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Beyond “bluespace” and “greenspace”: A narrative review of possible health benefits from exposure to other natural landscapes

Science of the Total Environment 856 (2023) 159292

Contents lists available at ScienceDirect

Science of the Total Environment

journal homepage: www.elsevier.com/locate/scitotenv

Review

Beyond “bluespace” and “greenspace”: A narrative review of possible health

beneﬁts from exposure to other natural landscapes

Hansen Li a, Matthew H.E.M. Browning b,⁎, Alessandro Rigolon c, Lincoln R. Larson d, Derrick Taff e, S.M. Labib f,

Jacob Benﬁeld g, Shuai Yuan b, Olivia McAnirlin b, Nazanin Hatami b, Peter H. Kahn Jr. h,i

a Institute of Sports Science, College of Physical Education, Southwest University, Chongqing 8400715, China

b Virtual Reality & Nature Lab, Department of Parks, Recreation and Tourism Management, Clemson University, Clemson, SC, USA

c Department of City and Metropolitan Planning, The University of Utah, Salt Lake City, UT, USA

d Department of Parks, Recreation and Tourism Management, North Carolina State University, Raleigh, NC, USA

e Department of Recreation, Park, and Tourism Management, The Pennsylvania State University, University Park, PA, USA

f Department of Human Geography and Spatial Planning, Faculty of Geosciences, Utrecht University, 3584, CB, Utrecht, the Netherlands

g Department of Psychology, The Pennsylvania State University, Abington, PA, USA

h Department of Psychology, University of Washington, Seattle, WA, USA

i School of Environmental and Forest Sciences, University of Washington, Seattle, WA, USA

HIGHLIGHTS

• Greenspace and bluespace research is

booming, but nature is not always green

or blue.

• Color-coding natural landscapes could

provide confusing and misleading descrip-

tions.

• Natural landscapes are largely composed

of plants, water, and rocks/minerals.

• Caves, deserts, and landscapes with ice/

snow may pose health beneﬁts and risks.

• More high-quality research on the broad

array of natural landscapes is needed.

GRAPHICAL ABSTRACT

ARTICLE INFO

Editor: Paulo Pereira

Keywords:

Nature therapy

Tourism

Nature

Well-being

Brown space

White space

ABSTRACT

Numerous studies have highlighted the physical and mental health beneﬁts of contact with nature, typically in land-

scapes characterized by plants (i.e., “greenspace”) and water (i.e., “bluespace”). However, natural landscapes are

not always green or blue, and the effects of other landscapes are worth attention. This narrative review attempts to

overcome this limitation of past research.

Rather than focusing on colors, we propose that natural landscapes are composed of at least one of three components:

(1) plants (e.g., trees, ﬂowering plants, grasses, sedges, mosses, ferns, and algae), (2) water (e.g., rivers, canals, lakes,

and oceans), and/or (3) rocks and minerals, including soil. Landscapes not dominated by plants or liquid-state water

include those with abundant solid-state water (e.g., polar spaces) and rocks or minerals (e.g., deserts and caves).

Possible health beneﬁts of solid-state water or rock/mineral dominated landscapes include both shorter-term

(e.g., viewing images) and longer-term (e.g., living in these landscapes) exposure durations. Reported beneﬁts span

improved emotional and mental states and medical treatment resources for respiratory conditions and allergies. Mech-

anisms underlying the health beneﬁts of exposure consist of commonly discussed theories in the “greenspace” and

⁎ Corresponding author.

E-mail addresses: mhb2@clemson.edu (M.H.E.M. Browning), alessandro.rigolon@utah.edu (A. Rigolon), lrlarson@ncsu.edu (L.R. Larson), bdt3@psu.edu (D. Taff), jab908@psu.edu

(J. Benﬁeld), syuan2@g.clemson.edu (S. Yuan), omcanir@g.clemson.edu (O. McAnirlin), pkahn@uw.edu (P.H. Kahn).

http://dx.doi.org/10.1016/j.scitotenv.2022.159292

Received 12 August 2022; Received in revised form 28 September 2022; Accepted 3 October 2022

Available online 5 October 2022

H. Li et al.

Science of the Total Environment 856 (2023) 159292

“bluespace” literature (i.e., instoration and restoration) as well as less discussed pathways in that literature (i.e., post-

traumatic growth, self-determination, supportive environment theory, and place attachment).

This is the ﬁrst review to draw attention to the potential salutogenic value of natural landscapes beyond “greenspace”

and “bluespace.” It is also among the ﬁrst to highlight the limitations and confusion that result from classifying natural

landscapes using color. Since the extant literature on natural landscapes - beyond those with abundant plants or liquid-

state water - is limited in regard to quantity and quality, additional research is needed to understand their restorative

potential and therapeutic possibilities.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2. Material and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

3. Results and discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

3.1. Types of natural landscapes and health beneﬁts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

3.1.1. Landscapes dominated by water in a solid state . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

3.1.2. Landscapes dominated by rocks and minerals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

3.2. Mechanisms driving health beneﬁts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

3.2.1. Restoring capacities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

3.2.2. Building capacities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.2.3. Risks and deﬁciencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.3. Limitations and future research directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

4. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

CRediT authorship contribution statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Data availability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Declaration of competing interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1. Introduction

The health beneﬁts of contact with nature are widely recognized across

human cultures. For example, 天人合一 (the harmony between humanity

and nature) is a core idea in Chinese culture (Lai et al., 2022). Shinrin-

yoku, or forest bathing, is an increasingly popular form of nature therapy

used to promote physiological and psychological health in many parts of

the world (Hansen et al., 2017). American poet Ralph Waldo Emerson de-

scribed “the lover of nature is he whose inward and outward senses are

still truly adjusted to each other; who has retained the spirit of infancy

even into the era of manhood” (Emerson, 1903, p. 9), inspiring a fascination

with nature-based health promotion in Western countries (Larson and

Hipp, 2022). Modern empirical research supports a strong link between na-

ture and human health, but it also highlights potentially variable effects

across diverse types of natural landscapes via different mechanisms

(Hartig et al., 2014).

The health-promoting potential of nature exposure is often assumed to

be driven by our genes (Kaplan and Kaplan, 1989; Wilson, 1986; Ulrich,

1983), an adaptive trait paralleled with biophilia, meaning humans’ inher-

ent afﬁnity for other forms of life (Kellert and Wilson, 1993). Most of

human evolutionary history has occurred in natural surroundings (Joye

and van den Berg, 2011; Moura et al., 2017). Not until recent centuries,

following the industrial revolution, have a majority of humans lived outside

of and apart from nature-rich environments (Turner et al., 2004; Vlahov

and Galea, 2002). Therefore, while humans' direct connection with natural

environments may be diminishing, our evolutionary-driven connections

with natural landscapes and resulting health impacts are likely to remain

viable today (Laland and Brown, 2006; Robinson and Breed, 2020).

Scholars have proposed the “therapeutic landscape” concept to explain

why certain places contribute to health promotion and treatment. With

roots in cultural ecology, structuralism, and humanism (Gesler, 1992;

Williams, 1998), this concept spans multiple dimensions of wellbeing

including material/physical, social, and spiritual (Bell et al., 2018). The

physical environment of therapeutic landscapes includes natural and

human-made environments (Gesler, 2018). Natural landscapes character-

ized by plants and liquid water have received perhaps the most attention

(Bell et al., 2018; Bell et al., 2017). This focus is not surprising, as these

two elements are common components in many natural landscapes

inhabited by people. They also supply basic resources for survival (Reid

et al., 2005). Water is a fundamental part of life, and plants provide many

ecological services, including the production of organic matter for food

and oxygen for breathing (Carpenter et al., 2009). For these reasons,

much research has been conducted on the health beneﬁts of natural settings

rich in these ecosystem services (Bratman et al., 2019; Zhang et al., 2020).

Studies on the health beneﬁts of plant and liquid water-dominated land-

scapes often use color schemes to code landscapes with these components

(Twohig-Bennett and Jones, 2018; White et al., 2020). In this context,

“greenspace” refers to landscapes rich with plants (e.g., trees, ﬂowering

plants, grasses, sedges mosses, ferns, and algae), and “bluespace” refers to

landscapes with open water (e.g., canals, rivers, lakes, oceans). However, na-

ture is not limited to plants or open water, and this binary characterization

omits key components of potentially therapeutic natural landscapes.

Emerging concepts such as “white space” (e.g., snow-covered landscapes;

Brooke and Williams, 2021; Finlay, 2018; Korpela et al., 2014; Olwig, 2005;

Yli-Panula et al., 2022), “brown space” (e.g., deserts; Nazif-Munoz et al.,

2020; Olvera-Alvarez et al., 2021; Yin et al., 2022), and “red nature”

(e.g., volcanoes; Kotera et al., 2021) bring more types of landscapes into

scholarly discourse. Human perceptions of landscapes are undoubtedly

shaped by sight and visual attributes, such as color, that contribute to expe-

riences related to place (Bell, 2012; Lengen, 2015; Zhang et al., 2022). Nev-

ertheless, there are limitations to the use of color-coding to describe natural

landscapes. Non-visual sensory perceptions such as sound may have a strong

inﬂuence on the health beneﬁts associated with nature (Buxton et al., 2021).

Additionally, color may not clearly indicate landscapes that are alien to most

people. For example, general readers may not associate “red nature” with

volcanoes without extra description (Kotera et al., 2021). To add more

complexity, plants and water change color with time, season, and place,

which might limit the relevance of the classic “green” and “blue” coding

(Zhou et al., 2022).

Some studies have revealed the psychological beneﬁts of landscapes

that have few plants or minimal liquid water, such as deserts (Yin et al.,

2022). Scholarly examination of the shorter-term psychological and physi-

ological responses to these landscapes, and the health outcomes associated

with longer-term exposure of living in these settings, may challenge the

H. Li et al.

consensus that people prefer natural resource-rich environments (i.e., those

with abundant plants and/or liquid water). These clues underscore the

importance of expanding the deﬁnition of nature beyond “greenspace”

and “bluespace.” These clues also emphasize the need to explore potential

mechanisms driving the health beneﬁts associated with exposure to natural

landscapes that have been discussed in the nature-health literature less

commonly.

The ﬁrst objective of this narrative review is to develop a framework

that categorizes the broad array of natural landscapes that is not based

solely on color. The second objective is to review the available literature

on the possible health beneﬁts of exposure to natural landscapes that are

not dominated by plants or liquid water. The third and ﬁnal objective is

to identify possible mechanisms that might explain how shorter-term and

longer-term exposure to these landscapes can promote human health and

well-being.

2. Material and methods

Given the novelty of the topic and the anticipated diversity of relevant

papers, we employed a narrative approach to identify and summarize the

literature. Narrative reviews are qualitative research syntheses that describe

the results of other studies without a dominant focus on the statistical signif-

icance of the ﬁndings (Baumeister and Leary, 1997; Siddaway et al., 2019).

We ﬁrst identiﬁed natural landscapes that were not dominated by plants

or liquid water but were discussed as restorative (or therapeutic) land-

scapes. We studied the keywords in the nature archetypes identiﬁed by

Scandinavian researchers Ottosson and Grahn (2021) and the nature inter-

actions identiﬁed by North American researchers Kahn et al. (2012). Addi-

tionally, we referenced the ﬁndings of a scoping review on therapeutic

landscapes (Taheri et al., 2021) and a book on the health beneﬁts of expo-

sure to eight types of natural landscapes (Loewe, 2022).

Keyword searches were then conducted in three databases: Scopus,

Pubmed, and Web of Science. The keywords included “brown space*”,

“brownspace*”, “desert*”, “arid”, “mountain*”, “ridge*”, “bedrock”,

“boulder*”, “big rock*”, “rock formation*”, “rock outcrop*”, “gray

space*”,” grayspace”, “grey space*”, “greyspace*”, “white space*”,

“whitespace*”, “snow-cover*”, “artic”, “Antarctic”, “red space*”, and

“redspace*”.1 We screened titles and abstracts for empirical, peer-

reviewed articles published in English that included some form of expo-

sure, along with psychological responses, physiological responses, or health

outcomes (i.e., incidence/prevalence of disease, illness, or mortality). Addi-

tional articles were retrieved by screening the authors' personal libraries

and using ancestry-search methods (i.e., forward and backward searches)

(Nørgaard et al., 2022).

All studies of natural landscapes aside from those dominated by plants or

liquid water were considered. Speciﬁc components of nature (e.g., animals

aromatic essential oils) were excluded since our focus was on entire land-

scapes that existed in the physical world or were presented in simulations

(i.e., pictures, movies, or virtual reality) (Browning et al., 2020). We ex-

cluded environments usually unavailable to the public, such as outer space

and deep underwater landscapes. All authors discussed the classiﬁcation

and inclusion of potential non-green and non-blue natural landscapes.

Disagreements were resolved by consensus.

Since the impacts of exposure could be regulated by the duration of expo-

sure (Shanahan et al., 2016), we followed the approach of previous reviews

by collecting information from the included papers about any reported

health beneﬁts and presenting mechanisms by shorter-term vs. longer-term

exposures. Shorter-term exposure refers to a singular experience that lasted

from a few minutes to a few hours or a whole day (Barton and Pretty,

2010), such as laboratory or ﬁeld experiments (Mason et al., 2022; Roberts

et al., 2019). Meanwhile, we refer to longer-term exposures as more than a

day of exposure or years of living in a landscape.

3. Results and discussion

Science of the Total Environment 856 (2023) 159292

3.1. Types of natural landscapes and health beneﬁts

We observed that most natural landscapes consist of one to three com-

ponents: water, plants, and rocks and minerals (Fig. 1). Water covers over

70 % of the earth's surface, and plants occupy over 30 % of the land

(Congalton, 2021). Plants are largely limited to regions with favorable

climatic conditions, water, or sunlight; otherwise, water, rock or minerals

are often dominant. Geologic processes including physical and chemical

weathering cause rocks or minerals to appear as bedrock, outcroppings, for-

mations, debris, sand, lava ﬁelds, and soil. Water can exist in three states:

liquid, solid, and gas. Liquid water only exists in a limited temperature

range, such that polar regions and landscapes at higher latitudes during

winter can be covered with solid-state water (i.e., ice and snow). In these

cases, landscapes are dominated not by a single component but by multiple

components (i.e., snow-covered boreal forests). Due to the complexity of

these layered landscapes and scarcity of available studies, we focused our

review on landscapes dominated by a single component and resultant

psychological or physiological responses from exposure.

3.1.1. Landscapes dominated by water in a solid state

Water-dominated landscapes usually refer to freshwater or marine land-

scapes, such as oceans, lakes, canals, or rivers (White et al., 2010). How-

ever, marine, freshwater, and even terrestrial areas can be covered with

ice or snow, representing landscapes visually different from those shaped

by liquid water (Fig. 2). For example, ice and snow are the main compo-

nents to which people entering the Arctic or Antarctic are exposed. Like-

wise, snow and ice may dominate other landscapes in winter, particularly

in high altitude or latitude areas (e.g., frozen alpine lakes, snowy moun-

tains, tundra, alpine meadows, and cold deserts) (Fig. 2). These landscapes

can be considered something other than “bluespace” given their colorful

shades of white and gray. Only a few clues have indicated the health bene-

ﬁts of exposure to these landscapes.

We found little evidence to support the beneﬁcial effects of shorter-term

exposure to landscapes dominated by solid water. Still, ice and snow are

regarded as a major tourism resource (Wang and Zhou, 2019). The beauty

and fascination of frozen landscapes are well documented (Brooke and

Williams, 2021; Duffy, 2013; Lengen, 2015), including in polar landscapes

(Shah, 2015; Summerson and Lieser, 2018), which may explain why many

tourists visit polar spaces for sightseeing (Bauer, 2013). Thus, although not

well studied, the aesthetic values of polar spaces may be associated with

emotional beneﬁts.

In addition to polar spaces, alpine landscapes in the European Alps,

Pyrenees, Himalayans, Andes, and Rocky Mountains are often covered

with ice or snow. Such landscapes attract many visitors and have motivated

glacier tourism (Wang and Zhou, 2019). Some scholars have suggested that

1 In keyword searches, the “*” symbol represents any group of characters following the ini-

tial string such as plural, adjective, and verb versions of a noun (i.e., “deserts” and “desertiﬁca-

tion” would be captured by “desert*”; “snow-covered” would be captured by “snow-cover*”).

Fig. 1. Most natural landscapes are composed of water in its liquid or solid state,

plants, rocks/minerals, or a combination of the three.

H. Li et al.

Science of the Total Environment 856 (2023) 159292

Fig. 2. Examples of landscapes dominated by water in a liquid (1–3) or solid-state (3–9).

glacier tourism and outdoor recreation activities in snow-covered environ-

ments (e.g., hiking, climbing, mountaineering, and skiing) promote ﬁtness

and generate emotional and social beneﬁts (Burtscher et al., 2019;

Finkenzeller et al., 2011; Müller et al., 2011). Nevertheless, we found little

empirical evidence of other health beneﬁts.

Clues to the health beneﬁts of longer exposures to landscapes domi-

nated by solid water can be obtained from studies of expeditions and

deployments. Zimmer et al. (2013) conducted a systematic review of

Antarctic psychological research between 2000 and 2010. The review con-

cluded that improved emotion, mood, and a decline in factors contributing

to psychological functioning disturbances were possible beneﬁts of Antarc-

tic experiences. Later studies underlined personal growth as a positive

outcome resulting from living in polar spaces. For instance, one study con-

cluded that personal strength and other aspects of personal growth were

perceived beneﬁts of Antarctic deployment (Blight and Norris, 2018).

Studes in the Artic found similar results. Kjærgaard et al. (2017) studied

six two-man Danish military teams deployed in the Arctic and found in-

creased personal strength after their time there. Another study compared

384 navy soldiers assigned to Antarctica with 2,396 counterparts assigned

elsewhere and found Antarctic soldiers showed relatively stronger health

and wellbeing gains over the winter season (Palinkas, 1991). Nevertheless,

it should be noted that polar expeditions or deployments are not akin to

tourism and have different risk levels. Expedition members or soldiers are

selectively recruited and trained and may have higher adaptability to

extreme environments (Otani et al., 2004). Possible self-selection bias in

these past investigations (Heckman, 1990) might have inﬂated the

observed longer-term beneﬁts of polar experiences.

3.1.2. Landscapes dominated by rocks and minerals

Rock and mineral-dominated landscapes are usually present in areas not

covered by plants and water. According to ecosystem classiﬁcations (Keith

et al., 2020), these landscapes mainly include deserts (terrestrial) and caves

(subterranean) (Fig. 3). Deserts can include cold and dry-heat landscapes.

Cold deserts are usually present in high altitude or latitude areas that are

dominated by ice/snow in the winter and rocks/minerals in the summer.

Dry-heat deserts are the one better known by most human populations

and present in tropical and temperate areas. Based on our review of the

extant literature, only the dry-heat deserts have been studied for their

potential health beneﬁts. These rock and mineral-dominated landscapes

can include sediment (i.e., soil, sand, and gravel), rock faces (i.e., slabs,

Fig. 3. Examples of landscapes dominated by rocks and/or minerals.

H. Li et al.

cliffs, and boulders), loose rocks (i.e., talus, scree, and glacial moraine), and

unique erosional forms (i.e., towers, domes, spires, blocks, rills, grikes,

clints, and hoodoos) (Migoń et al., 2017).

3.1.2.1. Deserts. Deserts may appear to hold little value, given their lack of

plants or water and life. However, deserts are prominent types of natural

environments on Earth and home to more than 20% of the global human

population (Tchakerian and Pease, 2015). Due to global climatic changes

and resulting desertiﬁcation, desert exposure is projected to increase in

the coming decades (Huang et al., 2015). Deserts are also valuable tourism

resources (Michopoulou et al., 2021).

Some simulation studies have also observed positive outcomes resulting

from desert exposure. College students from the Eastern Province of Saudi

Arabia exposed to a 1-min coastal desert video (an environment familiar

to this population) showed better performance on a subsequent memory

task than students showed videos of a temperate forest (a less familiar envi-

ronment) (Pilotti et al., 2019). Nursing students from El Paso, Texas, U.S.,

who viewed a 10-min 360-degree video of a desert in virtual reality (VR)

showed similar levels of stress recovery to those students who viewed a

360-degree video of a public park with trees and grass (Yin et al., 2022).

U.S. adults have also reported that exposure to a desert image is less deplet-

ing and stressful than exposure to a built-up urban center (Shalev, 2016). In

a desert-based walking program in Israel, themes of physical and mental

well-being (i.e., relaxation, peacefulness) were expressed across a diverse

range of participants, including those who previously disliked deserts

(Teff-Seker and Orenstein, 2019).

We found one experimental study of longer-term exposure to

deserts. Participants' brain activity during a 4-day trip to Utah, U.S.

showed reduced posterior alpha power, suggesting their attention was

directed by the environment (Hopman et al., 2020). A study in Kenya re-

vealed that living in the desert landscape supported physical and mental

well-being by offering freedom of movement and a sense of peace (Dan

et al., 2021). Similar ﬁndings have been observed along the Israeli-

Jordanian border (a desert area), where desert landscapes were

described as contributing to stress relief and fueling nature afﬁnity

among local residents (Sagie et al., 2013). Spatial epidemiology studies

have found mixed evidence for the health beneﬁts of living in desert

areas. For instance, in a study of students' homes in El Paso, Texas, U.S.,

associations of residential non-built up impervious areas (i.e., bedrock

and sand) with incidence of depression and diabetes were mixed (Nazif-

Munoz et al., 2020; Olvera-Alvarez et al., 2021).

Some medical therapies have originated in desert landscapes. Uyghur

sand therapy is a traditional Chinese medicine technique created by the

Uygur ethnic group that uses sand heated by the sun to cure chronic osteo-

arthritis (Wang et al., 2018). Such therapy usually requires repeated treat-

ments, so it can be considered a longer-term exposure. One study observed

that participants reported healing beneﬁts resulting from the haptic sensa-

tions (tactile and kinesthetic) of burning, heat, and swelling while touching

hot sand (Wang et al., 2018). Another study by Niyazi (2002) documented

13,115 cases of sand-based therapy in deserts in Xinjiang, China. Findings

suggested that sand-based therapy may help with arthritis, rheumatoid

arthritis, hyperosteogeny, sciatica, and lumbar disc protrusion. Efﬁcacy for

treating these symptoms related to these conditions was reported to be as

high as 90% (Niyazi, 2002). Controlled animal trials have further revealed

that Uyghur sand therapy might alleviate cartilage inﬂammation and

enhance bone strength (Hu et al., 2015; Kahal et al., 2009), although the

quality of evidence from human trials is limited.

3.1.2.2. Caves. Caves are subterranean rock/mineral-dominated landscapes

that lack plants due to insufﬁcient sunlight. We found no evidence to sug-

gest beneﬁts of shorter-term exposure to these landscapes. However, like

deserts, caves have some aesthetic qualities that might be beneﬁcial. For

example, caves with such features as stalagmites and stalactites attract

more than 70 million visitors every year globally (Chiarini et al., 2022).

Given their widespread allure and appeal, caves may promote some posi-

tive emotional responses.

Science of the Total Environment 856 (2023) 159292

Cave climates also may bring a series of respiratory health beneﬁts due

to their unique air qualities. Such potential beneﬁts have fueled multiple in-

terventions, which have been called “speleotherapy” and “halotherapy”.

Speleotherapy involves breathing the air in the unique climates of caves

to treat respiratory conditions (Freidl et al., 2020) while halotherapy

involves breathing air with micronized dry salt in an enclosed space that

mimics salt caves (Rashleigh et al., 2014). Since such therapies have been

developed for curing chronic respiratory issues and usually require

repeated and extended exposures, they can be considered longer-term

exposures (Beamon et al., 2001). Numerous studies have underlined the

potential of such therapies in treating allergic rhinitis, asthma, and chronic

obstructive pulmonary disease (Beamon et al., 2001; Eslaminejad et al.,

2017; Freidl et al., 2020). Also, owing to the cave climates, mitigation of

skin allergies is believed to be another beneﬁt (Lăzărescu et al., 2014).

Other evidence suggests that longer-term exposure to caves may beneﬁt

mental and physical health. A 19-day intervention revealed that speleotherapy

might be conducive to reducing anxiety and increasing walking ability

(Kendrová et al., 2016). Another 12-week study reported that speleotherapy

helped athletes enhance their athletic performance, such as increasing boxers'

punch speed, jump, reaction, VO2max (how efﬁciently someone uses oxygen

during exercise), and balance (Söyler et al., 2021). Salt therapy, an extension

of speleotherapy in caves dominated by salt crystals, has been claimed to

provide relaxation, a calm mind and emotions, and feelings of revitalization

and refreshment (Shah, 2019).

3.2. Mechanisms driving health beneﬁts

The normative perspective within evolutionary psychology suggests

people tend to prefer landscapes that are abundant in elements humans

have utilized for survival, such as water for drinking and plants for food/

shelter. The existence of health beneﬁts provided by natural landscapes

that are not rich in life-supporting resources may therefore seem counterin-

tuitive. Nevertheless, multiple theories used to explain the health beneﬁt of

nature may extend to natural landscapes not dominated by plants or liquid-

state water, while other theories and pathways may be more unique to the

natural landscapes discussed in this review. According to a widely refer-

enced theoretical framework developed by Markevych et al. (2017), three

dimensions link nature exposure to human health: reducing harm, restoring

capacity (i.e., restorative effects), and building capacity (i.e., instorative ef-

fects). Harm reduction refers to the functions of some natural landscapes

(e.g., tree-rich areas) in mitigating noise, heat, air pollution, and other

stressors (Wolf et al., 2020). Restoring capacity (or restorative effects)

refers to recovery from negative states, impacts, or deﬁcient conditions,

such as attentional fatigue or stress. Building capacity (or instorative

effects) refers to natural landscapes' ability to promote health through be-

havior and psychological states absent of a deﬁcient condition. Examples

of natural landscapes' building capacities include promoting social cohe-

sion and physical activity (Kondo et al., 2018; Korpela and Ratcliffe, 2021).

Although the three-domain framework was developed for plant-rich

landscapes (“greenspaces”), some parts (restoring and building capacities)

can be adapted to describe the potential mechanisms for natural landscapes

not dominated by plants or liquid-water. We found no evidence for the

“reducing harm” dimension within the landscapes we studied but retained

this dimension in our framework to recognize it may emerge in future

research. To highlight the potential risks posed by these landscapes, we

followed Marselle et al. (2021) and added risks (i.e., dangers) and deﬁcien-

cies (i.e., situations where or populations for whom health beneﬁts are not

observed) to illustrate possible adverse effects of exposure (Fig. 4).

3.2.1. Restoring capacities

Attentional resources can be rapidly consumed in city living, and urban

residents usually face attentional depletion (Sullivan and Li, 2021; White

and Shah, 2019). Natural landscapes have been shown to help recover such

resources. Attention restoration theory (ART) is a widely used theory for

explaining the psychological beneﬁts of shorter-term exposures to natural

landscapes. ART describes how certain landscape characteristics can improve

H. Li et al.

Science of the Total Environment 856 (2023) 159292

Fig. 4. Hypothesized pathways linking exposure to natural landscapes, including those not dominated by plants (“greenspace”) or liquid-water (“bluespace”), with human

health. Notes: shorter-term vs. longer-term exposure detonated by * and ** respectively. Reducing harm is a common pathway in other nature-health research

(Markevych et al., 2017) and was retained to recognize that this pathway may emerge in future research on natural landscapes not dominated by plants/liquid-water,

despite little evidence for its role to-date.

cognitive functioning through capturing people's attention involuntarily

(Kaplan, 1995). The four characteristics that facilitate attention recovery

include being away (providing an escape from habitual activities), soft fasci-

nation (aspects of the environment that capture attention in a gentle and

effortless manner), extent (richness and coherence of an environment to

form the feeling of a complete and different world), and compatibility (the

environment ﬁts one's purposes) (Kaplan, 1995). ART does not assume resto-

ration can be only facilitated by environments dominated by plants and

liquid water, as these characteristics can exist in a wide range of environ-

ments. Polar and/or alpine landscapes, deserts, and caves may not be as

fascinating as other natural landscapes due to the lack of desirable natural

elements and a smaller number of colors and low-level features, although

notable exceptions exist. Still, these landscapes can offer visitors with scenery

that is different from their daily lives and more unique than plant or liquid-

water-dominated landscapes, thus creating strong senses of being away

from everyday routines and worries (Pilotti et al., 2019). Several studies

have also underlined the beauty and physical appeal of some deserts

(Gutberlet, 2019) and polar spaces (Cajiao et al., 2022; Powell et al., 2012;

Summerson and Lieser, 2018). Aesthetics is also a key element of cave tour-

ism (Kim et al., 2008). All of these landscapes may contain beautiful objects

with low levels of movement, thereby attracting visitors' undirected or invol-

untary attention and in turn producing restorative directed or voluntary

attention beneﬁts.

Environmental stressors (e.g., crowding, noise, and air pollution) also

dominate urban areas that house the majority of the world's population

(Browning et al., 2022; Cohen et al., 2013). Stress reduction theory (SRT)

describes how non-threatening natural environments in which humans

evolved may activate the parasympathetic nervous system in ways that

reduce stress and autonomic arousal (Ulrich, 1983; Ulrich et al., 1991).

More speciﬁcally, SRT posits that human beings have rapid, biologically

prepared emotional responses to natural environments. Such biologically

prepared responses can facilitate subsequent approach-avoidance behaviors

(e.g., escape, stay in, and explore) and the induction or reduction of stress.

Because a stress state is energy consuming, if a threat situation is resolved

and the person enters a non-threatening natural environment, the adaptive

response is to reduce stress levels quickly to restore energy and explore

the resources in the landscape. Since plant and water-rich environments

are not the only landscapes where humans evolved or still live (Hägerhäll

et al., 2018; Zhang et al., 2021). Deserts, caves, and solid water landscapes

without the presence of immediate threats (e.g., poisonous insects, snakes,

and precipices) may also provide adaptive responses that would also be

energy saving for subsequent exploration. Therefore, urban residents may

experience mental health beneﬁts when they are exposed to deserts, caves,

and solid water landscapes.

Post-traumatic growth theory, which relates to recovery from a deﬁ-

cient state, may help explain the beneﬁts of longer-term exposure to

solid-water-dominated landscapes, caves, and deserts. This theory suggests

that people who endure psychological struggles following adversity may

see positive growth afterward. We placed this theory in the restoration

dimension as it requires pre-induced psycho-physiological declines to gen-

erate compensation or “super-compensation” (recovering to higher levels

than baseline). Landscapes without drinkable water and plants are gener-

ally harsh for animals, including humans. Unlike visitors who brieﬂy visit

these landscapes for recreation, residents/travelers who take longer stays

may experience multiple environmental stressors. For instance, snow and

ice may make outdoor physical activities very physically and mentally chal-

lenging (Chapman et al., 2019; Larsson and Chapman, 2020). Dust may also

cause respiratory distress in deserts (Goudie, 2014). Such stressors threaten

visitors even if modern technologies (i.e., protective clothing, climate-

controlled shelter, and regular provision of food and water) have partially

addressed resource constraints. But these stressors also present unique op-

portunities for personal growth. Successfully overcoming the challenges

of over-wintering have been reported as a reason for the mental improve-

ment during long-term stays in the Antarctic (Jenkins and Palmer, 2003).

Overcoming stressors also appears to be a common reason for the observed

positive effects on health and wellbeing among polar expedition members

(Palinkas and Suedfeld, 2008; Zimmer et al., 2013). Blight and Norris

(2018) have already explained some of the positive consequences of polar

space exposure with this theory. Although we found no scholars reporting

post-traumatic growth in deserts, we posit that similar effects may exist

since these landscapes are similar in their intensity of stressors and

demands.

In addition to psychological aspects, some medical treatments for

chronic respiratory and allergy symptoms are also based on landscapes'

physical features. Speciﬁcally, caves generate unique health promoting

mechanisms due to their micro-climates. These climates may help to regu-

late the immune system and hormone secretion (Bilha and Simionca, 2013;

Nagy et al., 2009). According to Freidl et al. (2020), the climates in caves

include ﬁve therapeutic features. The ﬁrst is the high relative humidity

(Lunghi et al., 2017), which can beneﬁt the respiratory system. The second

H. Li et al.

is cave aerosols, which may contain some health-promoting ions

(e.g., Ca2+) that can treat infected areas in asthmatic lungs (Alföldy

et al., 2002). The third is the absence of air pollutants resulting from

caves' unique structure (Kertész et al., 2002). The fourth is radiation and

ionization. Certain radon levels (a radioactive noble gas of natural origin

commonly present in caves) may help treat pain symptoms caused by

chronic degenerative diseases (Maier et al., 2021). The last is the lack of

ozone due to no sunlight (Korzhe, 2017).

In Uyghur sand therapy, desert sands can deliver heat to the human

body effectively and safely under proper procedures (Lina et al., 2005).

Such haptic sensations and corresponding physiological responses can

increase blood ﬂow in major arteries and decrease platelet deposition

(Han et al., 2019). Some practitioners have also surmised that the elements

in desert sands, such as silicon dioxide and magnetic particles, are physio-

therapeutic materials of Chinese medicine that positively affect physiolog-

ical responses and promote physical health (Niyazi, 2002).

3.2.2. Building capacities

Supportive environment theory (SET) may help explain how novel nat-

ural landscapes can build health capacity among individuals exposed to

them. Supportive environments refer to landscapes that are easy to under-

stand and manage. SET suggests that people need such environments to

maintain physical and mental health (Grahn and Stigsdotter, 2010). Al-

though SET has been employed to explain the beneﬁts of plant-dominated

landscapes, it may also relate to the psychological beneﬁts of deserts.

One's perception of landscapes is not only bonded by genes but also fostered

over the life course. For tourists who are unfamiliar with deserts, they may

be places where feelings of excitement mask feelings of relaxation, thereby

activating the innate responses of the sympathetic nervous system (Terzano

and Gross, 2020). In contrast, the millions of people around the world who

grew up in deserts may ﬁnd these ecosystems commonplace and familiar.

Thus, a desert could be a supportive environment for local residents.

Nazif-Munoz et al. (2020) and Yin et al. (2022) argued that desert residents

may be accustomed to the rocky natural elements and tend to feel safe

within them. Indeed, many people have written passionately about the

unique beneﬁts afforded by prolonged exposure to nature in desert land-

scapes (i.e., Abbey, 1968).

It is unclear if SET applies to solid-water-dominated landscapes. One

study revealed that some people who are accustomed to polar conditions

might feel snow and ice are manageable parts of everyday life (Finlay,

2018). Such evidence comes from a study in Minnesota, U.S., which has

only intermittent snow and ice, so it offers only indirect evidence to support

the relevancy of SET.

Caves are special because there are very few cave residents in the world.

China has villages that were settled in natural caves for long periods of

history. It is reported that some people still living in these caves today are

unwilling to move out because they are familiar with that environment

(Zhou, 2019). We speculate that caves can also be supportive environments

for these residents.

Relatedly, place attachment may explain some beneﬁts acquired from

familiar natural landscapes. Place attachment is composed of multiple di-

mensions, including person (personal meanings of place), process (affective,

cognitive, and behavioral psychological components of attachment), and

place (i.e., physical elements of a setting; Scannell and Gifford, 2010).

Place attachment can occur in landscapes of varying signiﬁcance, such as

landscapes bonded with personal experiences, particularly in childhood

(Riley, 1992). Attachment to place can also help to build resilience

and transformative capacity within these systems (Larson et al., 2018;

Masterson et al., 2017). In “greenspace” research, place attachment has

been described as a functional attachment associated with various recrea-

tional activities in a place, which partially explains why people prefer green-

ery in their neighborhood (Zhang et al., 2015). For local residents,

landscapes with abundant solid-state water or rocks and minerals may

also provide places for recreational activities to happen. These landscapes

usually lack noise and other disturbances due to limited trafﬁc or human

activities. Youth in particular may have positive experiences that foster

Science of the Total Environment 856 (2023) 159292

attachment to such places (Scannell et al., 2016). Place attachment has

been empirically linked to health and wellbeing (Molcar, 2006; Rollero

and De Piccoli, 2010), which can translate to stronger health outcomes as

a result of prolonged exposure to landscapes that are emotionally meaning-

ful to people.

Yang et al. (2022) proposed that self-determination theory (SDT) may

explain the enhanced psychological well-being of nature exposure - a rela-

tionship that may translate to the diversity of landscapes discussed here.

Basic psychological needs theory, as a mini-theory of SDT, describes how

autonomy (feeling capable of making one's own decisions and actions),

competence (feeling capable of accomplishing one's desired outcomes),

and relatedness (feeling connected to and accepted by others) are basic

needs for achieving wellbeing and optimal function (Deci and Ryan,

1985; Jacobs and Jacobs, 2000; Ryan and Deci, 2017). SDT may relate to

nature exposure in three ways. First, natural environments pose fewer so-

cial demands (e.g., everyday routines and social judgment) and thus satisfy

individuals' need for autonomy by offering more freedom to engage in self-

directed activities. Relatedly, natural environments may offer a sense of

control, and therefore competence, particularly in the landscapes discussed

here through challenging recreational activities (e.g., rock climbing, cave

exploration, and snow sports) that may help individuals demonstrate mas-

tery and gain control over their lives (Crockett et al., 2020). Lastly, nature

may be considered a special type of social entity. Enhancing connections

between humans and nature may thereby satisfy the human need for relat-

edness (Cheng and Monroe, 2012; Kellert and Wilson, 1993). SDT has only

been tested in a single experiment with a shorter-term exposure to nature.

However, Yang et al. (2022) underlined its beneﬁts may extend to popula-

tions preferring a variety of types of natural landscapes due to cultural

differences. Correspondingly, the beneﬁts related to SDT may be particu-

larly relevant to populations most accustomed to landscapes not dominated

by plants or liquid-water because of their longer-term exposures to these

landscapes.

Some longer-term health beneﬁts may also relate to landscapes' physical

features, especially if these features encourage physical activity. Similar to

many landscapes dominated by plants or liquid-water, landscapes rich with

rocks or ice may offer places for physical activity and sports. Solid-water-

dominated landscapes may be necessary for activities like skating and ski-

ing. These landscapes may motivate nature-based outdoor exercise among

some newcomers and locals, particularly during milder weather (Wagner

et al., 2019). In addition to cardiovascular beneﬁts related to exercise,

snow sports may be conducive to positive emotional arousal, social bond-

ing, and feelings of accomplishment, particularly in the presence of others

(Mirehie and Gibson, 2020). Desert landscapes are usually smooth and

open, which may also provide some novel physical activity opportunities.

Residents in Kenya reported that the desert topography allowed freedom

of movement and enhanced physical wellbeing (Dan et al., 2021). Such

topographic elements are foundations of desert sports that beneﬁt both

locals and tourists (Abyar et al., 2014; Hashemi et al., 2020; Yan, 2014).

3.2.3. Risks and deﬁciencies

Despite the many possible health beneﬁts, natural landscapes not dom-

inated by plants and/or solid-water also many deﬁciencies and potential

risks, like in all natural landscapes (Marselle et al., 2021). Some scholars

refer to these negative aspects as ecosystem disservices (Oosterbroek

et al., 2016). Snow and ice may limit mobility, evoke senses of boredom,

fear, and isolation, and cause concerns related to safety and vulnerability

(Finlay, 2018). Snow and ice might also aggregate depression and seasonal

affective disorder and even increase suicide risk (Leppämäki et al., 2002;

Rind, 1996). People engaging in ice and snow-covered alpine-based out-

door recreation are also prone to falling injuries (Selig et al., 2012),

frostbite (Ströhle et al., 2018a), mountain sickness (Imray et al., 2010),

and lightning strikes (Ströhle et al., 2018b). Activity in deserts can place

people at risk of dehydration, hyponatremia (electrolyte imbalance due to

excessive water drinking), heat stroke, and even hypothermia (Elbaz

et al., 2008; Krake et al., 2003; Shopes, 1997). Desert dust may carry bacte-

ria (Ruiz-Gil et al., 2020) and retreating lake beds may expose heavy metal

H. Li et al.

depositions that threaten health (Han et al., 2004; Riches, 2019). In

caves, excessive levels of radon may increase cancer risk (Maier et al.,

2021). Many caves are inhabited by bats, and bats can be hosts for

many viruses, which increases the risk of infections (Lottenberg et al.,

1979; Willoughby et al., 2017). Such occurrences underline the necessity

of risk management in these landscapes when considering nature-based

health interventions.

Counterevidence to the potential health beneﬁts of nature exposure in

environments that are not dominated by plants or liquid-water also exists.

For example, a study of Texas, U.S. college students reported that images

of deserts were less restorative than images of other terrestrial biomes,

including tundra and different types of forests (Han, 2007). Another study

found U.S. adults reported decreased conﬁdence in their ability to change

negative habits and increased feelings of depletion and stress when

shown a desert image compared to an image dominated by liquid water

(Shalev, 2016). Such contradictory evidence may be related to humans'

inherent familiarity with resource-rich landscapes and the need to test

responses among residents more accustomed to landscapes outside the

conventional spectrum, such as deserts.

Several health-promoting factors present in landscapes with abundant

plants or liquid water may not extend to other types of natural landscapes.

Biological factors such as environmental microorganisms and negative

oxygen ions, as well as beneﬁcial volatile biogenic compounds (VOCs) gen-

erated by plants (Roviello and Roviello, 2021; Stanhope et al., 2020), may

be nearly absent in polar regions, caves, and deserts. Climate regulation,

aerosols, and negative ions generated by water movement and water-

related organisms can also be absent in landscapes without liquid water

(White et al., 2020).

Therefore, more clarity is needed with regard to potential health-

promoting factors, risks, and deﬁciencies in landscapes not dominated by

plants and/or solid-water. Such knowledge would allow for risk-beneﬁt

calculations when developing nature-based therapies and speciﬁc health

promotion interventions.

3.3. Limitations and future research directions

Due to the types of included studies, we chose to use a narrative review

instead of a systematic review to offer insights into this topic. Narrative re-

views are suitable for describing the current state of a focal area and survey-

ing newer study areas not yet addressed (Ferrari, 2015). Narrative reviews

also have some inherent limitations, such as selection and interpretation

bias (Animasahun and Chapman, 2017). Even though we tried to use a

systematic search method and complementary methods to identify studies,

our search strategy may not have been comprehensive. Our selection of

keywords from existing research on the broad array of natural and possibly

therapeutic landscapes may have missed terms used to describe these land-

scapes by some cultures (Loewe, 2022; Kahn et al., 2012; Ottosson and

Grahn, 2021; Taheri et al., 2021). Furthermore, we could not assess the

overall direction, strength, or robustness of the potential health effects

resulting from exposure due to the diversity in research designs, exposure

assessments, analytical methods, data types, and health outcomes pre-

sented in the identiﬁed literature. Instead, we could only offer circumstan-

tial evidence and tentative conclusions that warrant additional, rigorous

investigation (Pae, 2015).

The available evidence for the health beneﬁts of exposure to natural

landscapes not dominated by plants/liquid-water is largely drawn from

observational research prone to residual confounding and self-selection

bias. Similar challenges are present in research on health beneﬁts linked

to other types of natural landscapes. Further examinations should use

more rigorous sampling techniques and study designs, such as following

cohorts over time and conducting randomized clinical trials (Frumkin

et al., 2017). Still, given the expense and challenges of these approaches,

we recognize value in additional observational research given how few

studies exist for each exposure-outcome pairing.

Consistent operationalizations of nature exposure are needed to better

compare ﬁndings across studies. We identiﬁed one attempt at quantifying

Science of the Total Environment 856 (2023) 159292

natural rock/mineral cover (Nazif-Munoz et al., 2020; Olvera-Alvarez

et al., 2021) and no attempts at quantifying snow or ice cover despite mea-

sures being available in remotely sensed datasets similar to what is used to

quantify plant cover (Gao et al., 2010). We also identiﬁed no attempts at

quantifying exposure to rocks/minerals or ice/snow cover using street

view imagery. These measures would allow complementary or even im-

proved exposure estimates given their ability to measure what can be

seen at eye-level (Kang et al., 2020).

Future work is also needed to validate and expand the mechanisms

linking exposure to health outcomes. The mechanisms we presented are

largely adapted from studies and theories focused on plant-rich landscapes

(Markevych et al., 2017; Marselle et al., 2021). Some of the arguments in

favor of these mechanisms are also based on indirect evidence. Given

how understudied this body of research is relative to other environmental

exposures (e.g., air pollution and water quality), we anticipate undiscov-

ered or under-discussed mechanisms to emerge. For example, while we

did not identify evidence for these natural landscapes reducing harmful ex-

posures, future research could investigate this possibility. The mechanisms

we presented are also likely to be reﬁned as the quantity and quality of this

body of literature grows.

Nature and health scholars should embrace the complexity of natural

landscapes, which often leads to co-occurring exposures to multiple compo-

nents of nature for humans in these settings (i.e., plants, water, and rocks/

minerals). Few attempts have been made to measure vegetative and rock/

mineral cover simultaneously (Nazif-Munoz et al., 2020; Olvera-Alvarez

et al., 2021). We are unaware of attempts to incorporate these components

at the same time as water (in its solid or liquid state) in a way that would

present exposure to all three components concurrently. Such efforts

would ﬁll several gaps and answer key questions related to the health

beneﬁts of nature exposure. For example, how much do the health beneﬁts

of different types of nature exposure overlap vs. diverge? Do natural land-

scapes with different components provide a multiplier effect whereby the

total is greater than the sum of the individual parts? Does the dosage

required to achieve health beneﬁts vary as people are exposed to more

diverse natural elements?

The changing of the seasons are likely to modify what components of

natural landscapes are present at different times of year and across the

lifecourse. For example, a high-alpine mountain landscape in a temperate

climate is dominated by rocks – and perhaps even plants – in the summer

and by snow and ice during in much of the winter, spring, and fall. Diurnal

ﬂuctuations in light levels across various landscapes (e.g., light pollution at

night) might also inﬂuence health outcomes (Davies and Smyth, 2018).

Apart from appearance changes, the health beneﬁts these landscapes afford

may change. Although we did not ﬁnd any studies on the seasonality of our

reviewed landscapes, "greenspace" studies may offer some indications. For

example, the attractiveness of plant-dominated landscapes can vary with

season (Morckel, 2015; Xu et al., 2022). Trees and other forms of vegeta-

tion may show heat buffering effects that vary by climate and season

(Chun and Guldmann, 2018). By contrast, some rock/mineral-dominated

landscapes may be perceived as less attractive or accommodating and in-

crease heat stroke risks due to extreme temperatures in summer months

(Varghese et al., 2005). These seasonal variations may be of importance

for shorter-term exposures, because visitors may be less aware of the risks

compared to residents when they are entering new landscapes (Skinner

et al., 2001). Ultimately, seasonal variations could make some of the land-

scapes we reviewed less beneﬁcial or even harmful (e.g., deserts during

daylight hours in summer months). We recommend accounting for sea-

sonal and climatic factors in future studies exploring beneﬁts associated

with nature. Ongoing climate change effects should be considered carefully

as they may dramatically modify some of the landscapes considered, such

as landscapes dominated by solid water and deserts. Time-varying expo-

sure data rather than cross-sectional data should also be used to account

for the full range of experiences with natural settings and minimize expo-

sure misclassiﬁcation.

Finally, the utility of these landscapes for nature-based therapies and

speciﬁc health promotion interventions warrants critical examination.

H. Li et al.

Speleotherapy and Uyghur sand therapy are examples of existing interven-

tions with insufﬁcient data regarding their recommended dosage, efﬁ-

cacy, and risk management. In contrast, therapies like forest-bathing

or horticultural therapy are more mature and have many empirical

research studies (Rosa et al., 2021) and practitioner-oriented articles

and books written on their safe administration (Li, 2019; Miyazaki,

2021; Schuh and Immich, 2022). Ultimately, the landscapes we

discussed may pose greater risks and challenges than other natural

landscapes. Risk-beneﬁt calculations must be made before pursuing

therapies in these landscapes at-scale and with the general population

(i.e., people less familiar with these landscapes). The extent to which

the possible health beneﬁts of exposure outweigh the risks is perhaps

the crux of future studies focused on these landscapes. We hope our

contributions inspire research on the wide-ranging diversity of natural

landscapes that exist, and how nature-based interventions can maxi-

mize the health beneﬁts of these landscapes.

4. Conclusions

Our narrative review introduced the potential beneﬁts of certain nat-

ural landscapes that are rarely studied in the rapidly growing literature

on the health beneﬁts of nature exposure. We presented a new and more

comprehensive classiﬁcation for types of health-promoting natural

landscapes that moves beyond color-coding (i.e., “greenspace” and

“bluespace”). This classiﬁcations focuses instead on natural compo-

nents, including plants, water, and rocks/minerals. We also reviewed

the extant literature on landscapes dominated by solid-state water

(e.g., polar spaces) and rocks or minerals (e.g., deserts and caves) to

reveal associations of shorter- and longer-term exposure with health

impacts. Despite the risks associated with visiting or living in these

landscapes, we observed the potential for beneﬁcial psychological and

physiological responses as well as physical and mental health beneﬁts,

including resources for medical treatment. We posited that restorative

and instorative pathways explained the health promotion capacities of

these landscapes on the basis of previous frameworks from “greenspace”

research (Markevych et al., 2017; Marselle et al., 2021). Further

research, including hypothesis-driven longitudinal studies, is needed

to strengthen the literature focused on these landscapes, document

exposure-outcome pairs, and validate mechanisms linking these land-

scapes with human health.

CRediT authorship contribution statement

Hansen Li: Conceptualization, Methodology, Data curation, Writing –

original draft, Writing – review & editing, Visualization. Matthew

H.E.M. Browning: Conceptualization, Methodology, Data curation,

Writing – original draft, Writing – review & editing, Visualization, Supervi-

sion, Project administration. Alessandro Rigolon: Conceptualization,

Methodology, Data curation, Writing – review & editing, Visualization. Lin-

coln R. Larson: Conceptualization, Methodology, Data curation, Writing –

review & editing, Visualization. Derrick Taff: Conceptualization, Data

curation, Writing – review & editing, Visualization. S.M. Labib: Conceptu-

alization, Data curation, Writing – review & editing, Visualization. Jacob

Benﬁeld: Conceptualization, Writing – review & editing. Shuai Yuan:

Conceptualization, Writing – review & editing, Visualization. Olivia

McAnirlin: Conceptualization, Writing – review & editing. Nazanin

Hatami: Conceptualization, Writing – review & editing. Peter H. Kahn:

Conceptualization, Writing – review & editing, Visualization.

Data availability

No data was used for the research described in the article.

Declaration of competing interest

We declare that we have no conﬂicts of interest.

Science of the Total Environment 856 (2023) 159292

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