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Effects of Forest Therapy on Psychological Improvement in Middle-aged Women in Korea

Brief Report

J Prev Med Public Health 2022;55:492-497 • https://doi.org/10.3961/jpmph.22.086

pISSN 1975-8375 eISSN 2233-4521

Journal of

Preventive Medicine

& Public Health

Effects of Forest Therapy on Psychological Improvement

in Middle-aged Women in Korea

Bum-Jin Park1, Won-Sop Shin2, Chang-Seob Shin2, Poung-Sik Yeon2, Chung-Yeub Chung3, Si-Hyung Lee4, Dong-Jun Kim2,

Youn-Hee Kim5, Chang-Eun Park6

1Department of Forest Environment Resources, Chungnam National University, Daejeon, Korea; 2Department of Forest Science, Chungbuk National

University, Cheongju, Korea; 3Institute of Mental Health, Seoul, Korea; 4Healience Seonmaeul, Hongcheon, Korea; 5Center for Contemplative Science,

Korea Advanced Institute of Science and Technology, Daejeon, Korea; 6National Center for Forest Therapy, Gimcheon, Korea

Objectives: Women experience more stress in middle age than in other periods of their lives. Therefore, health management programs

that enable middle-aged women to cope with and manage stress are needed. This study investigated the psychological effects of a

meditation-focused forest therapy program among 53 middle-aged women living in urban areas in Korea.

Methods: Participants were divided into 2 groups: one group underwent the program for 3 days in a forest, followed by 3 days in an

urban environment, and the other group underwent the program for 3 days in the urban environment, followed by 3 days in the for-

est. The psychological effects of the forest therapy program were evaluated using the Profile of Mood States-Brief (POMS-B). Differ-

ences in mood state before and after the program conducted in the forest (experimental group) and in the urban environment (con-

trol group) were evaluated using the paired-samples t-test.

Results: The program in the forest significantly reduced tension, depression, anger, fatigue, and confusion among the domains of the

POMS-B. The program in the urban area significantly reduced tension, but not depression, anger, fatigue, or confusion.

Conclusions: Meditation-focused forest therapy programs are expected to contribute to promoting psychological health and enhanc-

ing the quality of life of middle-aged women.

Key words: Forest therapy, Middle-aged women, Stress, Mood state, Psychological improvement

Received: February 23, 2022 Accepted: September 12, 2022

Corresponding author: Dong-Jun Kim

Department of Forest Science, Chungbuk National University,

1 Chungdae-ro, Seowon-gu, Cheongju 28644, Korea

E-mail: kdj63@chungbuk.ac.kr

Co-corresponding author: Youn-Hee Kim

Center for Contemplative Science, Korea Advanced Institute of Science

and Technology, 291 Daehak-ro, Yuseong-gu, Daejeon 34141, Korea

E-mail: salutare@hanmail.net

Co-corresponding author: Chang-Eun Park

National Center for Forest Therapy, 1237-89 Sudo-gil, Gimcheon 39695,

Korea

E-mail: pce0123@naver.com

This is an Open Access article distributed under the terms of the Creative Commons

Attribution Non-Commercial License (https://creativecommons.org/licenses/by-

nc/4.0/) which permits unrestricted non-commercial use, distribution, and repro-

duction in any medium, provided the original work is properly cited.

INTRODUCTION

Women spend half of their life in middle age and afterward,

and stress management in middle age is becoming increas-

ingly important for enjoying a healthy life in old age [1]. The

common types of stress management programs that are cur-

rently being used can be summarized as follows: first, cogni-

tive behavioral therapy aimed at changing ways of thinking or

behaving; second, physical therapy, such as yoga, massage,

and exercise; and third, meditation therapy that can induce

concentration and insight [2]. Some stress management pro-

grams are conducted in nature. In particular, there is an in-

creasing interest in forests as places to relieve stress [3], and

programs aimed at relieving stress in forests are attracting at-

tention from the perspective of preventive medicine [4].

Psychological Effects of Forest Therapy

Forest therapy refers to activities that use various environ-

mental factors of forests to improve human health. Forests

have environmental elements that make humans feel com-

fortable, such as beautiful scenery, clean air, sunlight, sound,

phytoncides, and negative ions.

A forest therapy program uses forest-specific healing factors

to maximize the healing effects of forests [5]. Six types of ther-

apies are used for forest therapy programs: plant therapy, wa-

ter therapy, diet therapy, psychotherapy, weather therapy, and

exercise therapy [6]. Meditation in forest therapy programs

aimed at managing stress is well regarded as a type of psycho-

therapy. Meditation can be actively used in forest therapy be-

cause a forest, where individuals can focus on the sounds of

water, wind, and birds, and experience things through the 5

senses, is a good environment for meditation.

Several studies have investigated forests as places of healing

that can improve health and prevent diseases. Increasingly many

people are pursuing nature-based activities to reduce stress [7],

and it is known that healing activities in forests help prevent

and alleviate the symptoms of stress-related diseases [8].

Contact with natural environments increases resilience from

stress, and is more effective in the rehabilitation of individuals

in deep crisis than in those at lower levels of crisis [9].

A study indicated that a higher greenness index, which is

the ratio of plant leaves within eyesight, was associated with

better recovery from stress [10]. This suggests that seeing the

color of the forest itself can help individuals recover from neg-

ative responses to stress. A recent review on meditation-fo-

cused forest therapy showed that previous studies were gen-

erally conducted among relatively young adults. Therefore,

studies on more diverse populations will be informative [11].

This study aimed to investigate the psychological effects of

a meditation-focused forest therapy program in middle-aged

women (aged 40-65 years). To verify the effects of the forest

therapy program in this study, the Profile of Mood States-Brief

(POMS-B) was administered before and after the program and

compared. The forest therapy program was conducted in a for-

est and in an urban environment, and the results were com-

pared between these 2 settings.

METHODS

Participants

The participants in this study were middle-aged women

(aged 40-65 years) living in urban areas. Women who were

pregnant, were smokers, had hypertension, had received treat-

ment at a hospital in the last 3 months, had circulatory disor-

ders, or had allergic diseases were excluded. The selected 53

participants were divided into 2 groups. The number of partic-

ipants in group A (forest-urban) was 25, and that in group B

(urban-forest) was 28.

From October 10 to October 15, 2017, one group participat-

ed in the program for 3 days in a forest, followed by 3 days in

an urban environment, and the other group participated in

the program for 3 days in the urban environment, followed by

3 days in the forest.

Study Sites

Forest site

The forest site used in this study was a private healing forest

located in Seomyeon, Hongcheon-gun, Gangwon-do, Korea.

This healing forest site is located in a mid-mountainous area at

an altitude of 250-580 m above sea level, and has an area of

approximately 747 800 m2.

The forest tree species comprise Quercus variabilis (53%),

Quercus mongolica (15%), Larix kaempferi (9%), Korean pine

(8%), Quercus mongolica and Korean pine (7%), Quercus varia-

bilis and Korean pine (4%), Quercus serrata and Korean pine

(2%), and Quercus variabilis and Pinus rigida (1%), and the

amount of water in the forest’s water system is abundant.

There are 10 walking trails and trekking courses built on gen-

tle slopes. Areas with a degree of green naturality of grade 7

or higher account for approx imately 80% of the forest.

Urban site

The urban site in this study was Wonkwang Digital Universi-

ty campus located in Daerim-dong, Yeongdeungpo-gu, Seoul,

Korea. There is no forest within a radius of 1 km of the urban

site; there are trees only on the sidewalk next to the road. The

street trees consist of ginkgo trees.

Instruments

The psychological effects of the forest therapy program were

measured using the Korean POMS-B that Yeun and Shin-Park

[12] translated from the POMS-B developed by McNair et al.

[13]. This tool consists of 6 domains: tension (5 items), depres-

sion (5 items), anger (5 items), vigor (5 items), fatigue (5 items),

and confusion (5 items), totaling 30 items. Each item is rated

on a 5-point scale, ranging from “strongly disagree” (0 points)

to “strongly agree” (4 points). To minimize the influence of ex-

493

Bum-Jin Park, et al.

ternal variables that might affect the measurement results,

each measurement was conducted during the same time slots.

The internal reliability of the Korean POMS-B in this study was

0.93.

Program Composition and Procedure

The forest therapy program developed in this study was fo-

cused on meditation while listening to the sounds of the wind,

water, and birds. The duration of the program was 3 days.

On the first day, an orientation to the program was provided.

The participants completed the consent form and question-

naires, and pre-program psychological measurements were

conducted. Subsequently, lying-down meditation and Zen

yoga were conducted. Lying-down meditation is a relaxation

meditation in which an individual lies down and relaxes his or

her whole body to take a deep rest. In the Zen yoga class, the

participants performed joint relaxation using yoga movements

that can be easily performed by beginners.

On the second day, the participants went for a walk in the

forest, and performed lying-down meditation, a healing touch

exercise, and stress relief meditation. Before taking the walk in

the forest, the participants were instructed to stretch their

body, feel their breath, and calm their mind. For the healing

touch exercise, they were instructed to pair up and give a mas-

sage to their partner to relieve their muscle tension and pro-

mote blood circulation. Then, they performed lying-down med-

itation and stress relief meditation. Stress relief meditation is a

type of meditation that trains an individual’s mind to effec-

tively cope with stress.

On the third day, they performed nature meditation, which

is a type of meditation that restores one’s 5 senses and allows

individuals to take a break by becoming aware of their inside

and outside. After completing the day’s schedule, they com-

pleted the questionnaires and underwent post-program psy-

(Measuring points) Before

After

Before

After

Group A

(n = 25)

Forest

session

Group B

(n = 28)

Urban

session

Figure 1. Design of the experiment.

494

Urban

session

Forest

session

chological measurements.

The POMS measurements were performed before and after

the forest and urban area programs were conducted, respec-

tively, as shown in Figure 1. In addition, there was no rest peri-

od between the forest session and the urban session. A rest

period was not set because the carryover effect of forest heal-

ing was not expected to be long based on previous studies [14].

The experiment was conducted using a 2-period crossover de-

sign to eliminate any possible carryover effect.

Statistical Analysis

Data analysis was performed using SPSS version 21.0 (IBM

Corp., Armonk, NY, USA). The demographic characteristics of

the participants were analyzed using frequency analysis. Dif-

ferences in POMS-B scores before and after the forest therapy

program were evaluated using the paired t-test. The statistical

significance level was set at p-value <0.05.

Ethics Statement

The study was conducted in accordance with the Declaration

of Helsinki, and the protocol was approved by the Institutional

Review Board of Chungnam National University (201708-SB-

020-01).

Table 1. Comparison of the outcomes: domains of the Profile

of Mood States-Brief

Factors

Before

After

t-value p-value

Tension

Urban

Forest

Depression

Urban

Forest

Anger

Urban

Forest

Vigor

Urban

Forest

Fatigue

Urban

Forest

Confusion

Urban

Forest

3.28±3.46

3.85±4.36

2.25±3.11

1.78±2.55

1.046 0.003

3.818 <0.001

2.78±3.81

3.85±4.36

2.15±3.51

1.78±2.55

1.576 0.062

3.818 <0.001

2.68±3.25

3.28±4.77

1.90±3.20

1.33±2.12

1.564

2.747

0.063

0.005

8.18±4.81

7.13±4.61

9.40±5.11

10.08±6.36

-1.743

-3.645

0.089

0.001

3.53±3.46

4.35±4.44

3.05±3.35

1.80±2.46

1.046 0.151

4.351 <0.001

4.48±2.30

4.85±2.89

4.18±2.54

3.83±1.65

0.873

2.225

0.194

0.016

Values are presented as mean±standard deviation.

Psychological Effects of Forest Therapy

Tension

Depression

Anger

Before

After

Urban

Forest

Urban

Forest

Urban

Forest

Vigor

Fatigue

Confusion

Urban

Forest

Urban

Forest

Urban

Forest

Figure 2. Comparison of the outcomes: domains (A: tension, B: depression, C: anger, D: vigor, E: fatigue, and F: confusion) of the

Profile of Mood States-Brief (POMS-B). *p<0.05.

RESULTS

General Characteristics of the Participants

Frequency analysis of the participants’ general characteristics

was performed, including age, education level, residential area,

household income, and occupation (Supplemental Material 1).

Psychological Effects of Forest Therapy

Changes in tension, depression, anger, vigor, fatigue, and

confusion after the forest therapy program were analyzed us-

ing the paired samples t-test. The program in the forest signifi-

cantly reduced tension, depression, anger, fatigue, and confu-

sion, and increased vigor among the domains of the POMS-B.

In contrast, the program in the urban area significantly reduced

tension, but not depression, anger, fatigue, or confusion, and

did not increase vigor (Table 1 and Figure 2).

DISCUSSION

The results of this study are consistent with previous studies

indicating that negative emotions such as tension, depres-

sion, anger, fatigue, and confusion decreased after forest ther-

apy, whereas positive emotions such as vigor increased [15].

Studies have reported that negative emotions, such as anxi-

ety, depression, anger, fatigue, and confusion decreased in

those who participated in a forest experience program [16].

Furthermore, contact with nature is effective in alleviating de-

pression [17].

A study that investigated the effects of forest therapy using

psychological indicators showed that a forest therapy program

spanning 3 days and 2 nights reduced depression and anger

and increased positive emotions in emotional workers [6]. Ac-

tivities in forests have also been reported to induce psycho-

logical relaxation [18].

The forest therapy program administered in this study was

focused on meditation. The forest therapy program was a

combination of various factors and therapies, such as exer-

cise, yoga, and meditation. Psychotherapy, 1 therapy of the 6

therapies used in the forest therapy program, mainly com-

prises meditation, which involves calming and concentrating

one’s mind and is derived from the Latin meditatio, which

means “to think deeply.” Therefore, meditation is a mental

process of achieving self-transcendence and self-develop-

ment through the concentration of consciousness [19]. Medi-

tation serves to activate the limbic system, the part of the

brain that is responsible for regulating emotions, thereby in-

creasing the activity of the amygdala and hippocampus.

Meditation in forests can be more effective than meditation

495

Bum-Jin Park, et al.

indoors because the healing factors of forests facilitate medi-

tation. Meditation in the forest is aimed at achieving aware-

ness while observing the precious vitality of nature through

encounters, communication, and contact with nature. In ad-

dition, mindfulness meditation has been proposed as a tech-

nique for forest healing. Mindfulness can have a healing effect

by integrating the body and mind through attention training.

Meditation in the forest is a way to actively use the healing

factors of the forest [20].

Meanwhile, the results of this study showed that when the

program was conducted in an urban environment, it reduced

depression, anger, fatigue, and confusion, and increased vigor,

but not to a statistically significant degree. Even though the

program conducted in the urban environment had the same

content as that in the forest, it had no significant effects on

psychological factors, indicating that the urban environment

was not appropriate for obtaining such effects.

This study demonstrated that a meditation-focused forest

therapy program had stress reduction effects in healthy mid-

dle-aged women. However, a limitation of this study is that

caution must be exercised when generalizing the present re-

sults because they were obtained in a short-term experiment.

A rest period was not set between the 2 sessions. If there was

a carryover effect of forest therapy, our results may have been

underestimated. Further studies involving other age groups

and participants are needed in the future. The results of this

study can be used as basic data for the development of forest

therapy programs.

The forest therapy program developed in this study was fo-

cused on meditation while listening to the sounds of the wind,

water, and birds. The participants performed the 3 types of

meditation—lying-down, stress relief, and nature meditation—

every day for 3 days. The contribution of this study is that a

meditation-focused forest therapy program led to psychologi-

cal improvements in middle-aged women.

SUPPLEMENTAL MATERIALS

Supplemental material is available at https://doi.org/10.

3961/jpmph.22.086.

CONFLICT OF INTEREST

The authors have no conflicts of interest associated with the

material presented in this paper.

FUNDING

This research was funded by Seokchun Caritas Foundation

(grant No. SF171).

ACKNOWLEDGEMENTS

The funders had no role in the design of the study; in the

collection, analyses, or interpretation of data; in the writing of

the manuscript, or in the decision to publish the results.

AUTHOR CONTRIBUTIONS

Conceptualization: Park BJ, Kim DJ, Kim YH, Park CE, Shin

WS, Shin CS, Chung CY, Lee SH. Data curation: Kim YH, Park CE.

Formal analysis: Park BJ, Kim DJ, Kim YH, Park CE. Funding ac-

quisition: Park BJ. Methodology: Park BJ, Kim DJ, Kim YH, Park

CE. Project administration: Park BJ, Kim YH, Park CE. Visualiza-

tion: Kim YH, Park CE. Writing – original draft: Park BJ, Kim DJ,

Kim YH, Park CE. Writing – review & editing: Park BJ, Yeon PS,

Kim DJ, Kim YH, Park CE, Shin WS, Shin CS, Chung CY, Lee SH.

ORCID

Bum-Jin Park

Dong-Jun Kim

Youn-Hee Kim

Chang-Eun Park

https://orcid.org/0000-0002-5214-5688

https://orcid.org/0000-0002-2986-9274

https://orcid.org/0000-0002-8625-1040

https://orcid.org/0000-0003-1322-2211

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