories I – IV). Target 3
of the Global Biodiversity Framework (GBF) adopt-
ed during the 15th Conference of the Parties (COP)
to the Convention on Biological Diversity (CBD)
in 2022 approved a target to protect at least 30%
of terrestrial areas through protected areas and
other effective area-based conservation measures
(OECMs).
Extensive versus limited rights
In general, more extensive rights (rights to ex-
clude others or to sell or lease) are more likely to
improve outcomes than more limited rights (use
rights of physical access to forests and withdraw-
al of forest products) (Miller et al., 2021). For ex-
ample, individuals of households in communities
in Bhutan who participated in community forest
management (and thus had management rights)
signicantly increased their calorie intake, as a
protection against the health risk of malnutrition
(Rahut et al., 2015). In Namibia, people living in
communal conservancies – areas under custom-
ary property rights in which rights to benet from
natural resources are devolved to local commu-
nities – have signicantly higher ownership of
bed nets (for malaria prevention) than people in
non-conservancy comparison areas. This is at-
tributed to the fact that the community struc-
ture provided by conservancies makes it easier
for authorities to distribute such nets (Riehl et
al., 2015). Communities around the Loita forest
in Kenya, which is managed under traditional
property rights in which local communities are
the owners of forests and have the right to ex-
clude others, perceived that the control of access
to forest resources granted to the communities
improved their health status (Mbuvi et al., 2015b).
Even having limited property rights can already
provide benets compared to having no rights,
as indicated by a study with households from 34
low-income countries (Naidoo et al., 2019). Liv-
ing in multiple-use protected areas with limited
rights to withdraw forest products (IUCN catego-
ries V – VI) promoted child growth (greater height-
for-age and weight-for-age) compared to living in
non-protected areas.
However, a few studies indicate greater health
benets of having limited rights compared to
more extensive rights. In Tanzania, for example,
local communities perceive improvement with
regard to access to forest medicinal plants, and
hence health, where there are more limited rights,
but not where there are more extensive rights
(Vyamana, 2009). Another study in Tanzania de-
tected signicant positive associations between
community forest management rights and child
nutritional status (height-for-age, weight-for-age),
where rights grant more limited control of access
to the forest communities. No signicant associa-
tion was detected where the management rights
allow for more extensive control of access (Pailler
et al., 2015). Such inconsistent ndings might be
explained by the fact that, though property rights
are important, they represent only one means by
which to gain access. Other contextual factors act
in parallel or interact with property rights to de-
termine access. Below, several of those contextual
factors relating to natural, physical, human, social
and nancial capital are discussed.
Capitals
Natural capital
Natural capital comprises the natural resources
people depend on for their livelihoods. The state
of forest resources affect people’s ability to access
the health benets that they provide. The amount
of forest and their conguration across landscapes
have been signicantly associated with diet quality,
a key determinant of nutritional status in Ethiopia,
Malawi, Nigeria, Tanzania and Uganda (Rasmussen
et al., 2020). A study found that in Indian villages,
women used to walk 1–2 km every day to gather
sufcient rewood for cooking, but where forests
were degraded, they needed to walk 8-10 km for
the same activity (Wan et al., 2011). Such an in-
crease in the time and energy needed by women
to collect rewood, reduces the time and energy
that they have available as primary caregivers
for food preparation, more careful child feeding
behaviours, income generation and health care,
which can impact the health of household mem-
bers (Johnson et al., 2013). As another example,
when forests in upstream areas of watersheds are
degraded, the quality of downstream water can be
affected (Cunha et al., 2016).

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
168
Physical capital
Physical capital includes infrastructure that peo-
ple need or tools and equipment that they use to
make a living. Roads, for example, open access for
alternative food and health services that can re-
duce communities’ dependence on forest resourc-
es (Myers et al., 2013). Living near roads can also
support forest-dependent people in converting
forest benets to nutritional benets (Rasolofoson
et al., 2018), although roads can also increase ac-
cess to forests for other (competing) users.
The role of physical capital in enhancing access
to the health benets of forests can also be illus-
trated by the multiple-barrier approach to clean
drinking water provision. From source watersheds
to water distribution, multiple consecutive barri-
ers to pollutants and contaminants are needed to
ensure safe drinking water (Ernst et al., 2004). By
ltering raw water, forested watersheds can act as
early barriers and reduce the cost of clean water.
Nevertheless, additional infrastructure is neces-
sary at point-of-use or source (e.g., point-of-use
chlorination, water treatment plant) to enhance
the benets of water ltration by forested water-
sheds in providing clean drinking water and pre-
venting waterborne disease (Cunha et al., 2016).
Multiple examples where physical capital im-
proved the health outcomes of forests can be seen
around the world. For example, local communities
in the Maya Biosphere Reserve of Guatemala who
started buying their own logging and processing
equipment saw an increase in net household rev-
enues and social cohesion as important health in-
uencing factors (Nittler and Tschinkel, 2005). In
the Democratic Republic of the Congo, gun own-
ership allowed richer people to enjoy the health
benets of bushmeat consumption (De Merode et
al., 2004). In the Gunung Palung National Park in
Indonesia, a programme that established a health
clinic and offered discounts to communities based
on reduction of illegal logging activity saw an in-
crease in clinic usage (Jones et al., 2020).
Human capital
Key components of human capital include skills,
education and knowledge. In Cameroon, develop-
ment of skills needed for indigenous tree domesti-
cation and agroforestry increased consumption of
nutritious fruits and use of medicinal plants, which
in turn, resulted in a reduction in the frequen-
cy of sickness and hospitalisation (Tchoundjeu
et al., 2010). Level of education can strengthen
the effects of forests on diet quality as more ed-
ucated people may be more diet-conscious and,
thus, more likely able to translate forest benets
into nutritious diet. A conservation project that
involved education on family planning increased
contraceptive use among women in a national
park in Madagascar (Korhonen-Kurki et al., 2004).
Nutrition knowledge for women is of high signif-
icance given that decisions regarding household
food use and practices are mostly made by women
(Vira et al., 2015). Knowledge on the use of medic-
inal herbs is another human capital that is essen-
tial for traditional medicine practice and is com-
mon in forest dependent communities (Mbuvi et
al., 2015a).
Social capital
Social capital generally refers to the network of
social relationships that people have, including
relationships with either more powerful people
or with others like themselves, or membership of
groups or organisations. Privileged relationships
with authoritative individuals or institutions that
design, implement or enforce forest use rules can
strongly inuence who benets from forest re-
sources (Ribot and Peluso, 2003). In Madagascar,
for example, there are reported cases in which
community elites, thanks to better skills and ed-
ucation (human capital), developed relationships
with state authorities and implementing organi-
sations (Pollini and Lassoie, 2011). Such relation-
ships led to rules favouring these community
elites, allowing them to capture forest benets
and other resources. Group membership can also
affect the distribution of benets from forest re-
sources. For example, in Ethiopia, members of
forest user groups – who were allowed to graze
livestock and harvest timber – enjoyed increased
livestock assets and income, while non-members
lost access to forest products and grazing – lead-
ing to income shocks (Ameha et al., 2014). In turn,
these income shocks can have repercussions on
household health care.
Exchange relations that provide access to mar-
kets are another type of social capital. The collec-
tion and sale of forest products can provide sup-
port especially for those who lack the means to
engage in other livelihood activities (women and
the most disadvantaged members of a communi-
ty) (Vinceti et al., 2013). Cash income can be used
for health care. Forest-based programmes involv-
ing improvement of market access, such as forest
certication, have shown positive or neutral ef-
fects on socio-economic outcomes (Burivalova et
al., 2019). Specically, in Indonesia, forest certi-
cation reduced rewood dependence, air pollution,
respiratory infections and malnutrition while hav-
ing no effect on the number of healthcare facilities
(Miteva et al., 2015). Creation of producer business
groups that link smallholder farmers of indige-

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
169
nous fruits to wholesale buyers have also been re-
ported to result in increases in farmers’ incomes in
Kenya and Uganda (Jamnadass et al., 2011).
Financial capital
Financial capital includes cash income and remit-
tances, credit, savings in kind and cash. The sta-
tus and power afforded by nancial capital can
be used to acquire other means of access. For in-
stance, nancial capital can be used to purchase
tenure rights, pay for rents or access fees, tools or
equipment (physical capital) for resource extrac-
tion, acquire education and knowledge (human
capital) and invest in relationships with or buy the
inuence of people with authority (social capital).
In the Democratic Republic of the Congo, for exam-
ple, poorer households made proportionately less
use of wild meat and sh because they could not
afford the high-capital tools (e.g., guns and nets)
necessary to exploit these resources (De Merode
et al., 2004). In a community-managed forest in
Uganda, wealthy households saw signicant gain
in income from forests because they were able
to extract and commercialise illegally harvest-
ed timber by offering bribes to forest ofcials re-
sponsible for monitoring and enforcement of rules
(Jagger, 2008). In a study in the Sundarbans, great-
er availability of nancial capital was correlated
with higher capacity to harvest crab and fuelwood
from the mangroves (Kibria et al., 2018).
5.2.3 Inequity in access to forest health benets
Dependence on the benets of forests, including
dependence on health benets, differs across dif-
ferent groups of people and communities. More
vulnerable people and communities often have
greater dependence on these benets than less
vulnerable ones. Vulnerable people and commu-
nities have limited resources that enable them
to access health services provided through infra-
structure and market, and therefore turn to for-
est resources for the provision of these services
(Myers et al., 2013; Fisher et al., 2019). However,
vulnerable people and communities also often
have limited means (rights and capitals) to benet
from forest resources (Miller et al., 2021). There-
fore, benets from forest resources, are inequita-
bly distributed with studies reporting more bene-
ts for wealthier, better educated or male-headed
households (e.g., De Merode et al., 2004; Pailler
et al., 2015; Rahut et al., 2015; Rasolofoson et al.,
2018; Nerfa et al., 2020)
The inequitable distribution of forest
health benets operates through three major and
interlinked pathways. First, without adequate
property rights and capitals, vulnerable people
will not be able to directly benet from forest
products of direct relevance to human health (e.g.,
nutritious forest food, medicinal plants). For ex-
ample, some forest products cannot be extracted
without the use of tools, and without knowledge
of nutritional or medical virtues of forest prod-
ucts, nutritious and medicinal forest products
will be left unused. Second, other forest prod-
ucts (e.g., timber, fodder) and ecosystem services
need to be transformed or enhanced by capitals
to yield health benets. For example, timber needs
markets to generate income that can be used for
health care; pollination needs agriculture assets
to be transformed into nutritious food products.
Vulnerable people who do not possess the capitals
to achieve such transformation will not be able to
derive health benets from these forest products
and ecosystem services. Third, wealthier, better
educated and male community members tend to
be more likely to participate in forest management
and conservation activities that promote health,
such as the promotion of contraceptive methods
or the distribution of bed nets. Such participation
reinforces their rights and capitals while leaving
the vulnerable destitute.
5.2.4 Solutions
Efforts of governments and other authorities to
improve access of local communities to forest ben-
ets are often framed in terms of socio-econom-
ic benets. However, as described in this section,
having access is also of crucial importance to the
ability to derive health benets from forests, and
as such deserves more attention. Policies, regula-
tions, legislation and interventions aimed at im-
proving access to health benets of forests need to
consider a wide range of interconnected factors in-
cluding property rights and natural, physical, hu-
man, social and nancial capitals. When commu-
nities have more extensive control over their forest
resources, they are empowered and incentivised to
engage in collective action leading to more equi-
table health and health-related outcomes. Such
collective action does not only deliver equitable
outcomes, but also strengthens capitals, which,
in turn feeds back into sustaining acquired health
outcomes.
Governments and authorities may also directly
strengthen local communities’ physical, human,
social and nancial capitals (for example through
educational programmes or through forest certi-
cation) particularly for vulnerable community
members, to ensure that they are able to benet
equally from forest health resources. However,

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
170
care is needed because these capitals can also
lead to unsustainable use of forest resources and
thus imperil natural capital. An accountability
mechanism, which links local forest user groups
and external organisations (e.g., Korhonen-Kurki
et al., 2004; Miteva et al., 2015; Jones et al., 2020;
Miller et al., 2021), can be another way to promote
equitable and sustainable outcomes (Persha and
Andersson, 2014).
5.3 Response Options Related to
the Management of Spatial Dimensions
of Forests
5.3.1 Introduction
The spatial dimensions of providing health-pro-
moting forests revolve essentially around two
questions: where are forests located today in
relation to urban, rural or forest-dependent hu-
man communities? What is the optimal spatial
conguration of forests in terms of human health
benets? When it comes to the location of for-
ests, most people now live in settings where for-
ests are often not readily available, unless cities
and towns have good urban forest infrastruc-
tures. However, even in rural areas the availabil-
ity of forests can be limited, for example due to
clearing for agricultural uses or resource extrac-
tion. Issues that arise with a further distancing
from forests include a disconnection from nature
(Farcy et al., 2018) and poor mental health (Bolton
et al., 2021).
The spatial conguration of forests (i.e., the
size and arrangement of forest patches across a
landscape) affects ecological functions and hu-
man access to forest resources (Rasmussen et al.,
2020). Forest fragmentation, for example, increas-
es the proportion of forest coming into contact
with the edge (‘edge effect’), which in turn can re-
sult in increases in tree mortality; changes in plant
and animal composition, diversity, seed dispersal,
predation; and altered microclimate (Broadbent et
al., 2008). All of these changes impact the avail-
ability of forest products and services important
to human health. However, forest fragmentation
also makes it easier for people to access forest re-
sources that were deep in the forest interior before
fragmentation (Peres, 2001).
This section rst introduces some key spatial
dimensions related to the location and spatial
conguration of forests, followed by a discussion
of challenges and opportunities for spatial man-
agement aimed at optimising health benets of
forests. The section closes with an overview of
solutions.
Forests provide settings for camping in nature as well as rewood for cooking
Photo © Nelson Grima

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
171
5.3.2 Factors relevant to spatial dimensions
of forest health benets
Proximity and accessibility
Proximity of forests is an important indicator of
spatial availability. When forests are nearby, they
are more likely to be used for recreational and
other activities that promote health and well-
being. In urban and peri-urban areas, for exam-
ple, research has shown the importance of prox-
imity and ease of access (Hörnsten and Fredman,
2000; US Forest Service, 2019). More generally for
urban green spaces, the World Health Organiza-
tion (2017) calls for a maximum of 300 metres
from one’s home to the nearest green space. Many
studies, as discussed in the previous chapters,
have shown that having forests and other green
spaces nearby can be related to better physical
and mental health.
While proximity is mostly favourable to health,
in some cases forests nearby can also result in
more negative health impacts, for example in the
case of vector-borne diseases, dangers from wild
animals, forest res and their resulting smoke and
haze, and the like. Sometimes the term ‘ecosystem
disservices’ (see Chapter 4) is used in this con-
text (Dobbs et al., 2014). Having forests too close
can evoke feelings of fear and danger (Skår, 2010;
Konijnendijk, 2018); fears which can result from a
wide range of causes, including fear of other peo-
ple, of getting lost, of wild animals or a more gen-
eral anxiety related to nature (Dobbs et al., 2014).
Sanjay Ghandi National Park which is surrounded
by the megapolis of Mumbai in India hosts a resi-
dent population of leopards that sometimes roam
the city’s streets and pose dangers to pets and hu-
mans (Surve et al., 2022).
Recent years have seen increasing focus on the
issue of ‘urban forest equity’ and the fact that ur-
ban forest canopy cover is often unevenly distrib-
uted across a city (Shiraishi, 2022). It is also com-
mon for higher urban forest cover to be found in
the more afuent parts of a city, while areas with
lower socio-economic status and more vulnerable
populations are not well catered for. Forest equity
can also be considered more generally, including
a fair and equal distribution of forests and forest
benets in rural areas, and access to forests for for-
est-dependent communities (Larson et al., 2008).
Both in urban and rural areas, forest proximity
in combination with accessibility play an impor-
tant role for example, in recreation and tourism.
People may be willing to travel greater distances to
specic forests that are of high recreational, nat-
ural or cultural value, but they will also make an
evaluation of the costs (e.g., travel time) and ben-
ets involved. Urban dwellers may be willing to
travel several kilometres to an urban or peri-urban
forest if there are no ‘forest experiences’ available
nearby, or when they want to avoid overcrowding
or conicts with other recreational users (Bakhtiari
et al., 2014).
Visibility
Visibility of, and visual access to, forests is another
important spatial dimension. Just seeing trees and
other vegetation has been found to promote men-
tal and other types of health benets (Wolf et al.,
2020). Both visual and physical access to forests
are also important for specic user groups, such
as school children. Offering forest experiences to
children during their school time can generate
improved learning and health benets. The so-
called ‘Forest Schools’ that have been established
across Europe and elsewhere are an example of a
response to this nding (O'Brien, 2009).
Connectivity
Connectivity can enhance the functionality of
forests and green infrastructure. Many cities
across the world have focused on developing
green infrastructure networks (Lafortezza et al.,
2013). Barcelona, Spain, is one example of a city
with an ambitious green infrastructure and bio-
diversity plan that also has strong links to public
health (Ajuntament de Barcelona, 2022). Urban
forest fragmentation in contrast can be linked to
loss of human health benets, for example, due
to a decrease in ecosystem functioning and patch
sizes (Tsai, 2014; Haaland and Konijnendijk van
den Bosch, 2015) resulting in loss of biodiversity
as well as a reduction of ecosystem service provi-
sion (Mitchell et al., 2015).
Multifunctional landscape mosaics charac-
terised by patches of forests or trees intermixed
with small-scale agricultural production systems
have the potential to provide nutrient-rich foods
and support diverse diets for women, young chil-
dren and families, especially those living in rural
communities (Sunderland and Vasquez, 2020).
A study covering rural households in Ethiopia,
Malawi, Nigeria, Tanzania and Uganda shows that
the amount and spatial conguration (number or
size of forest patches) of forests across landscapes
are positively associated with more diverse diet
(Rasmussen et al., 2020). This association can be
explained by multiple pathways. Pollination is an
important ecosystem service for the production of
fruits and vegetables (Eilers et al., 2011; Garibaldi
et al., 2022). However, pollinators, such as birds,
bats, butteries, moths, ies, beetles, wasps, small
mammals and bees have a limited foraging range

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
172
(Kennedy et al., 2013). Multiple forest patches offer
pollinators habitats scattered across a landscape
enabling them to reach a large total crop area
within their foraging distance. Wild foods in for-
est patches are also more accessible than those in
large blocks of forests (Hickey et al., 2016), where
access may be more limited, not only because of
their size, but also because they are more likely
to be protected for conservation (Ickowitz et al.,
2019).
Strategic spatial arrangements
The strategic location of forests in upstream ar-
eas of watersheds may increase the effectiveness
of water treatment and thereby reduce diarrhoeal
disease prevalence in downstream areas (Herrera
et al., 2017; Rasolofoson et al., 2021). Forests may
also be strategically placed to provide a buffer be-
tween livestock and water bodies. Also, forests can
help to keep pathogens (e.g., Cryptosporidium) in
livestock waste from reaching water sources, miti-
gating the effect of livestock and human waste on
water quality (Brauman et al., 2007; Pattanayak
and Wendland, 2007). The strategic spatial ar-
rangement of forests is particularly relevant for
vulnerable communities in low-income countries
that cannot afford expensive water treatment
technology. Similarly, programmes have been de-
veloped to reduce re risk especially close to where
people live, by leaving buffers, selecting less am-
mable tree species and managing undergrowth
(Calkin et al., 2014).
Figure 5.3
The Landscape Mosaic showing 19 mosaic classes and their proportions
to the three land cover types - Agriculture (A), Natural (N) and Developed (D)
0.0 0.1
0.9
0.2
0.8
0.3
0.7
0.1
0.01.0
0.2
0.3
0.4
0.6
0.5
0.5
0.6
0.4
0.4
0.5
0.6
0.7
0.3
0.8
0.2
0.9
0.1
0.7
0.8
0.9
1.0
0.0 1.0
More Natural
(more Green)
More Agriculture
(more Blue)
More Developed
(more Red)
D
DD
NN
AA
Da Ad
Dan Adn
ad
adn
Nad
A
Dn An
dn an
Nd Na
N
Adapted from a living document in the free online EU GuidosToolbox Source: European Commission, 2021

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
173
5.3.3 Managing spatial aspects
Enhancing the proximity, availability, visibility,
connectivity and strategic spatial arrangement of
forests (and trees) is a key issue for policy- and
decision-making, as a neglect of these spatial
aspects can reduce potential health gains. If po-
licymakers and other decision-makers fail to ad-
dress these aspects, interests of different popula-
tion groups can clash; for example, when natural
and rural forest areas are made available for re-
creation and tourism mainly for urban dwellers,
with negative side effects for rural dwellers.
To manage spatial aspects requires rstly
analysing where forests are located in relation to
human populations using geospatial tools. More-
over, specic forest types need to be placed in rela-
tion to different population groups (see also Chap-
ter 4). Next, the specic health benets for the
different groups have to be determined, balanced
with other forest ecosystem services and with
each other. When clear gaps are determined, a
next step is to see whether new forests can be cre-
ated, which can be challenging because of compe-
tition with other land uses. In urban areas this can
be particularly challenging due to lack of available
space, the high competition for land and high land
prices. Connectivity is also important, as less frag-
mented and more connected forests in different
settings can provide more health and other bene-
ts due to better ecosystem functionality.
Management challenges and opportunities are
thus central to the spatial dimensions of forests
for human health. Although overall global g-
ures indicate a net forest loss (FAO, 2020), there
are signs of a reversing trend at least regionally
or locally. Climate change, public health and bio-
diversity policies and actions have resulted in
larger-scale afforestation and reforestation pro-
grammes in many countries. A megacity like
Beijing, for example, has planted 50 million ad-
ditional trees during recent years, and is in the
process of adding another 50 million, with pub-
lic health as an important consideration (Yao et
al., 2019). Prior to afforestation, a detailed spatial
mapping was carried out to determine where new
forests were most needed and feasible. Many cities
have launched efforts to expand their urban tree
cover, although a key challenge lies in the proper
protection of existing forests and tree canopy cover,
for example on private properties (Ordóñez-Barona
et al., 2021).
5.3.4 Solutions
From a spatial perspective, it will be important
to include the health outcomes of forests in both
forest and overall land-use planning. Current-
ly this is rarely the case, especially in high-in-
come countries where there has been more focus
on providing recreational forests close to urban
centres. Standards such as the Woodland Access
Standard prepared by the Woodland Trust (2010)
in the UK, and the WHO standard for access to
urban green space (WHO, 2017) are examples of
spatial planning guidance. The distributional as-
pects are also important, ensuring forest equity
and the equal provision of health benets of for-
ests to all segments of the population. American
Forest’s Tree Equity Score is a good example of an
assessment tool that addresses this issue (Amer-
ican Forests, 2022). The example of Beijing’s af-
forestation strategy illustrates how spatial anal-
ysis can help determine which areas should be
prioritised for afforestation, notably, from a
health perspective.
A key task for spatial planning will be the de-
velopment of well-connected networks of forests
and other green spaces. A green infrastructure
planning approach has been applied across cities
worldwide that has proven successful in enhanc-
ing connections between forests and other green
spaces, promoting better ecosystem functionality
and easier movement for people and other species
(Lafortezza et al., 2013).
During their history, many cities across the
globe have developed forest greenbelts, primarily
with protection and recreation benets in mind
(Konijnendijk, 2018). China’s Forest City pro-
gramme rewards cities based on a detailed set of
criteria and indicators related to the provision of
forests and trees (Pei et al., 2019).
At the same time, potential negative impacts
of forests on health need to be recognised, min-
imised, and managed. These negative impacts,
sometimes called disservices (Dobbs et al., 2014)
can have a spatial dimension, with nearby forests
potentially bringing diseases, wildres and re-
sulting smoke, roaming wild animals, and a wide
range of risks and fears, most of which are con-
nected to specic segments of the human popula-
tion living close to forests and unable to move to a
safer place for economic or other reasons. Spatial
analysis can assist with determining where the
highest risks are in relation to where people live,
and nd ways of buffering and managing these
risks. Nevertheless, in most cases the health and
other benets of forests will surpass the potential
risks and disservices.

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5.4 Response Options Related to
The Design of Forests, Trees and
Green Spaces
5.4.1 Introduction
There is increasing demand for forest design prin-
ciples and guidelines that promote the health and
wellbeing of visitors, locals and other user groups.
This applies specically to recreational for-
ests and woodlands in urban areas that provide
health services to large numbers of urban dwell-
ers. In this context, positive health functions of
forests need to be balanced with potential nega-
tive aspects of forest experiences such as the fear
of getting lost, feeling unsafe, physical barriers,
conicts between different groups of users, and
diverse usage patterns among genders and age
groups.
A key challenge for landscape architects and
designers is to support forest managers in achiev-
ing an optimal balance between meeting basic
needs (for safety, comfort, accessibility and usabil-
ity) and more advanced needs for enjoyment and
challenge. This design principle is also known as
balance between “prospect and refuge” (Appleton,
1975; Gatersleben and Andrews, 2013) or between
“understanding and exploration” (Kaplan and
Kaplan, 1989). It is allegedly rooted in the evolu-
tion of the human species in natural environments
with concomitant survival-promoting needs for
safe shelter with a good overview of threats and
dangers, and needs for exploration of the environ-
ment to nd food, water, relief and other essentials
(Wilson, 1984).
This section rst discusses design aspects of
forests that support and promote safety, usabil-
ity, comfort and challenge, as key pathways to
promoting health and wellbeing, followed by an
overview of culture and crisis as moderators to
consider in designing forests for different target
audiences. The section closes with an overview of
solutions on how to enhance health benets of for-
ests through forest design. This section mostly fo-
cuses on more intensively managed and designed
urban forests and recreational area in different
parts of the world.
5.4.2 Design aspects relevant to forest health
benets
In recent years, the discipline of landscape ar-
chitecture has seen a transition from formal
approaches that rely on expert knowledge and
formal design principles and patterns, to a more
evidence-based approach that is informed by
scholarly work (Fagan, 2017). This evidence-based
approach has yielded many relevant aspects to
be considered when designing forests in order to
optimise users’ health and wellbeing (Doimo et
al., 2020; Grilli and Sacchelli, 2020). Studies have
highlighted, among other things, the importance
of accessibility (De Meo et al., 2015); type of for-
ests (e.g., mixed, deciduous, coniferous) (Liu et al.,
2021); tree species composition, canopy openness,
stand structure (Ebenberger and Arnberger, 2019);
facilities (Zhao et al., 2020); and perceptual indi-
cators and visual quality (Li et al., 2020).
Several schemes for organising these
health-promoting design aspects have been de-
veloped. Of these, the Perceived Sensory Dimen-
sions (PSD) scheme is one of the best-known and
most used (Stigsdotter et al., 2017; see Table 5.1).
The scheme comprises eight sensory dimensions
that may contribute to restoration from stress:
social; prospect; rich in species; serene; culture;
space; nature; and refuge. For each of the dimen-
sions, several key natural qualities and features
are specied. As illustrated in Box 5.1 describing
the design of a mangrove forest park in Malaysia,
the PSD scheme is particularly useful as a tool for
designing restorative spaces (or ‘rooms’) within
forest areas.
For the purpose of this report, a more broadly
applicable scheme is used that organises the var-
ious health-related design indicators found in the
literature in terms of their contribution to users’
needs for safety, usability, positive experience and
challenge. These indicators can be divided into
objective indicators (e.g., tree diversity) and per-
ceived indicators (e.g., naturalness). The latter are
often less spatially explicit and leave more room
for interpretation by architects and designers. A
review of the recent literature assists with identi-
fying a set of structural and functional indicators
according to the following criteria (Harshaw et al.,
2007):
• Relevant to health and wellbeing
• Credible
• Measurable
• Cost-effective
• Connected to [urban] forestry
Design aspects of forests that promote safety
Design guidelines for promoting safety relate to
waynding, signing, amenities, trails, the density,
maturity and diversity of the forest, tree form and
the quality of views.
Clear waynding and adequate signing re-
spond to the fear that visitors have of getting lost
if they were to venture more into the forest interior

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
175
(Sonti et al., 2020). Proper parking amenities, suf-
cient numbers of rubbish bins, and presence of se-
curity guards and rangers may give users a sense
of familiarity and increase perceived safety.
Providing multiple trails of different lengths
can increase perceived possibilities to escape po-
tential threat encounters. In addition, trails should
be well-maintained and have adequate lighting
for physical activity after dark (Ballantyne and
Pickering, 2015). Preferences for paved versus un-
paved paths may differ widely across different
cultures and regions (Hochmalová et al., 2022) and
with the age and other characteristics of visitors
(Arnberger et al., 2010).
Open and visually accessible forests are per-
ceived as less dangerous and evoke less fear
than dense environments with no clear lines of
vision and many hiding places (Gatersleben and
Andrews, 2013). Mature trees, natural plantings
and native species promote feelings of safety by
creating a sense of place and refuge and, in urban
areas, reinforcing neighbourhood identity (Liu et
al., 2021). Mixing various types of trees and plants
such as deciduous and evergreens, rough and ne
textures, and dense and thin branches, offers an
open view and visual diversity that reduce per-
ceived situational threats (Chiang et al., 2014).
Number (Nr.), names and short descriptions of the eight perceived
sensory dimensions (PSD) - a tool for designing restorative spaces in forests
Source: Adapted from Stigsdotter et al., 2017
Nr. PSD name Key nature qualities and features
1 Social Possibility to:
• watch shows/films
• attend exhibitions
• visit restaurants
2 Prospect • Lawns and well-cut grass
• Vistas over the surroundings
• Sports facilities
3 Rich in species • Several animal species
• Native fauna and flora
• Many native plants to study
4 Serene • Silent and calm
• No bicycles
• Few people
5 Culture • Decorated with water features, statues
• Various exotic, ornamental and kitchen plants
6 Space • Spacious
• Areas without paths/roads
• Presence of lots of trees
7 Nature • Nature-like
• Wild and untouched
• Free growing lawns
8 Refuge • Many bushes
• Animals in feeding/petting pens
• Play areas such as sandpits
Table 5.1
Number (Nr.), names and short descriptions of the eight perceived
sensory dimensions (PSD) - a tool for designing restorative spaces in forests

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
176
With tree tops representing safe places for our
ancestors, forest users today still tend to judge
a tree by its climbability (Townsend and Bar-
ton, 2018). Climbable trees are an implicit sign of
safety in modern human minds, and forest man-
agers should be careful in removing lower branches
which represent a key visual cue for climbability.
As a more indirect indicator, the attractiveness
of views along the forest road (as measured by
forest diversity) has been reported to reduce the
speed of vehicles, lowering the frequency of road
accidents and fatalities (Janeczko et al., 2016b).
Design aspects of forests that promote
accessibility and usability
Design guidelines for improving physical access
relate to the number, length and maintenance
of the trails, the use of suitable materials for the
surface, and the principle of universal design.
Providing multiple trails of different lengths
can offer users different options for their activities.
Trails can be in the form of boardwalks (e.g., con-
crete and paved) that reduce soil erosion due to ex-
cessive trail usage and the risk of the trail widen-
ing. They may also be designed as small informal
bare earth trails that bypass large trees, with min-
imum disturbance to existing forest structure and
canopy cover. Another option to consider is treetop
walkways which have the potential to enhance the
forest infrastructure, offer a different perspective
and experience, and introduce an attractive ele-
ment in the forest (Ke et al., 2021).
By implementing the idea of universal design,
the aim is to make forests accessible for all users,
including those with a physical disability. An analy-
sis of 20 projects and studies in Britain revealed
that disabled respondents emphasised the need
for detailed information about access and facil-
ities, preferably supported with photographs, so
that they could choose appropriate woodlands and
plan their visit (Morris et al., 2011). A survey among
people in wheelchairs from three European coun-
tries on their preferences for forest trail features
showed that they preferred asphalt surfaces, con-
crete surfaces or surfaces made of paving stones.
Wooden surfaces were least appreciated (Janeczko
et al., 2016a). In general, paving materials from
wood should be avoided as they are slippery when
wet. In the Netherlands, nature organisations are
experimenting with supplying balance bikes for
adults with walking difculties to enable them to
visit the forest.
Design aspects of forests that promote
positive experiences
Design guidelines for promoting positive and
pleasurable experiences relate to visual access,
naturalness, size, visual variety, elevations, water
elements, sound and lightscape, and number of
users.
An evaluation of forest trails in the Royal Na-
tional Park in Australia showed that visual access
improved forest experiences by decreasing situa-
tional concerns about getting lost or fears of wild-
life (Chiang et al., 2014). This study also showed
that visual access can be achieved by having veg-
etation on one side of the trail planted in layers,
and the other side having either large trees or no
vegetation to maintain visual transparency. Oth-
er design characteristics that contribute to visual
access include the forest’s topography and the il-
lumination cast by the foliage (Füger et al., 2021).
Look-out towers enable users to get an overview of
the whole area above the treetops, as well as pro-
viding a point of interest and rest (Hansen-Møller
and Oustrup, 2004).
Surrounding forests and green spaces enhance the spiritual health benets of Kinkakuji temple in Kyoto, Japan
Photo © Sital Uprety

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
177
Mixed forests with irregular structure are gen-
erally perceived as more natural and attractive
than mono-specic forests and have been reported
to contribute to the restorative experiences of us-
ers (De Meo et al., 2015). Landscape elements such
as large trees, buttress roots in coniferous forest
settings and small-scale landscape elements such
as owering plants, may contribute to naturalness
and visitor satisfaction (Zhang et al., 2020).
Creating an undulating terrain with gentle hills
and variation of elevation in trails can increase
visual variety while offering visual openness and
partial concealment (Chiang et al., 2014). A change
in elevation can offer different experiences in de-
signs through the use of existing undulating ter-
rain (Skłodowski et al., 2013).
Water elements are also generally much appre-
ciated (Skłodowski et al., 2013). In particular, open
views of streams along forest trails are an impor-
tant factor that inuences visitors’ satisfaction
with the trail (Cervinka et al., 2020; Zhang et al.,
2020). However, users of different types of forests
may differ in their preferences concerning water
elements. Lowland forest users prefer forest sites
near waterscapes or water edges (e.g., sea or wa-
ter reservoir), while mountain forest users prefer
forest sites that are open and easy to access (e.g.,
forest openings, trails, forest roads) due to the dan-
ger of steep slopes and inaccessible terrain (Gołos,
2013).
The soundscape of the forest, including both
natural sounds and background noise, provides
positive and relaxing forest experiences (Fang et
al., 2021; Ratcliffe, 2021; Hong et al., 2022). In ur-
ban areas, the Health Restoration Soundscapes
Criteria (HeReS-C) model (see Figure 5.4) provides
a practical tool for evaluating and improving the
soundscape of forested areas in terms of ve con-
ditions: naturalness; sound levels; perceived sound
sources; soundscape assessment; and sensescape
coherence (Kogan et al., 2021).
The lightscape may also inuence visitors’ ex-
periences. Forest areas with good natural lighting
conditions may support visitors’ visual interest in
the nearby and more distant surroundings during
forest walks (Gao et al., 2021). Focusing the pres-
ence of articial light towards greenery versus
parking lots and roads may enhance the perceived
restorative potential of urban night time in forest
environments (Nikunen and Korpela, 2009).
The number of users and forest carrying capac-
ity have also been mentioned in relation to creat-
ing positive experiences in the forest environment,
with lower numbers of users being preferred, while
at the same time preserving the forest’s intrinsic
values (De Meo et al., 2015).
Figure 5.4
Summary of Health Restoration Soundscapes Criteria (HeReS-C)
Source: Kogan et al., 2021

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Design aspects of forests that promote challenge
Design guidelines for promoting challenge relate
to ‘allowing the forest to be wild and unpredict-
able’ thereby ‘allowing the users to challenge
themselves mentally and physically’ This design
aspect may especially apply to children, who are
often restrained in their opportunities to discov-
er the more challenging side of the woods (Louv,
2008).
Participants of wilderness programmes that
challenge them to go beyond their own mental and
physical boundaries, often report improvements in
psychological wellbeing (Kaplan and Talbot, 1983).
These benecial effects can be linked to the expe-
rience of forests’ immensity, which contributes to
a sense of feeling connected to a “greater power”;
the experience of interconnectedness, which elic-
its a sense of belonging to all other living things
on earth; and the reection of internal nature and
truth by external nature as an accepting setting,
which contributes to the discovery of an authentic
self (Naor and Mayseless, 2020).
The available literature provides few design
guidelines for promoting challenge – perhaps
the best guideline is not to overdo measures for
safety and usability, as discussed in the previous
paragraphs. One concrete guideline, deriving from
research on visual preferences, is to introduce
an element of mystery, as indicated by winding
paths and rivers, and hilly mountains (Kaplan
and Kaplan, 1989). This may seduce users to fur-
ther explore the environment. In a similar way, the
presence of climbable trees, hills, water bodies,
muddy grounds and other obstacles can seduce
both adults and children to go outside their com-
fort zone to challenge themselves (Heft, 1988).
5.4.3 Moderators
Health impacts of forest design can differ accord-
ing to moderating variables such as gender, per-
sonality, culture, age, income, education, personal
situation and type of usage, as well as perceptions
and needs linked to these variables. For example,
individuals with a low need for sensation tend to
be more oriented towards safety than high-sensa-
tion seekers (Van den Berg and Ter Heijne, 2005). In-
volvement of users in the design process, by means
of user-oriented design and participatory ap-
proaches, provides a way to gain insight into these
individual differences. Below, we highlight culture
and crisis as two important moderating factors.
Culture
Designers of forests and green space need to take
into account the preferences of different users to
avoid potential conicts between visitors with dif-
ferent needs. Within all cultures, some individu-
als are more oriented to safety, and others more
towards seeking challenge. Some cultures, notably
in Asia, are more oriented towards group activities,
while most western countries are more individu-
alistic (Zhai et al., 2018). Therefore, forest designs
should allocate areas to accommodate both group
activities, such as lawns and barbecue areas, and
more solitary experiences. The size of the areas
should be carefully thought out as overcrowding
in forest visits may induce conict, noise and am-
bient disturbance, and obstruction of views.
Crisis
During the COVID-19 pandemic, many people
turned to nature for solace and healing experi-
ences. Several studies have reported on these ex-
periences (Pichlerová et al., 2021; Weinbrenner et
al., 2021). One study describes how urban forests
in Bogor, Indonesia, were improved to meet visi-
tors’ needs (Paramitadevi et al., 2021). An online
survey provided insights to improve forest experi-
ences during the crisis, including aspects related
to whether the visited site evoked feelings of com-
fort and/or tranquillity, the availability of facili-
ties such as seats and toilets, and the presence of
edges that help structure the area provided by trees,
bushes and fences. Forest managers and planners
could add more restrooms, resting facilities, ramps
to facilitate wheelchair/disabled access, compost-
ing areas, rain and stormwater harvesting, special
environmental events, solar lighting and ‘smart’
seating that include solar-powered charging op-
portunities for mobile devices.
5.4.4 Solutions
From a design perspective, it is important to ex-
plicitly include health as a guiding design princi-
ple in master plans and more detailed designs for
forest areas. Currently, when it comes to meeting
users’ needs, most designs and master plans for
green spaces are focused solely on recreation-
al and aesthetic values. However, while these
values provide important pathways to deriving
health benets from forests and trees, a more
health-specic focus is required for optimal use
of the health potential of forests. A common mis-
conception is that the promotion of aesthetic val-
ues will automatically translate into health bene-
ts but health values depend to a large extent on
accessibility and usability. As such, these aspects
should be prioritised in the design.
A key challenge for health-promoting design of
forests is to create universal designs that meet the

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needs of all users. This entails the provision of ad-
equate infrastructure that accommodates all user
needs, regardless of their disability or handicap. It
also entails balancing the different psychological
needs for safety and challenge of individuals and
user groups. Multidisciplinary project teams with
experts from landscape architecture, psychology
and geography, can provide well-informed and
consensual guidelines on how to adequately ad-
dress these issues.
The COVID-19 pandemic has highlighted the
importance of visits to the forest for maintaining
good mental and physical health. Many lessons
were learned regarding design strategies that ac-
commodate these health functions of forests in
times of crisis, ranging from the provision of more
toilets to the availability of protocols for ensuring
health and safety. It is important that forest man-
agers as well as researchers share their insights
with landscape architects and designers to make
forests more robust and equipped to welcoming
large inuxes of visitors in future times of crisis.
5.5 Response Options Related to
Communications and Education
5.5.1 Introduction
Communications and education can play a signif-
icant role in conserving and optimising the health
benets of forests. To date, however, the human
health benets of forests have largely been inef-
fective or absent from communications regarding
forests and/or health (Doimo et al., 2020). Despite
mounting evidence that forests offer a distinct,
powerful solution and/or treatment to innumer-
able ecological, sociological, medical and psycho-
logical problems, in practice and policy, all too
often, forests continue to be treated as a short-
term commodity and are razed and/or degraded
(Karjalainen et al., 2010). At this critical juncture
in history, limited public understanding of the
health benets of forests can result in missing vi-
tal opportunities for improving human health, and
for conserving multifunctional forests.
Box 5.1
Designing a Mangrove Forest for Health in Malaysia
Mangrove Point is a newly designed park
located within a mangrove forest along the
Klang River in Malaysia which opened to vis-
itors in early 2022. The 28ha park is the rst
of its kind in Malaysia, designed based on
the concept of ‘biophilia’ which incorporates
nature into the built environment to create
healthy, restorative and connective spaces.
The idea of turning the mangrove area
into a health-promoting park was inspired by
similar initiatives in Scandinavian countries,
such as the health forest Octovia in Den-
mark. However, its location in a vulnerable
mangrove ecosystem with a delicate balance
between land and water is unique and posed
many challenges for landscape architects.
Most importantly, the architects needed to
ensure the mangrove provided recreational
benets while also protecting sensitive areas
along the river.
Using the Perceived Sensory Dimensions
(PSD) approach (see Table 5.1), the architects
created several restorative places in different
areas in the existing mangrove to help park
users unwind. Following the principle of uni-
versal design, physical and sensory barriers
were avoided to ensure that everyone, re-
gardless of age, gender or disability could use
the space. To further promote usability and
accessibility, the forest layout was designed
to be easily understandable for new users
through locatable entrances and exits. The
design included walkways with appropriate
signage, clear connections and destinations.
Opportunities for diverse activities were in-
cluded to stimulate active use by different
users.
For safety purposes, dense vegetation,
walls or other features were avoided along
primary routes to maintain a feeling of open-
ness, clear visibility and avoid entrapment
areas. Pathways were designed to allow night
movement along well-lit routes. The design
also ensured that the edges of the park were
open enough to allow views in and out of the
site.
To support positive experiences, a com-
bination of different materials, vegeta-
tion and various path layouts was applied,
and planting schemes using textures, col-
ours and shapes were employed. Appealing
scenery with interesting views during differ-
ent times of the day and the year were creat-
ed throughout the site.

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The role of communications and education is
culturally dependent. In the case of forests and
health the focus of communications and educa-
tion will depend upon the extent and nature of,
and access to, local forests, as well as the common
ailments, health care options, lifestyles and con-
cerns of local people. Equitable access to forests
and to information regarding the benets offered
by forests is necessary in light of the profound
contribution of forests to human health.
This section discusses aspects of communica-
tions and education relevant to optimising health
benets of forests. It draws on concepts and ap-
proaches from various relevant elds including
health promotion, communication science and en-
vironmental education (e.g., Monroe et al., 2008).
The distinctions between urban and rural commu-
nities, and age group (children, adults, the elderly)
are key moderators to consider in developing com-
munication and education strategies for different
target audiences. Besides the general public, forest
managers are also discussed as a distinct target
group for communications and education. The
section closes with an overview of solutions on
how to enhance health benets of forests through
spatial management.
5.5.2 Aspects of communications and education
relevant for health benets of forests
Communications
For millennia, Indigenous cultures have recognised
and relied upon the healing power of forests. Many
long-held beliefs about the ‘healing powers of na-
ture’ are now being conrmed through research
and shared with the public through information
campaigns, Internet resources, and reports issued
by governments and other institutions.
To convey persuasive communication mes-
sages, authorities and other actors can choose
between statistical approaches (that rely on
quantitative scientic evidence) and narrative ap-
proaches (that tell a personal story of a real person
sharing his or her experiences). Research suggests
that statistical approaches are more effective in
changing beliefs and opinions while narrative ap-
proaches are more effective in stimulating inten-
tions to change behaviour (Zebregs et al., 2015).
Especially in low-income countries, culturally
responsive approaches that account for interper-
sonal, sociocultural and socio-economic reali-
ties are essential for effective communications
(Kaholokula et al., 2018). The effectiveness of these
approaches can be enhanced by using narratives
and visuals (Hinyard and Kreuter, 2007; Bergeron
et al., 2019; see also Box 5.2).
Thus far, communications in the forest-health
domain has mostly relied on informing (adult)
audiences about the scientic evidence, using a
statistical approach. However, to inspire action,
it seems essential to build a deeper and informed
understanding of why and how forests support hu-
man health and wellbeing, using a more narrative
approach. Such a compelling, inclusive approach
which includes youth and marginalised popula-
tions, can reduce health care costs and diminish
access disparities.
Disciplines like behavioural psychology, social
learning and public health have generated meth-
ods that bring scientic understanding to the pub-
lic; these methods, eld-tested over decades, can
provide important insights and guidance for for-
estry initiatives seeking to bridge knowledge and
action (Shackleton et al., 2009; Garzón-Galvis et
al., 2019). Participatory research, in which scientif-
ic evidence is combined with lived experiences of
local stakeholders provides an alternative to ‘blind
science’, and may provide results that are useful
for practitioners, policymakers and local commu-
nities (Bannister, 2018). Participatory approaches
strive to take an equitable approach to research
and communication, balancing and interweav-
ing local, Indigenous and Western scientic ways
of knowing and viewing the world (Shanley and
Lopez-Binnqüist, 2009; Wright et al., 2019).
Over the past several decades, a new mod-
el of ‘citizen science’ has emerged which enlists
the public in collecting data across a wide range
of habitats over long-term time frames, from mi-
crobiomes to galaxies (Bonney et al., 2009). The
model is effective not only in advancing scientic
knowledge, but also in helping participants gain
hands-on experience with biodiversity. Positive re-
sults indicate that citizen science will continue to
be employed as a cost effective, inclusive, research
methodology, with the added benet of connecting
people with nature.
Education
Current approaches to environmental education
strongly rely on facilitating hands-on experiences
with nature (Stern et al., 2014). These approaches,
which are mostly targeted at young children and
people from urban backgrounds, are primarily
aimed at strengthening the connection with na-
ture through embodied experiences that use all
senses. Teaching practical skills is another key
element of environmental education, for exam-
ple, learning how to make a re, climb a tree, or
knowing how to orient oneself using the moon or
sun as guidance (Bergeron et al., 2019). Hands-
on experiences and practical skills help students

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build self-esteem and take away psychological
barriers, exaggerated fears or even avoidance of
forests, and more generally, help to overcome im-
pediments to the use of forests for mental and
physical health and wellbeing (Mirrahimi et al.,
2011). Although outdoor experiences are known
to benet children’s psychological and intellec-
tual development, a global review of educational
themes in schools nds a lack of hands-on activi-
ties related to biodiversity and climate. Notably, a
review of national education documents from 46
countries found that 45% made little-to-no ref-
erence to environmental themes (UNESCO, 2021).
Children living both in hunter gatherer villag-
es and city centres spend the bulk of their days
indoors at school, losing the biocultural knowl-
edge of surrounding wild foods, medicines, sh
and wildlife (Dounias and Aumeeruddy-Thomas,
2017). One telling outcome of modern education is
that many youths graduate without the ability to
identify a single tree. Scholars have described the
current chasm between people and nature as the
‘extinction of experience’ (Pyle, 1979; Miller, 2005).
Outdoor education (which may involve both formal
education in schoolyards, and informal education
in areas outside the school) provides a much-need-
ed alternative to formal indoor education, especial-
ly for children with special needs such as attention
decit-hyperactivity disorder (ADHD) who nd it
difcult to sit still and concentrate (Van den Berg
and Van den Berg, 2011). Many local and Indige-
nous groups have long called for systemic changes
in public educational systems to respect the tra-
ditions, knowledge, languages, values, history and
identities of their cultures. As a transdisciplinary
approach to solving complex problems, local, in-
digenous education holds the profound potential
to address the array of forest, health and sustain-
ability challenges facing the planet (Cajete, 2012;
Fernandez-Llamazares et al., 2022).
Box 5.2
The importance of visuals
Visuals help viewers to better retain mes-
sages than if they are in written form. About
a decade ago, British lm-maker David Bond
became concerned about his children spend-
ing too much time indoors. He decided that it
was time to reconnect children with nature,
and initiated ‘Project Wild Thing’. He direct-
ed a lm in which he, as a father, attempts,
mostly with little success, to get his own
daughter and son off the couch and into the
outdoors. The lm, which is available for free
on YouTube, is entertaining, and has reached
a large audience. Project Wild Thing also re-
leased a popular short animation in which
the health benets of nature are explained in
less than 90 seconds.
Today, Project Wild Thing has evolved into
The Wild Network, a coalition of organisa-
tions eager to encourage children and par-
ents to get into the great outdoors.

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182
There is growing recognition of forests or wood-
lands as interconnected systems, with their own
means of communicating among trees and other
elements, through biochemical compounds spread
via the air and the roots (Wohlleben, 2016). Indig-
enous people have long recognised this intercon-
nectedness of forests and the reciprocal relation-
ship with human health and wellbeing (Arnold
et al., 2021). Making students aware of forests as
interconnected systems is an important element
in both formal and nonformal education about the
health benets of forests. However, educators need
to consider different cultural backgrounds and en-
try levels of students when it comes to their open-
ness to a more holistic, spiritual approach.
Figure 5.5
Actions promoting connectedness to and disconnectedness from nature
Connectedness to Nature Disconnectedness to Nature
Environmental
protection
Place-based
experiental
learning
Social trust
Kinship –
sense of
belonging to
the natural
world
Inclusive
processes
Empathy
Willingness
to help
Agency Close
contact
Community
driven
Inter-
generational
transmission
of knowledge
Customary
beliefs,
languages &
traditions
intact
ACTIONS TO PROTECT NATURE
Industrialisation
Land as a
commodity
Indoor
lifestyles &
education
Proliferation of
technology
Species
extinction
Urbanisation
Diminished
access to
nature
Dominion
over nature
Erosion of
social
cohesion
and trust
Human and
environmental
impoverish-
ment
ACTIONS WHICH DEGRADE NATURE
Source: IPBES, 2022
In general, nature education, aims to (re)con-
nect children and adults to nature, as an impor-
tant pathway to deriving the health benets of
nature. Figure 5.5 illustrates the actions, related
to protection and degradation of nature, involved
in the processes of becoming connected to or dis-
connected from nature (IPBES, 2022). An ongoing
trend creating a chasm between people and na-
ture, is the proliferation of technology. However
social media can also change public perception,
and raise awareness of environmental issues, with
subsequent policy impact (Mavrodieva et al., 2019).
5.5.3 Shifting the focus: Forest managers as a
target group for communications and education
Historically and presently, most national for-
est management systems have developed with
a focus on timber extraction with a short-term
economic lens and narrow spectrum of uses. In
light of research ndings demonstrating the crit-
ical role of forests in supporting human health,
mitigating climate change and curbing species
extinction, it is urgent to tailor communications
to forest managers and policymakers about the
need to manage forests for multiple goals, includ-
ing health. Interestingly, this policy reform is cur-
rently taking place mostly in more low-income
parts of the world, but in some medium- and
high-income countries as well. In countries such
as Argentina, Brazil, India, Mexico, the Philippines
and South Korea, forestry ministries and training
programmes are being restructured to encompass
a wide-ranging view of the human health benets
which forests offer, as well as ofcially recognis-
ing the advantages of community and indigenous
forest management systems. For example, in Bra-
zil, ofcial forest management training includes
identication and understanding of the nutri-
tional and medicinal values of non-timber forest
products to urban and rural populations during
forest inventories and harvesting (Neri-Numa et
al., 2018). In the Philippines, forestry ofcials have
updated policies in support of traditional resource
management systems. The Mexican government
based sustainable management regulations of

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183
chicle on local stewardship practices and em-
bedded this within national legislation (Shanley
et al., 2002). And in some regions, Indigenous
knowledge regarding the use of re as a valuable
tool rather than a threat, is now recognised and
used as an intentional and legitimate instrument
to maintain forest resources (Trauernicht et al.,
2015).
Parallel to policy reform in forestry manage-
ment, innovations are also occurring in forest-
ry education. At the Tropical Research Centre
(CITRO) at the University of Veracruz in Xalapa,
Mexico, traditional farmers have transformed a
ve-acre forest on campus into a research area
collaboratively managed with Indigenous peoples,
where students learn forestry techniques from
rural farmers. The Ministry of Education in the
Philippines has revised elementary and secondary
education whereby traditional ecological knowl-
edge, values and skills are integrated into the
school curricula and bilingual teaching materials.
Time spent in forests with elders learning forest
traditions, is now ofcially acknowledged as be-
ing in school, thereby introducing responsibility
and knowledge about forest management during
an early life stage (Quierrez and De Beer, 2014). In
Argentina, a United Nations Environment Pro-
gramme (UNEP) project is bridging scales and
sectors, resulting in strengthening national and
provincial regulations to support sustainable
management and use of high conservation value
forests at the landscape scale. This is being accom-
plished through education, participatory work-
shops, forest enrichment, and new nancial mech-
anisms to support trade in medicinal and food
plants as a source of genuine employment, health
and nutrition while empowering local smallhold-
ers, mainly women (Sharry et al., 2022).
Multi-institutional collaborative research
through the European Forest Institute (EFI), is
highlighting the bio-economies of standing for-
ests and communicating to policymakers and the
public the profound value of cultural landscapes
to urban and rural lifestyles and human health
(Malkamäki et al., 2022). In the USA, the Nature Rx
programme encourages medical prescriptions on
spending time in nature for health purposes. Such
programmes are not actually new, but a re-emer-
gence of the therapeutic use of nature that existed
in the late 19th and early 20th centuries (Crnic and
Kondo, 2019). University campuses from Asia to
the Americas are also beginning to promote time
spent in nature and forests as an essential anti-
dote to the stress of college life (Rakow and Eells,
2019).
5.5.4 Solutions
From a communications perspective, it is im-
portant to shift the focus of messages from in-
forming people about the evidence for health
benets of forests to building understanding of
why forests are benecial for health and wellbe-
ing. While mere exposure to forest environments
can already set into motion a wealth of bene-
cial effects including lower stress levels and en-
hanced resilience, such direct effects are hard to
understand intuitively, and cannot be explained
by secondary causes, such as exercise or fresh air
(Marselle, 2019). Relevant explanations that are
not yet broadly known may include immune func-
tion support deriving from contact with a bio-
diverse environment (Rook et al., 2017) or frac-
tal patterns in nature as an easy-to-process in-
put for the human visual/perceptual system
that is grounded in human evolutionary history
(van den Berg et al., 2016).
From an educational perspective, informal
learning through hands-on experiences and teach-
ing practical skills are essential tools for recon-
necting people with nature as a basic requirement
for overcoming fears and reaping the health bene-
ts of forests. Trends in both educational research
and practice encourage outdoor and environmen-
tal education in which learning is based on a com-
bination of experiences in forests, community and
culture, centring on stories, ecologies, languages,
histories and politics embedded in place (Orr, 2004;
Cajete, 2012). However, forest-based education re-
mains the exception, as it is often unavailable,
costly and/or inaccessible. Therefore, formal recog-
nition and implementation by national education-
al systems of forest-based learning, cross-genera-
tional knowledge transmission and a wider range
of outdoor, experiential approaches, would allow
greater engagement of school children with for-
ests, leading not only to personal health gains, but
long-term connections with nature, place and im-
proved local stewardship.
As the impacts of climate change intensify, a
global movement with signicant representation
from young people has emerged which provides a
contemporary model of effective communication
and education (Bowman and Pickard, 2021). While
this movement has garnered substantial attention
from policymakers, the public and youth, forests,
are sometimes missing from the messaging. This
oversight reects a persistent lack of comprehen-
sion as to the vital role that forests play in human
and planetary health. Moving forward, increased
time in forests, and intersectoral cooperation is

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
184
needed to help the public and policymakers appre-
ciate the synergistic effects of forests on climate
resiliency, biodiversity protection and human
health.
5.6 Response Options Related to Governan-
ce and Economics
5.6.1 Introduction
Human health benets of forests often do not
feature strongly, nor explicitly in governance and
economics. Instead, other ecosystem services of
forests, such as climate change mitigation and
adaptation and biomass production, have often
been prioritised. If human health benets are ad-
dressed, it is mostly implicitly. At the global level,
for example, in the UN Strategic Plan for Forests
2030, Strategic Goal 2 calls for enhancing forest-
based economic, social and environmental bene-
ts, including the livelihoods of forest-dependent
people (United Nations, 2019). However, the goal
mentions food security and clean drinking water
but not human health specically.
The section starts with an introduction to di-
mensions of governance arrangements relevant
to health benets of forests, followed by a discus-
sion of economic issues and innovations. Possible
solutions presented are based on case studies of
successful inclusion of health benets in forest
governance and economics.
5.6.2 Aspects of governance relevant
for health benets of forests
Governance arrangements involve the dimensions
of discourses (i.e., the key narratives under dis-
cussion), actors and the alliances they can form,
resources (including power) that are mobilised by
actors in decision-making, and the rules of the
game in terms of the ways in which decision-mak-
ing is structured (Arnouts et al., 2012). Forest and
wider landscape governance are complex, as they
involve a wide range of discourses, actors, resourc-
es and rules of the game, often at the intersection
between forestry and other sectors.
Discourses
With regard to discourses, policies and pro-
grammes at different scales highlight the essential
contributions of forests, but the links to health are
often more indirect or implicit. Forest policies that
fully recognise and include health considerations
can help with avoiding or minimising potential
conicts and trade-offs, as well as assist with pri-
oritising forests in land-use planning lobal. Glob-
ally, the recent Worldwide Fund for Nature (WWF)
report on the vital role of forests for human health
for all types of communities is a good example of
a new discourse that includes the functions of for-
ests for human health (Beatty et al., 2022). In the
UK, forest policies specically highlight human
health benets (Department for Environment Food
and Rural Affairs (DEFRA), 2021). Other countries,
like China, have also started highlighting the hu-
man health benets of forests, especially in an ur-
ban context (Pei et al., 2019). At the local level, one
of the key objectives of Melbourne’s Urban Forest
Strategy is to promote human health and wellbe-
ing. A priority of the strategy is to design urban
forests for health and wellbeing, enhancing cool-
ing effects and encouraging the recreational use of
public green spaces (City of Melbourne, 2014).
Actors and alliances
The need for more collaboration and coordination
between different governance actors is another
key issue. Although forest governance has started
to include a wider range of actors, there is still a
lack of involvement of key actors such as the med-
ical eld as well as Indigenous and/or forest-de-
pendent populations. Perhaps the most promising
governance approaches along these lines have
been developed in urban areas, where the health
benets of urban forests are often prioritised. Here
we also see new partnerships and policy alliances
emerge that slowly start engaging with the medi-
cal eld. Examples of this are the green prescrip-
tion programmes, such as PaRx in Canada (PaRx,
2022) which represent alliances between the med-
ical sector, green space sector and policymakers
(James et al., 2019; Kondo et al., 2020). In these pro-
grammes, physicians are encouraged to prescribe
spending (active) time in nature for different ail-
ments. Similar thoughts are integrated into the
regional Natural Health Service programme in the
UK (Natural Health Service, 2022) which connects
to forestry actors that have started prioritising the
health benets of forests. Increasingly, global pol-
icies and programmes are starting to consider ur-
ban forests and other green spaces, climate adap-
tation, public health and biodiversity conservation
(WHO, 2016; UNECE, 2021).
Resources
A wide range of government resources needs to
be mobilised for the optimisation of forest health
benets, from mainly raising awareness about the
health benets of forests to dedicated policy plans
and funding streams, legislations and regulations,
and management plans and strategies. When it
comes to raising awareness, government agencies

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185
A strong connection to nature enhances human wellbeing
Photo © Nelson Grima

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
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are key actors, but not-for-prot organisations can
also play an important role, as demonstrated by
the example of The Nature Conservancy (TNC) in
the USA (The Nature Conservancy, 2022). As part of
its strategic goals for 2030, TNC has included ‘Our
Nature’s Health is our Health’ and issued a series
of research reviews and policy briefs to inform de-
cision-making at national, regional and local lev-
els (e.g., House et al., 2016). Another example is the
Flemish ‘Dokter Bos’ (Doctor Forest) programme
targeted at healthcare institutions and other
stakeholders (Bos+, 2022). A key aspect of resourc-
es is that of power and power relations, as these
determine which discourses are prioritised, who
has a say and who takes the decisions. As such,
power issues need to be explicitly addressed, also
when it comes to including the knowledge and in-
terests of IPLCs.
Rules of the game
A nal relevant dimension of governance relates
to the rules of the game, i.e., the ways in which
decision-making is structured and organised. Cur-
rently, forest policies, as well as health and other
policies, are often organised sectorally, whereas
cross-sectoral approaches may be more appro-
priate. This implies bringing in actors from oth-
er sectors in decision-making, also to foster the
new alliances and actor constellations mentioned
above. The example of other key forest contri-
butions, such as water, can provide inspiration,
where some cross-sectoral governance approach-
es using regulatory and information instruments
have been set up (see Baulenas and Sotirov, 2020,
for an example of EU member states). Beatty et al.
(2022), in their recent report on the importance
of forests to human health, call for systems and
collaborative approaches. The authors note that
improving forest and land management requires
removing economic incentive structures and pol-
icies that reward forest conversion and weak gov-
ernance systems unable to control illegal logging
and forest conversion. They call for cross-sectoral
governance and management approaches, for ex-
ample, involving agriculture and public health.
Urban forest governance in the USA is a true part-
nership endeavour between the federal, state and
local governments, but also not-for-prot organi-
sations such as American Forests. An example of
this is the Tree Equity Score tool (American For-
ests, 2022), which assesses cities for their (non-)
equitable provision of access to urban forests, in-
cluding access to their important health benets.
The involvement of not-for-prot organisations
like the ParkRx partnership programme between
the forest sector on the one hand, and the medi-
cal sector on the other, are other good examples
of this effort. As the health of local communities
is concerned, mechanisms need to be in place to
involve these communities and their interests
in governance processes. This also relates to the
tenth sustainable development goal (SDG 10) on
reduced inequalities within and among countries
and greater environmental justice (Basnett et al.,
2019) and the recent call for ‘tree equity’.
5.6.3 Economic issues and innovations
Governments often overlook the value of their
natural resources, typically due to many of these
resources not having clear market prices. In
many low- and middle-income countries, govern-
ments sell or even gift forest land to companies
looking to exploit it (Cisneros et al., 2021). The
government may receive a one-time payment or
some sort of stream of rents from the compa-
nies, but the amount often neglects accounting
for an assortment of services the forest provides
to the wider community. In many areas of the
world, deforestation and land use change have
been associated with increased disease risks due
to loss of services provided by healthy forests
such as air and water purication, which may in
turn lead to additional health expenses for gov-
ernments through lost workdays, incurred treat-
ment costs and death (Pattanayak and Wendland,
2007; Pattanayak et al., 2009; Bauch et al., 2015).
Additionally, by allowing a company to deforest,
governments fail to take into account the extent
to which residents rely on the forest for their live-
lihoods (Miller et al., 2020). Accounting for these
neglected values may help to consider forests’
real costs and benets, prompting governments
to prioritise forest conservation rather than sell-
ing forest land.
A solution to counteract the drivers of deforesta-
tion that has grown in popularity in recent years
is establishing Payments for Ecosystem Services
(PES) schemes. The concept of PES emerged in the
early 1990s aiming to integrate the economic value
of ecosystem services into market prices. This con-
cept is based on the idea that those in charge of
managing landscapes that provide ecosystem ser-
vices should be compensated by those who benet
from these services (Pagiola and Platais, 2002; Van
Hecken et al., 2015). Although compensating stew-
ards of ecosystems for their benecial land man-
agement practices already existed for a long time
in different forms, the concept of PES provided the
necessary structure to optimise and replicate this
idea (Wunder et al., 2008). The initial denitions of
PES proved to be limited, and often did not reect

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
187
the reality on the ground (Muradian et al., 2013).
Consequently, authors have kept revisiting the
conceptualisation of PES to provide more suitable
denitions based on lessons learnt (Wunder, 2015).
Despite the concept of PES being criticised by some
authors for putting a price on nature (McCauley,
2006; Peterson et al., 2010; Midler et al., 2015) and
for limitations on implementation and outcomes
(Schröter et al., 2014), the fact is that PES schemes
are a tool widely used by governments, NGOs and
private enterprises, which nowadays not only ad-
dresses ecosystem degradation, but also aims to
improve the socio-economic context of the actors
involved (Hayes et al., 2019).
Some PES schemes aim to address the ob-
served lack of balance between high-income (and
sometimes middle-income countries) willing to
pay for forest conservation, and the many forests
with high conservation values and high levels of
ecosystem services that tend to be in low-income
countries, where residents are often incentivised
to cut down forests for agriculture or to harvest
from them at unsustainable rates (Milder et al.,
2010). PES schemes have the potential to bridge
this gap and make both parties better off. Howev-
er, the established markets are often unclear, and
corruption can lead to payments being captured
by elites before they reach the local level. Direct
and transparent channels are needed between
these groups of countries to reach the full con-
servation potential of PES. Further streamlining of
payment channels from governments or private
enterprises – both within countries and across
countries – to individuals could aid in PES schemes
being adopted more widely. Here it is important to
also consider individual forest owners and forest
managers, as they are often insufciently reward-
ed for the health (and other) benets provided by
their forests.
5.6.4 Solutions
Tackling governance issues related to health ben-
ets of forests requires a change in the forest
conservation and land-use discourse, as well as
collaboration and new alliances between govern-
ments, markets and civil society actors, mobili-
sation of resources, and changes in governance
rules of the game. Opportunities exist, for exam-
ple, linking the health aspects of forests to the
discourses that highlight the important role of
forests in climate change action, biodiversity con-
servation, poverty alleviation and securing liveli-
hoods. This will require better linking SDG 3 with
other SDGs when it comes to forests, strengthen-
ing health objectives in global, national, and local
forest policies and programmes, as well as bring-
ing forest aspects into public health policies and
programmes.
Cross-sectorally, little has been done so far to
promote approaches specically for the health
benets of forests, unlike in other areas such as
biodiversity and water. Recent initiatives of the
American government that mobilise urban forests
to protect vulnerable communities (and workers)
from heat can be mentioned (The White House,
2021). This work is supported and implemented by
various agencies, including, but not limited to, the
US Forest Service, which issued a report on climate
adaptation actions for urban forests and human
health, explicitly linking several key areas of policy
(Janowiak et al., 2021). The report synthesises ad-
aptation actions to address climate change in ur-
ban forest management while also promoting hu-
man health and wellbeing through nature-based
solutions.
From an economics perspective, the lack of
consideration of forest health benets is not un-
like that of many other (especially cultural) forest
ecosystem services. Currently very few econom-
ic assessment methods are in place that include
health impacts of forests and trees, apart from
some initial attempts to monetise the value of for-
ests and trees in urban contexts. It is important to
include health benets in ecosystem service valu-
ation, as these can be substantial, for urban, rural
and forest-dependent communities alike. From a
market perspective, PES schemes are one mecha-
nism to address the health benets of forests, but
only a few examples are available, often at a more
local level. To date, the focus of PES schemes and
subsidies has been mostly on other benets of
forests, such as carbon storage, water protection
and biodiversity conservation. PES needs to en-
sure that forest owners and managers, from pub-
lic actors to local communities, benet nancial-
ly. Box5.3 provides an example from Italy, based
on the phenomenon of ‘forest bathing’ or ‘forest
therapy’, which was developed in Japan and oth-
er Asian countries where it has become common
practice (Hansen et al., 2017; Li, 2018).
For markets to develop, it is important for the
green economy around health benets of forests
and trees to mature, based on market outlooks, op-
portunities, local entrepreneurship and improved
knowledge of these benets. This could be done
through the emergence of green entrepreneurs at
the interface between forests and healthcare, but
also in relation to activities such as forest recre-
ation and tourism. The European Green4Care pro-
ject has looked into ‘green care’ and prepared a se-
ries of European market outlooks for this activity,

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
188
including forest-based care and urban green care
(Green4Care, 2021). Moreover, markets need to be
fair and inclusive of the interests of local commu-
nities, especially those in low- and middle-income
countries.
In summary, good governance and market in-
clusion of the health benets of forests, both pos-
itive and negative, require full integration of these
benets in all relevant strategies, policies, assess-
ments and markets. Moreover, dedicated initiatives
Box 5.3
Forest therapy in northern Italy
In 2014, the Terapia Forestale in Friuli
Venezia Giulia project was established in the
Natisone Valleys of northeastern Italy with
nancing from the regional government. This
forest therapy project aimed to establish a
base to attract sustainable health tourism,
following the notion that the abundance of
nature in the region would have a wide range
of psychophysical benets, in particular re-
garding anxiety and respiratory issues (Droli
et al., 2021). This notion was guided by the
outcomes of previous studies and clinical
trials stating the health benets of spending
periods of time as short as a week in similar
conditions (Saretta et al., 2007)
As part of the project, the association
Malin-Mill was created to manage and co-
ordinate the development of activities such
as forest bathing, to train local residents to
become forest therapy guides, and to inves-
tigate the potential of the region for the pur-
pose of health tourism (Malin-Mill, 2022). The
association also aims to promote further aca-
demic research in the region, such as a study
conducted in a path called Cascata di Kot, a
short walking route through a broadleaved
forest culminating in a waterfall that proved
to lower the anxiety levels of its users (Droli
et al., 2018).
Public funding of this project is com-
bined with private funding, not only through
the in-situ expenditures of tourists, but also
through initiatives created by Malin-Mill. One
of these initiatives is called Adotta un Sentiero
(Adopt a Path), and focuses on channelling
donations from the general public into di-
rectly maintaining existing historical paths
and managing the forests in which these
paths are located.
The initial success of the project attracted
the attention of further public and private or-
ganisations and academic centres (e.g., local
governments, universities, health providers),
which in turn allowed for further investment
and the expansion of the project to the for-
ests of neighbouring municipalities. This ex-
pansion included the presentation in 2020 of
a full programme of activities named Servizi
Ecosistemici per la salute umana (ecosystem
services for human health) to be implement-
ed in the region for the period 2021-2023.

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
189
are needed that focus on health aspects, inspired
by some of the examples provided in this section.
Governance, economic assessments and markets
need to be inclusive and address the interests and
stakes of local communities.
5.7 Conclusions
This chapter has given an overview of the re-
sponse options available for putting into action
the evidence for health benets of forests, as de-
scribed in the previous chapters. Five areas for
action are distinguished: the management of
access; spatial dimensions; design; communica-
tions and education; and governance and eco-
nomics. Across these areas, some common solu-
tions emerge. Perhaps the most crucial of these
is the need to explicitly include and acknowledge
human health as an important value (or ecosys-
tem service) in the development of visions, plans
and other strategic policy documents pertain-
ing to forests. As noted in the section on design,
benets of forests for human wellbeing are still
mostly considered in terms of recreation and aes-
thetic values. However, as this report makes clear,
health constitutes a distinct value that cannot
be fully optimised by promoting recreational and
aesthetic values. To realise the health benets of
forests, national forest management programmes
need to undergo transformation from a single
lens focus on timber, to a broader focus on the
urgent priorities of planetary and human health.
This requires updating forestry programmes to
include the nutritional, cultural, ecosystem ser-
vice values and human health benets offered by
forests.
Once health benets of forests are recognised
in strategic plans, the next question becomes:
what can be done to (better) realise them? This
chapter makes clear that many evidence-based as
well as practice-based options are available. How-
ever, as noted in the section on governance, put-
ting these options into practice requires a system
change in the world of forestry, with more open-
ness to collaboration and new alliances between
governments, markets, and civil society actors,
mobilisation of resources, and changes in govern-
ance rules of the game. Although this represents a
major challenge, even small initiatives, like mak-
ing an animation movie about health benets of
nature (Box 5.2.) can have big impacts and set into
motion a train of positive actions. Successful local
examples, like the creation of a health-based man-
grove park in Malaysia (Box 5.1.) and the forest
therapy project in Italy (Box 5.3.) can also inspire
similar initiatives in other regions and countries.
While taking the steps towards a new, more
health-focused approach to forests, three impor-
tant and recurrent lessons from this chapter need
to be taken into account. First, response options
towards optimising the positive impacts of forests
on human health should consider and adequate-
ly address, possible negative health impacts (e.g.,
proximity increases the ability to derive health
benets, but at the same time also makes people
more vulnerable to risks such as forest res). Sec-
ond, it is important to distinguish between differ-
ent types of populations, and more specically ur-
ban, rural and forest-dependent communities, as
these will have different needs and requirements
vis-à-vis the forest. Finally, there may be trade-offs
between options aimed at managing the health
of forests, and options aimed at managing forests
for the health of people, that need to be taken into
consideration.

5. RESPONSE OPTIONS: ACCESS, SPATIAL DIMENSIONS, DESIGN, COMMUNICATIONS AND ECONOMICS
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6

201
Chapter 6
Key Messages and Conclusions
Coordinating Lead Author: Cecil Konijnendijk
Lead Authors: Agnes van den Berg, Matilda van den Bosch, Payam Dadvand, Dikshya Devkota,
Stephanie Mansourian, Liisa Tyrväinen, Sjerp de Vries and Christoph Wildburger
TABLE OF CONTENTS
6.1 Overview .................................................................................................................................................... 202
6.2 Key Messages and Implications for Decision-Makers ........................................................................... 203
6.3 Research Priorities and Knowledge Gaps ............................................................................................... 210
6.4 Transformations towards Integrative Policies and Initiatives for Forest-Health Outcomes ............. 213
6.5 References .................................................................................................................................................. 214

6. KEY MESSAGES AND CONCLUSIONS
202
6.1 Overview
In this chapter, we summarise key ndings that
have emerged from the GFEP assessment on for-
ests7 and health and discuss their implications
for decision-makers. We identify critical gaps in
knowledge that require further research and con-
clude by reecting on the future of forest-human
health relations in light of contemporary chal-
lenges and opportunities, as well as a changing
global burden of disease.
This GFEP assessment has highlighted the im-
portance of forests, trees and green spaces for hu-
man health in settings and communities across
the globe. Urbanisation and a disconnect from
nature have contributed to the health challenges
faced by society today, such as malnutrition and
stress-related morbidity. The global burden of dis-
ease has shifted: non-communicable diseases, in-
cluding mental health problems, are on the rise,
while the same can be said for zoonotic diseases as
illustrated by the recent COVID-19 pandemic (The
Lancet, 2019). In many cases, health challenges are
directly or indirectly related to disturbed relations
between people and forests, or nature more gen-
erally. Logging, forest degradation and fragmenta-
tion associated with large-scale agriculture create
a launch pad for novel human viruses, improv-
ing and altering the habitats of disease vectors
(Dobson et al., 2020; Beatty et al., 2022; Chapter 4).
The expert panel has taken a broad view of for-
est-health relations, dening health in a compre-
hensive way, and looking at forests, trees outside
forests and other green spaces (see Chapter 2). The
importance of a more integrative perspective of
human health and the health of ecosystems and
other beings was stressed in Chapter 2, with the
use of novel frameworks such as the One Health
perspective.
Forests affect our physical, mental, social and
spiritual health in multiple ways, through a range
of direct and indirect pathways, as shown in Chap-
ters 2 and 3. Research has identied proven health
outcomes of forests for all human life stages,
starting from the prenatal stage. A systematic re-
view and meta-analysis of longitudinal epidemio-
logical studies found a strong correlation between
increments in green space surrounding homes
and reduced all-cause mortality (Rojas-Rueda et
al., 2019).
By far, most of the health outcomes are posi-
tive, but there are also some negative health out-
comes that need to be considered and mitigated.
Negative impacts, such as those related to zoonot-
7 All terms that are dened in the glossary of this report (Appendix 1) appear in italics the rst time they are mentioned.
ic diseases, are generally the result of disturbed
relationships between forests and people, and a
lack of good forest governance and management.
The COVID-19 pandemic is a clear illustration of
this disturbed relationship (IPBES, 2020; Beatty et
al., 2022).
Research to date on the links between forests
and health has focused predominantly on high-in-
come countries and urban communities, while
much less is known about forest-health relations
in low-income countries. In urban areas, proximi-
ty and exposure to forests, trees and green spaces
in general have been found to be essential for en-
hancing positive health outcomes. For rural and
forest-dependent communities, the pathways by
which forests affect health will be different than
for urban communities given that their livelihoods
are more directly dependent on forests (see Chap-
ter 4). Moreover, forest-dependent communities
are more directly affected by forest loss and deg-
radation. Evidence to date has been stronger for
some outcomes (e.g., mental health) than for oth-
ers (e.g., cancer prevention), although that is most
likely due to a lack of studies.
Health outcomes of forests are also depend-
ent on the types of forests and forest characteris-
tics. Chapter 4 offered a more in-depth analysis of
the role of different forest attributes, also further
elaborating on differences between forest-health
relations in urban, rural and forest-dependent
communities. It showed, for example, that almost
a quarter of all new drugs from 1981 to 2019 de-
rived from nature, and another 20% of new drugs
were mimicking nature (Chivian, 2002; CBD and
WHO, 2015; Newman and Cragg, 2020). This chap-
ter also highlighted the importance of forests in
low-income countries and the dependency of
many vulnerable communities on forests, also as
‘safety nets’ during times of crises (FAO, 2020). As
forests across the globe are increasingly threat-
ened by urbanisation, climate change, biodiversi-
ty loss and other negative trends (FAO, 2022), this
role has come under greater pressure. Chapter 4
also discussed a range of synergies and trade-offs
between health outcomes and various ecosys-
tem services provided by forests, demonstrating
that in many cases health and other services go
hand in hand. However, there can also be trade-
offs between services and priorities, for example,
between recreational uses of forests and tourism,
that need to be carefully managed.
This report also offered a series of response
options for strengthening the positive health out-
comes of forests and trees, while mitigating the

6. KEY MESSAGES AND CONCLUSIONS
203
negative ones. Chapter 5 in particular discussed
ways in which governance, spatial planning, man-
agement of access to forests, design, and commu-
nications and education can be directed towards
improving forest-health relations. This comes at
a time when these relations are still insufcient-
ly addressed by decision-makers, in forestry and
land use but also in the healthcare sector.
KEY MESSAGE 1
Forests, trees and green spaces impact
human health across all life stages
A growing body of evidence points to the (mostly
positive) impacts of forests, trees and green spaces
on human health (Chapter 3). This concerns
all life stages, starting from the prenatal stage
to the elderly. For example, exposure to green
space has been associated with longer telom-
ere length which is associated with slower cellu-
lar ageing (Martens and Nawrot, 2018; Miri et al.,
2020).
Forests and trees affect our physical, mental,
social and spiritual health through the various
sub-systems of the human body (e.g., nervous,
immune, cardiovascular and digestive systems).
They also enhance social interactions and social
health, and provide important spiritual benets.
Although all life stages are affected, the signicant
impacts on children deserve to be highlighted, not
least because of repercussions in later life. Medi-
cinal plants from forests and other ecosystems are
also an important component of health impacts
as they provide primary healthcare to 70% of the
world’s population (Chapter 4).
Decision-makers from different sectors and at
different scales, and specically those concerned
with forests and human health, need to have ac-
cess to the current knowledge on forest-health out-
comes, so that they can integrate this essential role
of forests, trees and green spaces in their strate-
gies and policies. Although some initiatives have
been taken recently, also at the global level (for ex-
ample, CBD and WHO, 2015; FAO, 2020; WHO, 2020;
FAO, 2022), much more remains to be done.
6.2 Key Messages and Implications for Decision-Makers
Several key messages that have implications for decision-makers at different scales can be derived from
this report (see Table 6.1 for an overview).

6. KEY MESSAGES AND CONCLUSIONS
204
KEY MESSAGE 2
Positive health outcomes of forests, trees
and green spaces signicantly outweigh
negative ones
The evidence collected in this report demon-
strates the multiple types of positive benets that
forests, trees and green spaces have on health
outcomes. These positive effects range from men-
tal wellbeing, to reduced cardiovascular events
and an overall reduction in mortality.
Yet, this report also shows that sometimes for-
ests and trees can have negative effects on human
health, for example, through zoonotic diseases,
reduced air quality because of forest res and al-
lergies. Evidence suggests that these negative im-
pacts result in most cases from factors such as the
disturbed forest-people relationship, poor forest
conservation and management or wrong tree spe-
cies choices in areas where people live (see also
WHO, 2011; CBD and WHO, 2015).
It is clear however, that positive health out-
comes from forest interactions far outweigh neg-
ative ones, with overall positive effects in terms of
reduced mortality and morbidity, improved birth
outcomes, and enhanced affect resulting in well-
being and happiness. Furthermore, where there are
negative health outcomes, the underlying causes
(e.g., tenure conict) often generate multiple ad-
verse outcomes on people, well beyond health.
Decision-makers in both the forest and health
domains need to understand the extent of the pos-
itive outcomes and ensure that they are secured
and enhanced through their effective integration
into policies and strategies. At the same time, neg-
ative impacts need to be managed and minimised,
for example through policies and management
that conserve healthy forests and promote healthy
forest-people relationships. Vulnerable popula-
tions are more signicantly affected and need to
be carefully considered in forest and health poli-
cies and management.

6. KEY MESSAGES AND CONCLUSIONS
205
KEY MESSAGE 3
The health outcomes of forests
are the result of several pathways
that are dependent on context and
individual lifestyles
Forests and trees affect health through multiple
pathways such as physical activity or the relief
of stress. All population groups are dependent
on forests for human health to some extent but
the intensity, the priority pathways and primary
health outcomes depend on the context and indi-
vidual lifestyles. This report has shown that con-
text matters, and that health outcomes of forests
and trees are different between low-, medium-
and high-income countries, as well as between
urban, rural and forest-dependent communities.
Differences also occur depending on life stage,
cultural background, gender, as well as many oth-
er factors. Policies and initiatives to promote pos-
itive health outcomes of forests and trees should
recognise these differences. Priorities and focus
will differ, reecting the diversity of roles, types
of forests, pathways, and so forth.
By better understanding the different path-
ways, decision-makers can promote opportunities
for more vulnerable populations to benet from
forests and trees, and better tailor responses to
different population groups – such as increasing
green spaces in disadvantaged neighbourhoods.

6. KEY MESSAGES AND CONCLUSIONS
206
Key message 4
Forest-health relations offer solutions
to global crises
The role that forests play in health outcomes may
provide solutions for tackling global crises, nota-
bly pandemics and climate change. In times of
crises, forests and trees provide important safe-
ty nets for vulnerable populations, but climate
change, urbanisation, land-use change and bio-
diversity loss all endanger this important role.
Global health crises, such as the recent
COVID-19 pandemic, can have devastating and
far-ranging impacts on human societies. The
links between forest-health relations and climate
change are many and cannot be understated
(WHO, 2020; 2022b). In cities, for example, green
spaces and trees contribute to cooling the effect
of infrastructure, which is especially important as
we anticipate more frequent heat waves (Masoudi
et al., 2019). Forests across the world are impact-
ed by climate change, resulting in a negative spiral
that includes an increase in forest res and forest
degradation, which in turn fuel the climate crisis.
Biodiversity loss is another global crisis that can
have adverse impacts on human health, for exam-
ple by affecting food security and more generally
on opportunities to be in contact with nature.
In the face of accelerating global trends and
challenges, with climate change leading the way,
there is an urgency for decision-makers to act. For-
ests are already an important component of cli-
mate change and biodiversity policies at the global
and other scales, but there is still a lack of aware-
ness and consideration of complex and important
forest-human health relations. Inclusion of the
forest-human health link in relevant policies is es-
pecially urgent as forests are also directly affected
by global change and trends.

6. KEY MESSAGES AND CONCLUSIONS
207
Key message 5
Integrative and cross-sectoral approaches
need to be adopted to improve the forest-
health link
A number of approaches that consider the hu-
man-nature relationship in a more inclusive
fashion have been recently developed. They in-
clude the One Health, Planetary Health and Eco-
Health frameworks, all of which stress the need
to link human health to the health of other be-
ings, of ecosystems and of the planet as a whole.
Such approaches hold the promise of improving
the understanding of the human-forest link and
its impact on human health.
Policies associated with health and forests, as
in other sectors, have often been siloed, failing to
properly integrate across disciplines and policy
areas. Although consideration of health outcomes
has recently emerged in forest policy, wider con-
sideration of the multiple impacts of forests, trees,
green spaces and other natural elements, on peo-
ple has often been lacking.
Forest-health interactions, as highlighted in
this report, offer an opportunity to broaden the
solution space – in policy, practice and steward-
ship – both for forest and health management.
As healthcare across the world is changing and
shifting its focus to more holistic approaches that
focus not only on curing but also on preventing
ill health, linking health and environment, univer-
sal health coverage, and building resilience in hu-
man populations (WHO, 2016; 2022a), forests and
trees need to be given due consideration in new
strategies. Equally, forest policies, conservation
and management have to recognise their essential
impacts on human health and consider this role
as one of the key aspects of forest and tree man-
agement.
Wider adoption of One Health, Planetary Health
and EcoHealth frameworks by both health and for-
estry decision-makers can lead to better consider-
ation of forest and health relationships, and the
design of more integrative solutions. These frame-
works can also help with gaining more in-depth
understanding of complex forest-health relation-
ships, for example by guiding new research. More
cross-sectoral policies and initiatives can build
on past efforts to link human health, biodiversi-
ty (with forests and trees as important elements)
and climate change (WHO, 2011; CBD and WHO,
2015; FAO, 2020). For forestry, as well as other dis-
ciplines and sectors that manage trees and green
spaces, better consideration of health impacts can
result in increased preservation and multi-target-
ed management of forests, trees and green spaces.

6. KEY MESSAGES AND CONCLUSIONS
208
Table 6.1
Summary table of key messages on forest-health outcomes and
implications for decision-makers
Key message
1. Forests, trees and green
spaces impact human health
across all life stages
By bringing together the evidence
and considering both direct and in-
direct pathways, it is clear that for-
ests affect human health in multiple
ways, through various sub-systems of
the human body (e.g., nervous, im-
mune, cardiovascular and digestive
systems) and across all life stages.
2. Positive health outcomes
of forests, trees and green
spaces significantly outweigh
negative ones
Positive health outcomes far out-
weigh negative health outcomes of
forest interactions, with overall posi-
tive effects on reducing mortality and
morbidity, improving birth outcomes
and overall wellbeing and happi-
ness.
3. The health outcomes of for-
ests are the result of several
pathways that are dependent
on context and individual
lifestyles
The intensity, the priority pathways
and primary health outcomes of for-
ests depend on context and individu-
al lifestyles, but all population groups
and communities are dependent on
forests for their health to some extent.
Implications
for decision-makers
Decision-makers should recognise
the multiple roles of forests and trees
in promoting human health across
life stages, and they should integrate
this role into forest, land use and
health policies and management.
Decision-makers should promote
and enhance the positive health
outcomes of forests and trees, while
minimising and managing potential
negative impacts especially on vul-
nerable populations.
When taking action and developing
policies, decision-makers should take
into account that forest-health rela-
tions will depend on contexts, life-
styles and socio-demographics.
Chapter
reference
Chapters 3, 4
Chapter 3
Chapters 2, 3, 4

6. KEY MESSAGES AND CONCLUSIONS
209
4. Forest-health relations need
to be considered when
dealing with global crises
The acceleration of negative global
trends and challenges, including cli-
mate change and pandemics, alters
and intensifies the importance of
forest-human health relations, and
requires urgent action.
5. Integrative and cross-
sectoral approaches need to
be adopted to improve the
forest-health link
Integrative and cross-sectoral ap-
proaches that apply One Health /
Planetary Health / EcoHealth per-
spectives can lead to better consider-
ation of the forest-health relationship.
Forest-health interactions offer an
opportunity to broaden the solution
space – in policy, practice and stew-
ardship – both for forest and health
management.
Decision-makers should acknowl-
edge the critical role of forest-health
relations in tackling global challeng-
es and crises. They also need to be
aware that this role is in turn impact-
ed by challenges such as climate
change.
Decision-makers in forest, health and
related domains should adopt more
integrative perspectives for address-
ing forest-human health relations.
By linking forest and human health
policies and strategies, new and in-
novative solutions can be identified.
Chapters 1, 2, 4
Chapters 2, 4, 5

6. KEY MESSAGES AND CONCLUSIONS
210
6.3 Research Priorities and
Knowledge Gaps
Although more is known today about a wide range
of forest-human health outcomes, there are also
many knowledge gaps. The evidence base on spe-
cic health impacts is growing, but remains frag-
mented. For example, there is more evidence for
green spaces (in cities in particular, such as ur-
ban parks) than for forests per se. This GFEP as-
sessment revealed a number of priority research
needs. Table 6.2 provides an overview of the most
pressing research priorities and associated ques-
tions, grouped under ve overall themes.
Research priority 1
Developing rigorous methods and studies
Many of the direct and indirect pathways that link
forests to human health outcomes need more in-
vestigation. Moreover, causality rather than cor-
relations needs to be conrmed (see Appendix
2). Finding innovative and viable solutions to en-
hance the positive health outcomes of forests will
also require knowing the impact of different forest
types and characteristics, in different contexts. To
do this, more robust research designs are needed
as well as different types of research designs giv-
en the complexity of forest-health relations. For
example, in light of the rise of reforestation and
afforestation projects, it would be valuable to have
more experimental studies including so-called
natural experiments where the health impacts
of new afforestation or greening projects can be
studied.
Research priority 2
Studying different populations and contexts
Not all populations, life stages and forest contexts
have been equally well studied when it comes to
forest-health outcomes. There are major gaps for
specic health outcomes as well as pathways. We
still know very little, for example, about spiritual
health benets of forests and trees. Urban con-
texts have so far been much better studied than
rural and forest-dependent ones, and the evi-
dence base is much stronger for most health out-
comes in high- rather than low-income countries.
Particular groups, such as Indigenous communi-
ties and vulnerable groups, should be given more
attention in future research. Studies are needed
that explore individual versus community-level
health outcomes.
Research priority 3
Strengthening the valuation, assessment
and sharing of health benets (and costs)
Sound valuation and assessment methods of for-
est-health outcomes are an essential part of deci-
sion-making. Assessment methods should include
health impact assessments of forests, trees and
greening projects. Valuations and assessments will
also provide an important background for the eq-
uitable sharing of health benets (and costs) and
need to consider full costs and benets, expressed
in monetary or other terms.
Research priority 4
Broadening the scope
Applying more holistic One Health, Planetary
Health or similar frameworks should also guide
research, so that studies of human health can
be linked to research on species and ecosystem
health. A more integrative perspective will contrib-
ute to studying the crucial climate-forest-health
nexus – an area where research has still been
limited. Understudied topics, such as the role of
medicinal plants and aspects of spiritual health,
need to be added to research agendas. Also of im-
portance is understanding the linkages between
forest and landscape management and zoonotic
diseases.
Research priority 5
Strengthening the science-policy interface
Research and new evidence underscore effective
policymaking related to both forests and health,
providing the evidence base to steer guidelines
and norms. The science-policy interface needs
strengthening, based on a more holistic view of for-
est-health outcomes. Not only do we need to know
“what works” in terms of positive health outcomes,
but also what does not work (and can potentially
generate negative impacts). The relationship be-
tween health outcomes and other forest impacts
needs to be studied, notably in terms of synergies
and trade-offs. Importantly, research can help
identify barriers as well as possible facilitators of
response options (e.g., policy priorities, funding,
institutions, land use, legislation, amongst others)
that enhance positive health outcomes and miti-
gate negative ones.

6. KEY MESSAGES AND CONCLUSIONS
211
Research priority
❥ Developing methods and studies
❥ Studying different populations
and contexts
❥ Strengthening valuation,
assessment and sharing of
health benefits (and costs)
Some key questions
• How can we design studies to learn more about different
direct and indirect pathways (and their suitability for health
promoting activities), including determining pathway causality
(e.g., what is the causal relationship between disease and
exposure) and dealing with residual confounding factors?
• What are the respective contributions of different forest types
and forest characteristics to different health outcomes?
• How can the health outcomes of different measures and
interventions be properly assessed?
• How can more tangible exposure measures be included in
research?
• How can natural experiments be used in research, for example
actual cases of greening or green loss?
• How can longitudinal studies, cross-scale studies and
intervention studies be designed in different contexts?
• Which design methods would best identify critical thresholds in
forest-health relationships?
• What are the differences in outcomes and pathways between
high-, medium- and low-income countries?
• What is the relative, context-dependent importance of different
pathways?
• How do forest-health outcomes affect Indigenous
communities?
• How can research better inform inclusiveness of vulnerable
groups?
• How do different worldviews and relationships with nature
affect health outcomes, for example in relation to mental and
spiritual health?
• How do individual and community benefits compare?
• What types of health impact assessments and economic
valuations of health benefits and costs can be carried out to
support decision-making?
• How can the results of valuation studies be best included in
forest and health decision-making?
Table 6.2
Research priorities and key questions related to forest-health outcomes

6. KEY MESSAGES AND CONCLUSIONS
212
• What are the synergies and trade-offs between forest-health
outcomes, but also between health outcomes and other
impacts of forests?
• How can access and benefit sharing be promoted to enhance
health equity?
• How can One Health and other integrative frameworks, guide
research, for example, to link ecosystem and species health to
human health (e.g., in relation to biodiversity, forest health, the
role of micro-organisms)?
• What is needed to promote joint research programmes across
the climate, forest and health disciplines?
• How can research on spiritual health in relation to forests
improve broader knowledge and decision-making on health?
• How do different landscape management types affect
outbreaks of zoonotic diseases?
• What can be done to develop a more comprehensive
knowledge base on medicinal plants, both at the regional and
global level?
• How can research better inform the development of
guidelines and norms, and more evidence-based planning and
management in forests and health?
• How can we deal with the mismatch between demand and
supply of positive health outcomes of forests in different
contexts?
• How do we generate more knowledge on what does not work
in terms of forest-health relations?
• How can research inform the carrying capacity of different
forests in terms of health outcomes?
• What are the barriers and facilitators (e.g., related to policy
priorities, funding, institutions, land use, legal aspects) to
options that aim to enhance positive health outcomes and
mitigate negative ones?
❥ Broadening the scope
❥ Strengthening the science-policy
interface

6. KEY MESSAGES AND CONCLUSIONS
213
6.4 Transformations towards Integrative
Policies and Initiatives for Forest-Health
Outcomes
In a world that is one third covered in forests –
where forests and trees play a critical role in the
maintenance of planetary life-support systems
such as pollination services, carbon and nutrient
cycling, food production and medicinal plants -
forests and human health are inextricably linked.
As a result, much more should be done to pro-
mote positive health impacts of forests and trees,
while mitigating negative ones. In order to do this
in a meaningful, impactful and equitable man-
ner, the combined efforts of the forestry, land
use and healthcare sectors are needed. Holistic
frameworks such as the One Health, Planetary
Health and EcoHealth perspectives can all guide
these efforts and ensure that the essential links
between human health, the health of other be-
ings, forest ecosystem health, as well as that of
the planet as a whole, are recognised.
As new strategies are rolled out to foster
healthy forest-people relations it is important to
apply cross-sectoral and transdisciplinary ap-
proaches. Health professionals should just as
much be part of forest-health initiatives as for-
esters and other natural resource professionals.
Forest-health outcomes need to be much better
integrated into health, forest and land use policies
and programmes. Specic attention should be giv-
en to the climate-forest-health nexus, as climate
change, forest health and human health are close-
ly intertwined.
Opportunities exist to make better connections
with other global and policy initiatives that fo-
cus on health and forests. The latter includes the
work within the Convention on Biological Diversi-
ty (CBD), where links between biodiversity and hu-
man health have been specically highlighted and
addressed (CBD, 2022). The two-way link between
the forest-health relationship and the Sustainable
Development Goals (SDGs) is fundamental and
bringing it to the fore can help to accelerate imple-
mentation of both agendas.
As the world is facing numerous planetary
challenges, this report provides decision-makers
with a sound knowledge base of available scien-
tic evidence on forest-health linkages, as well
as identifying priorities to foster transformation
towards more integrative policies and initiatives.
Forests, trees and green spaces are essential to
our health and wellbeing and much can be gained
from developing stronger and more positive rela-
tions between people and forests, while also en-
hancing the health of ecosystems and the many
other species with which we share this planet.

6. KEY MESSAGES AND CONCLUSIONS
214
6.5 References
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Folse, M. and Cody, A. 2022. The Vitality of Forests:
Illustrating the evidence connecting forests and human
health, Washington DC: Worldwide Fund for Nature.
CBD 2022. Kunming-Montreal Biodiversity Framework,
Montreal: Secretariat of the Convention on Biolog-
ical Diversity.
CBD and WHO 2015. Connecting Global Priorities: Biodiver-
sity and Human Health – A state-of-knowledge review.
Montreal and Geneva: Convention on Biological Di-
versity and World Health Organization.
Chivian, E. 2002. Biodiversity: its importance to human
health, Cambridge, MA: Center for Health and the
Global Environment, Harvard Medical School.
Dobson, A. P., Pimm, S. L., Hannah, L., Kaufman, L., Ahu-
mada, J. A., Ando, A. W., Bernstein, A., et al. 2020.
Ecology and economics for pandemic prevention.
Science, 369(6502), 379-381.
FAO 2020. Forests for human health and well-being –
Strengthening the forest–health–nutrition nexus, Rome:
Food and Agriculture Organization of the United
Nations.
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A

217
APPENDIX I: GLOSSARY OF TERMS AND DEFINITIONS
AAppendix I
Glossary
Adaptation (in relation to
climate change impacts)
Afforestation
Agroforestry
Anthropocentrism
(also ‘anthropocentric’)
Biodiversity
(= Biological diversity)
Climate change
Disability-Adjusted Life
Years (DALYs)
In human systems, the process of adjustment to actual or expected
climate and its effects, in order to moderate harm or exploit benecial
opportunities. In natural systems, the process of adjustment to actual
climate and its effects; human intervention may facilitate adjustment to
expected climate and its effects (IPCC, 2022).
Establishment of forest through planting and/or deliberate seeding on
land that, until then, was not classied as forest (FAO, 2010). According to
the denition used by the UNFCCC, afforestation can take place on land
that has not been covered by forest for at least 50 years.
A collective name for land use systems and practices in which woody
perennials are deliberately integrated with crops and/or animals on the
same land management unit. The integration can be either in a spatial
mixture or in a temporal sequence (World Agroforestry Centre, 2017).
There are normally both ecological and economic interactions between
woody and non-woody components in agroforestry (Leakey, 1996; Leakey
and Simons, 1998).
Valuing nature because of material or physical benets it can provide for
humans (Thompson and Barton, 1994)
The variability among living organisms from all sources including, inter
alia, terrestrial, marine, and other aquatic ecosystems and the ecological
complexes of which they are part; this includes diversity within species,
between species, and of ecosystems (CBD, 1992).
A change in the state of the climate that can be identied (e.g., by using
statistical tests) by changes in the mean and/or the variability of its
properties and that persists for an extended period, typically decades
or longer. Climate change may be due to natural internal processes
or external forcings such as modulations of the solar cycles, volcanic
eruptions and persistent anthropogenic changes in the composition of
the atmosphere or in land use.
Note that the United Nations Framework Convention on Climate
Change (UNFCCC), in its Article 1, denes climate change as: ‘a change of
climate which is attributed directly or indirectly to human activity that
alters the composition of the global atmosphere and which is in addition
to natural climate variability observed over comparable time periods’. The
UNFCCC thus makes a distinction between climate change attributable
to human activities altering the atmospheric composition and climate
variability attributable to natural causes (IPCC, 2022).
The World Health Organization (WHO) denes DALYs for a health
condition or disease as “the sum of the years of life lost to due to
premature mortality (YLLs) and the years lived with a disability (YLDs)
due to prevalent cases of that disease or health condition in a population”
(WHO online).

218
APPENDIX I: GLOSSARY OF TERMS AND DEFINITIONS
The conversion of forest to another land use, or the long-term reduction
of the tree canopy cover below the minimum 10% threshold (FAO, 2010).
Explanatory notes:
• Deforestation implies the long-term or permanent loss of forest cover
and implies transformation into another land use. Such a loss can
only be caused and maintained by a continued human-induced or
natural perturbation.
• Deforestation includes areas of forest converted to agriculture,
pasture, water reservoirs, and urban areas.
• The term specically excludes areas where the trees have been
removed as a result of harvesting or logging, and where the forest
is expected to regenerate naturally or with the aid of silvicultural
measures.
• Deforestation also includes areas where, for example, the impact of
disturbance, overutilisation, or changing environmental conditions
affects the forest to an extent that it cannot sustain a tree cover above
the 10% threshold (FAO, 2001).
See 'Forest degradation' and 'Land degradation'.
Acknowledging the intrinsic value of “non-human” nature and
ecosystems and not for the potential services they provide to human
beings (Batavia and Nelson, 2017).
An approach that is committed to fostering the health of humans,
animals, and ecosystems and to conducting research which recognizes
the inextricable linkages between the health of all species and their
environments (EcoHealth Journal Online).
The ability of a system to absorb impacts before a threshold is reached
where the system changes into a different state (Gunderson, 2000). See
also 'Resilience'.
A dynamic complex of plant, animal, and micro-organism communities
and their non-living environment interacting as a functional unit (CBD,
1992).
All of the physical, chemical, and biological actions performed by
organisms within ecosystems. Some of these functions are ecosystem
services, including production, pollination, nutrient cycling (e.g.,
decomposition, N2-xation), and carbon storage that directly benet
humans (MEA, 2005). Other examples include photosynthesis, predation,
scavenging, and herbivory.
The process of managing or assisting the recovery of an ecosystem that
has been degraded, damaged, or destroyed as a means of sustaining
ecosystem resilience and conserving biodiversity (CBD, 2016).
Ecological processes or functions having monetary or non-monetary
value to individuals or society at large (i.e., the benets people obtain
from functioning ecosystems). These include i) provisioning services such
Deforestation
Degradation
Ecocentrism
EcoHealth
Ecological resilience
Ecosystem
Ecosystem (or ecological)
functions
Ecosystem restoration
Ecosystem services

219
APPENDIX I: GLOSSARY OF TERMS AND DEFINITIONS
as food, water, timber, and bre; (ii) regulating services that affect climate,
oods, disease, wastes, and water quality; (iii) cultural services that
provide recreational, aesthetic, and spiritual benets; and (iv) supporting
services such as soil formation, photosynthesis, and nutrient cycling
(MEA, 2005).
A disease that is consistently present but limited to a particular region,
for example, malaria (CDC online).
An unexpected increase in the number of disease cases or behaviours in a
specic geographical area, for example West Nile virus and obesity (CDC
online).
The study and analysis of the distribution (who, when, and where),
patterns and determinants of health and disease conditions in a dened
population (Porta, 2014).
The ‘sameness’ of a distribution of attributes, such as income or
consumption, across a whole population (i.e., the state of being equal)
(Haughton and Khandker, 2009; Harris and Nisbett, 2018). A popular
measure of (in)equality is the Gini coefcient, which ranges from 0
(perfect equality) to 1 (perfect inequality), but is typically in the range of
0.3 to 0.5 for per capita expenditures.
Refers to how capabilities (e.g., access to health, education, and good
nutrition) are distributed within a certain group of individuals (Mora
and Muro, 2018). Inequity is the unequal distribution of capabilities (Sen,
1999).
A situation that exists when all people, at all times, have physical, social,
and economic access to sufcient, safe, and nutritious food that meets
their dietary needs and food preferences for an active and healthy life
(FAO et al., 2014). In contrast, ‘food insecurity’ exists when people lack
secure access to sufcient amounts of safe and nutritious food for normal
growth and development, and an active and healthy life. It may be caused
by the unavailability of food, insufcient purchasing power, inappropriate
distribution, or inadequate use of food at the household level. Food
insecurity may be chronic, seasonal, or transitory (FAO et al., 2014).
Land spanning more than 0.5 hectares with trees higher than 5 metres
and a canopy cover of more than 10 percent, or trees able to reach these
thresholds in situ. It does not include land that is predominantly under
agricultural or urban land use (FAO, 2010). Forests include both natural
forests (sensu CPF, 2005) and planted forests (sensu FAO, see below). It
also includes areas temporarily unstocked, e.g., after disturbance, that are
expected to revert back to forest.
For the purposes of this report dened as “forests and land, partly or
completely covered with trees, shrubs, grass or other vegetation, including
parks, street tree plantings, community gardens and cemeteries, but also
rooftop gardens and vertical gardens, meadows and woods”.
For the purposes of this report dened as “Clearance of natural forests
for other land uses, such as plantations, agriculture, pasture for cattle
settlements, mining, and infrastructure/urban development.” This process
is usually irreversible.
Endemic
Epidemic
Epidemiology
Equality (and its opposite:
Inequality)
Equity (also its opposite:
'Inequity')
Food security (also its
opposite ‘food insecurity’)
Forest
Forests, trees and green
spaces
Forest conversion (also
‘conversion of forests')

220
APPENDIX I: GLOSSARY OF TERMS AND DEFINITIONS
Changes within the forest which negatively affect the structure or
function of the stand or site, and thereby lower the capacity to supply
products and/or services (FAO, 2001, 2010). Also, when a forest delivers
a reduced supply of goods and services from a given site and maintains
only limited biological diversity; it has lost the structure, function, species
composition, and/or productivity normally associated with the natural
forest type expected at that site (ITTO, 2002).
For the purposes of this report, dened as “People that have a direct
relationship with forests and trees and live within or adjacent to forested
areas, and rely on them for their subsistence and/or income”.
For the purposes of this report, dened as “Any process that results in the
conversion of formerly continuous forest into patches of forest separated
by non-forested lands”.
Forest health can be dened as a condition of forest ecosystems that
sustains their complexity and resilience while simultaneously providing
for human needs (O'Laughlin et al., 1994; Teale and Castello, 2011).
The processes of planning and implementing practices for the
stewardship and use of forests and other wooded land, aimed at achieving
specic environmental, economic, social, and/or cultural objectives.
Includes management at all scales such as normative, strategic, tactical,
and operational level management (FAO, 2004).
Forest stands established by planting and/or seeding in the process of
afforestation or reforestation. They are either of introduced species (all
planted stands), or intensively managed stands of indigenous species,
which meet all the following criteria: one or two species at plantation,
even age class, regular spacing (FAO, 2004). (See also 'Plantation forest')
Those resources found in forests and other wooded land, and as trees
outside forests (FAO, 2004).
See ‘Restoration of forests’
Ecosystem services derived from forests.
For the purposes of this report, dened as “Deriving all or part of one’s
livelihood from the use of resources from forests and trees”.
Interactive processes through which society, the economy, and the
environment are steered towards collectively negotiated objectives (Ansell
and Torng, 2016). The concept includes the formation and stewardship of
both formal and informal rules that regulate the public, market, and civil
society actors that make and implement them (Hydén and Mease, 2004).
Health is a state of complete physical, mental and social wellbeing and
not merely the absence of disease or inrmity (WHO, 1946).
A group of countries classied as high income based on gross national
income estimates using the World Bank Atlas method (World Bank, 2023).
High-income economies are currently dened as those with a GNI per
capita of USD 13,205 or more in 2023 (See also ‘Low- and Middle-Income
Countries’)
Forest degradation
Forest-dependent
(-reliant) people (also
‘communities’)
Forest fragmentation
Forest health
Forest management
Forest plantation
Forest resource
Forest restoration
Forest services
Forest-based (or ‘-related
livelihood)
Governance
Health
High-Income Countries
(HIC)

221
APPENDIX I: GLOSSARY OF TERMS AND DEFINITIONS
An individual’s experience of their life as well as a comparison of life
circumstances with social norms and values (WHO, 2012a).
For the purposes of this report, dened as: Practices of harvesting trees
inconsistent with the national and subnational law.
Area in which entities, including humans, interact according to rules
(physical, biological, and social) that determine their relationships (Sayer
et al., 2013). The European Landscape Convention denes ‘landscapes’ as
part of the land, as perceived by local people or visitors, which evolves
through time as a result of being acted upon by natural forces and
human beings (ELC, 2000).
Key stages in people’s lives have particular relevance for their health. The
life-course approach is about recognizing the importance of these stages
(WHO, 2011).
The assets (natural, physical, human, nancial, and social capital),
activities, and access to them (mediated by institutional and social
relations) that together determine how an individual or household makes
a living (Scoones, 1998). This denition emphasises means rather than
outcomes of making a living, whereas poverty is typically an outcome
measure of livelihood performance (Sunderlin et al., 2005).
See ‘Traditional ecological knowledge’
A group of countries classied as low-income or middle-income based
on gross national income per capita estimates using the World Bank
Atlas method (World Bank, 2023). Low-income economies are currently
dened as those with GNI per capita of USD 1,085 or less. Middle-income
countries consist of two groups: lower middle-income countries with
a GNI per capita between USD 1,086 and USD 4,255 and upper middle-
income countries with a GNI per capita between USD 4,256 and USD
13,205. (See also High-Income Countries)
A human intervention to reduce emissions or enhance the sinks of
greenhouse gases (IPCC, 2022).
Refers to having a disease or a symptom of disease, or to the amount of
disease within a population (National Cancer Institute online).
Refers to death rate, or the number of deaths in a certain group of people
in a certain period of time (National Cancer Institute online)..
see ‘Non-Wood Forest Product’
Human wellbeing
Illegal logging
Landscape
Life-course approach
Livelihood
Local knowledge (also
Indigenous Technical
Knowledge, Traditional
Knowledge (TK),
Indigenous Technical
Knowledge (ITK), Local
Knowledge (LK), and
Indigenous Knowledge
System (IKS))
Low- and Middle-Income
Countries (LMIC)
Mitigation (of climate
change)
Morbidity
Mortality
Non-Timber Forest Product

222
APPENDIX I: GLOSSARY OF TERMS AND DEFINITIONS
All biological materials other than wood, which are extracted from
forests, other wooded land and trees outside forests for human use. In
addition to trees, forest products are derived from all plants, fungi, and
animals (including sh) for which the forest ecosystem provides habitat
(FAO, 2008).
A remote-sensing based method that quanties vegetation by measuring
the difference between near-infrared (which vegetation strongly reects)
and red light (which vegetation absorbs) (NASA website, 2000).
An integrated, unifying approach that aims to sustainably balance and
optimise the health of people, animals and ecosystems (OHHLEP, 2021).
An epidemic occurring worldwide, or over a very wide area, crossing
international boundaries and usually affecting a large number of people
(CDC online).
A type of economic compensation (monetary or otherwise) offered to
ecosystem managers as an incentive to apply practices that increase
or maintain the ow of goods and services provided by the land they
manage (Grima et al., 2018). These incentives are typically provided by
those who benet from environmental services, including local, regional,
and global stakeholders, but can also come from other sources such as
tax revenues.
Limits to self-regeneration of planetary resources and global ecosystems
in response to human resource use and modication (Rockström et al.,
2009).
The achievement of the highest attainable standard of health, wellbeing,
and equity worldwide through judicious attention to the human systems –
political, economic, and social – that shape the future of humanity and
the Earth’s natural systems that dene the safe environmental limits
within which humanity can ourish (Whitmee et al., 2015).
Planted forests that have been established and are (intensively) managed
for commercial production of wood and non-wood forest products, or to
provide a specic environmental service (e.g., erosion control, landslide
stabilisation, windbreaks) (Carle and Holmgren, 2003). (See also 'Forest
plantation')
A lessening of deprivation or disadvantage such that wellbeing is
improved. This lessening may include movement above a certain income
or consumption threshold, such as international or country-specic
poverty lines (termed ‘poverty reduction’ or ‘poverty elimination’). It may
also include a lessening in the degree of poverty experienced or avoiding
falling into poverty (termed ‘poverty mitigation’) (World Bank, 2001).
The art and science of preventing disease, prolonging life, and promoting
health through the organised efforts of society (Acheson, 1988).
An individual's perception of their position in life in the context of the
culture and value systems in which they live and in relation to their goals,
expectations, standards and concerns (WHO, 2012b).
Non-Wood Forest Product
(NWFP) (also ‘non-timber
forest products (NTFP)’)
Normalised Difference
Vegetation Index (NDVI)
One Health
Pandemic
Payments for ecosystem
(or environmental)
services (PES)
Planetary boundaries
Planetary Health
Plantation forest
Poverty alleviation
Public health
Quality of Life

223
APPENDIX I: GLOSSARY OF TERMS AND DEFINITIONS
A form of scientic experiment used to control factors not under direct
experimental control, thereby reducing bias and providing the highest
possible level of evidence (Concato et al., 2000).
Re-establishment of forest through planting and/or deliberate seeding
on land classied as forest after a temporary period (< 10 years) during
which there was less than 10 percent canopy cover due to human-
induced or natural perturbations (FAO, 2010). According to the denition
used by the UNFCCC, reforestation can occur on land that was forested
but that has been converted to non-forested land.
The capacity of interconnected social, economic and ecological systems
to cope with a hazardous event, trend or disturbance, responding or
reorganising in ways that maintain their essential function, identity and
structure. Resilience is a positive attribute when it maintains capacity for
adaptation, learning and/or transformation (Arctic Council, 2016).
For the purposes of this report dened as: Management applied in
degraded forest areas which aims to assist the natural processes of
forest recovery in a way that the species composition, stand structure,
biodiversity, functions, and processes of the restored forest will match, as
closely as feasible, those of the original forest.
Systems in which the interrelation and interdependence between social
and ecological subsystems is explicitly acknowledged and subject to
feedbacks (Ostrom, 2009).
A dynamic and evolving concept. Aims to maintain and enhance the
economic, social, and environmental values of all types of forests,
for the benet of present and future generations. The seven thematic
elements of sustainable forest management are: (a) extent of forest
resources; (b) forest biological diversity; (c) forest health and vitality; (d)
productive functions of forest resources; (e) protective functions of forest
resources; (f) socio-economic functions of forests; and (g) legal, policy,
and institutional framework. The thematic elements are drawn from
the criteria identied by existing criteria and indicators processes, as a
reference framework for sustainable forest management (UN, 2007).
Systems of tenure dene and regulate how people, communities, and
others gain access to land, sheries, and forests. These tenure systems
determine who can use which resources, for how long, and under what
conditions. The systems may be based on written policies and laws, as
well as on unwritten customs and practices (FAO, 2012).
The knowledge that an Indigenous (local) community accumulates
over generations of living in a particular environment. This denition
encompasses all forms of knowledge – technologies, know-how
skills, practices, and beliefs – that enable the community to achieve
stable livelihoods in their environment. A number of terms are used
interchangeably, including Indigenous Knowledge (IK), Traditional
Knowledge (TK), Indigenous Technical Knowledge (ITK), Local Knowledge
(LK), and Indigenous Knowledge System (IKS). It is unique to every culture
and society, and it is embedded in community practices, institutions,
relationships, and rituals. It is rooted in a particular community and
situated within broader cultural traditions (UNEP, 2008).
Randomised Controlled
Trial
Reforestation
Resilience
Restoration of forests
Social-ecological systems
Sustainable forest
management
Tenure
Traditional Ecological
(or forest-related)
Knowledge (TEK)

224
APPENDIX I: GLOSSARY OF TERMS AND DEFINITIONS
For the purpose of this report, an urban area (or urban agglomeration)
is dened as “a human settlement with a high population density and
infrastructure of built environment (all structures built by man to
support human activity (Portella, 2014))”.
An urban or metropolitan area that is signicantly warmer than its
surrounding rural areas due to human activities (Oke, 1973).
A disease or infection that is naturally transmissible from vertebrate
animals to humans (WHO online, 2020).
Urban area
Urban Heat Island
Zoonotic disease, zoonosis

225
APPENDIX I: GLOSSARY OF TERMS AND DEFINITIONS
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228
APPENDIX II: LIST OF PANEL MEMBERS, AUTHORS AND REVIEWERS
Thomas Astell-Burt
University of Wollongong
Wollongong, Australia
Email: thomasab@uow.edu.au
Nicole Bauer
Swiss Federal Institute for Forest, Snow and Land-
scape Research (WSL)
Zurich, Switzerland
Email: nicole.bauer@wsl.ch
Agnes van den Berg
University of Twente
Enschede, The Netherlands
Email: natuurvoormensen@gmail.com
Gregory N. Bratman
University of Washington
Seattle, USA
Email: bratman@uw.edu
Matthew H. E. M. Browning
Clemson University
South Carolina, USA
Email: mhb2@clemson.edu
Matilda van den Bosch
Barcelona Institute for Global Health (ISGlobal)
Barcelona, Spain
Email: matilda.vandenbosch@isglobal.org
Victoria Bugni
EcoHealth Alliance
New York, USA
Email: tori.Bugni@gmail.com
Payam Dadvand
Barcelona Institute for Global Health (ISGlobal)
Barcelona, Spain
Email: payam.dadvand@isglobal.org
Djibril S. Dayamba
African Forest Forum (AFF)
Nairobi, Kenya
Email: D.Dayamba@cifor-icraf.org
Dikshya Devkota
International Union of Forest Research Organiza-
tions (IUFRO)
Vienna, Austria
Email: devkota@iufro.org
Geoffrey Donovan
USDA Forest Service
Oregon, USA
Email: geoffrey.donovan@usda.gov
Xiaoqi Feng
University of New South Wales
Sydney, Australia
Email: xiaoqi.feng@unsw.edu.au
Elaine Fuertes
Imperial College London
London, UK
Email: e.fuertes@imperial.ac.uk
Emma Gibbs
European University Institute
Florence, Italy
Email: Emma.Gibbs@eui.eu
Nelson Grima
International Union of Forest Research Organiza-
tions (IUFRO)
Vienna, Austria
Email: grima@iufro.org
Cecil Konijnendijk
University of British Columbia
Vancouver, Canada
Email: cecil.konijnendijk@ubc.ca
Appendix II
LIST OF PANEL MEMBERS, AUTHORS
AND REVIEWERS
Panel Members and Authors

229
APPENDIX II: LIST OF PANEL MEMBERS, AUTHORS AND REVIEWERS
Sarah Laird
Peoples and Plants International
Vermont, USA
Email: sarahlaird@aol.com
Stephanie Mansourian
Consultant, Environment and Development
Gingins, Switzerland
Email: smansourian@infomaniak.ch
Serge Morand
Centre National de la Recherche Scientique
(CNRS)
Paris, France
Email: serge.morand@umontpellier.fr
Cristina O'Callaghan-Gordo
Universitat Oberta de Catalunya (UOC)
Barcelona Institute for Global Health (ISGlobal)
Barcelona, Spain
Email: co_callaghang@uoc.edu
Unnikrishnan Payyappallimana
University of Transdisciplinary Health Sciences &
Technology (TDU)
Bangalore, India
Email: unnikrishnan.p@tdu.edu.in
Ranaivo Rasolofoson
Duke University
North Carolina, USA
Email: rrasolof@gmail.com
Roseline Remans
Alliance of Biodiversity International and CIAT
Geneva, Switzerland
Email: r.remans@cgiar.org
David Rojas-Rueda
Colorado State University
Colorado, USA
Email: David.Rojas@colostate.edu
Giovanni Sanesi
University of Bari
Bari, Italy
Email: giovanni.sanesi@uniba.it
Joshitha Sankam
Indian Institute of Science
Bangalore, India
Email: joshitha95@gmail.com
Charlie Shackleton
Rhodes University
Grahamstown, South Africa
Email: c.shackleton@ru.ac.za
Patricia Shanley
People and Plants International
Woods & Wayside International
New Jersey, USA
Email: pshanley@woods-wayside.org
Shureen Faris Abdul Shukor
Universiti Putra Malaysia
Selangor, Malaysia
Email: shureen@upm.edu.my
Giuseppina Spano
University of Bari
Bari, Italy
Email: giuseppina.spano@uniba.it
Margarita Triguero-Mas
Massachusetts Institute of Technology
Massachusetts, USA
Email: Margarita.Triguero@uab.cat
Liisa Tyrväinen
Natural Resources Institute Finland (LUKE)
Helsinki, Finland
Email: liisa.tyrvainen@luke.
Sjerp de Vries
Wageningen University & Research (WUR)
Wageningen, The Netherlands
Email: sjerp.devries@wur.nl
Christoph Wildburger
International Union of Forest Research Organiza-
tions (IUFRO)
Vienna, Austria
Email: wildburger@iufro.org
Bo-Yi Yang
Sun Yet-Sen University
Gangzhou, China
Email: yangby23@mail.sysu.edu.cn

230
APPENDIX II: LIST OF PANEL MEMBERS, AUTHORS AND REVIEWERS
Christos Gallis
Hellenic Agricultural Organization Demeter
Thessaloniki, Greece
Email: cgalis@fri.gr
Christopher Golden
Harvard University
Massachusetts, USA
Email: golden@hsph.harvard.edu
Qing Li
Japanese Society for Forest Medicine
Tokyo, Japan
Email: qing-li@nms.ac.jp
Michelle Kondo
US Forest Service
Philadelphia, USA
Email: michelle.c.kondo@usda.gov
Kjell Nilsson
Nordregio
Stockholm, Sweden
Email: nilsson.landscape@gmail.com
Abi Tamim Vanak
Ashoka Trust for Research in Ecology and the En-
vironment (Atree)
Bengaluru, India
Email: avanak@atree.org
Benedict Wheeler
University of Exeter
Exeter, UK
Email: B.W.Wheeler@exeter.ac.uk
Maxine Whittaker
James Cook University
Queensland, Australia
Email: maxine.whittaker@jcu.edu.au
Kathleen Wolf
University of Washington
Washington, USA
Email: kwolf@uw.edu
Reviewers
Additional review comments were provided by the Food and
Agriculture Organization of the United Nations (FAO), Rome, Italy

IUFRO Headquarters
Marxergasse 2
1030 Vienna, Austria
Tel + 43 (0)1 877 01 51-0
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CPF members (as of 20 February 2023)
GFEP donors