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Alyan, E. Impact of Virtual Nature Therapy on Stress Responses. Encyclopedia. Available online: https://encyclopedia.pub/entry/18306 (accessed on 31 July 2024).
Alyan E. Impact of Virtual Nature Therapy on Stress Responses. Encyclopedia. Available at: https://encyclopedia.pub/entry/18306. Accessed July 31, 2024.
Alyan, Emad. "Impact of Virtual Nature Therapy on Stress Responses" Encyclopedia, https://encyclopedia.pub/entry/18306 (accessed July 31, 2024).
Alyan, E. (2022, January 17). Impact of Virtual Nature Therapy on Stress Responses. In Encyclopedia. https://encyclopedia.pub/entry/18306
Alyan, Emad. "Impact of Virtual Nature Therapy on Stress Responses." Encyclopedia. Web. 17 January, 2022.
Impact of Virtual Nature Therapy on Stress Responses
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This entry is adapted from the peer-reviewed paper 10.3390/f12121776

Previous research has found that virtual reality (VR) experiences affect socio-affective behavior, indicating the potential of using VR for cognitive and psychological stress therapy. However, evidence for the impacts of virtual forest therapy as a stress-reduction technique is lacking, and the usefulness of these techniques has yet to be determined. 

virtual reality (VR) virtual forest therapy (VFT) virtual nature stress psychology

1. Introduction

Nature has played an essential role in people’s lives [1][2]. Today, however, our ties to mother nature are tenuous at best. People can boost sensory awareness and balance their lives by taking soothing and meditative walks in nature. Nature walks are based on a Japanese technique known as “shinrin-yoku”, which translates to “forest bathing” and is sometimes referred to as “forest therapy” [3]. This technique was first developed in the early 1980s by Tomohide Akiyama, director of the Japanese Forestry Agency [4], based on the idea that cultivating a love relationship with nature can help preventative healthcare, well-being, and healing. In addition to Japan, several other developed countries in Europe and North America have practiced these natures’ walk methods to reduce stress levels in patients [5].
Consequently, the impacts of forests and nature on human well-being and health have piqued researchers’ interest in recent years. Forest therapy is a therapeutic, immersive environmental experience that promotes well-being [6]. It also has been shown to have a beneficial influence on the health of the human body and mind. According to previous studies, intensive involvement with nature, such as “shinrin-yoku”, can be helpful to health. This claim has been supported by numerous studies in the medical field [7][8][9][10]. A study by [6] found that, compared to an urban environment, two days of forest bathing could increase the number of natural killer cells in the immune system, significantly increase parasympathetic nervous activity, and suppress substantially sympathetic activity in the participants. Another study revealed that looking out a hospital window at trees helped patients recover faster after surgery, implying that a visual component alone can improve human health [11]. It showed that visual aspects, such as merely viewing the green forest environment, may be a source of positive benefits and apparently reflect on people’s psychological state throughout their time in the forest. Today, people are occupied with everyday life, and most reside in cities where noise pollution, air pollution, water pollution, work pressure, and lack of green environments are available. These conditions lead to stress symptoms in a large portion of the urban population [12]. Stress levels will increase in the following 30 years due to an increase in development [13][14][15][16]. Other than that, lack of time because of work makes it difficult for people to spend time going to places that can relieve stress. However, instead of stepping outside, new technology based on virtual reality (VR) has been introduced to allow us to bring forest, park, or nature into the house.
VR can be defined as a class of computer-controlled multisensory communication technology that enables more natural interaction with data and engages the human senses in new ways [17]. Another definition of VR is a computer-created environment in which the user feels existent [18]. The modern technological advances in VR have become a useful supporting tool in several environments, such as disorder therapies [19][20][21], rehabilitation processes [22][23][24], marketing [25][26][27], industry [28][29], or safety and industrial training [30][31]. VR systems are also increasing promptly, with countless new applications in the ranges of healthcare and psychology [32]. Researchers may fine-tune the design and elaboration of environmental settings using VR, bypassing the limits of field studies, which cannot account for a wide range of potentially confounding elements (e.g., temperature, crowd, traffic).
Furthermore, VR can develop a strong sense of presence, defined as the personal sensation of being there in a virtual environment [33]. It simulates experimental scenarios where comparable real-life situations are unavailable (e.g., forest with or without river). VR can be executed by using a flat-screen display [34], a projection-based cube room known as a computer-automated virtual environment [35], or a head-mounted display [36]. The use of flat-screen displays and the other two visualization technologies offer an immersive experience in which the user is entirely encircled by the virtual environment, generating a more real-life experience.
Nowadays, people spend more time indoors than outdoors, especially during the period of the COVID-19 pandemic. This tendency has caused individuals to be isolated from contact with nature, negatively influencing their mental and physical health. The human mind has become stressed and depressed owing to various problems such as self-harm and eventually suicide. Therefore, human beings need to find something to be free from stress and lead to a healthy lifestyle.
Many studies have been using stress as a health-related variable, revealing that prolonged stress can affect health and have a negative effect on a person [37][38]. It has been shown that stress is linked to various cardiovascular diseases and mental disorders [12][39][40]. In 1991, the theory of stress relief was proposed by [41] to improve psychology, which states that acquaintance with the natural environment can decrease stress and directly affect mental recovery. In other words, exposure to nature views or simulations of nature may help individuals recover from psychological and physiological-related stress. Psychotherapists consider VR therapy (VRT) one of the most promising psychiatric interventions in the future decades to treat mental stress through virtual forest therapy (VFT) that restricts the user’s interaction with various virtual nature environments and stimuli. Nature scenery exposure could increase positive effects and reduce negative emotions, such as fear or anger [42]. A further study by [43] found that nature could improve health in four ways: air quality, physical activity, social interconnection, and stress reduction. Though, a lack of understanding of the relationship between physiological mechanisms and the quality of urban green spaces, making stress problems challenging to curb. In today’s technologically advanced world, where time is a valuable element, green spaces can be brought into the home using virtual application technology.

2. Psychosocial and Physiological Effects of Forest Therapy

Recent studies focused on investigating the combined effect of psychological or physiological variables and the external environment on physical and mental health. Earlier studies on forest therapy concentrated on psychosocial and physiological factors, often enhancing an individual’s moods (Table 1). Most studies on the psychosocial impacts of forest therapy used self-report surveys to assess participants’ mood states and overall mental health. Among the most employed methods were the Profile of Mood States (POMS), positive and negative affect scale (PANAS), visual analogue scales (VAS), standard stress scale (SSS), perceived stress scale (PSS), and state and trait anxiety inventory (STAI-S). Along with psychosocial impacts assessment, twelve studies [35][36][44][45][46][47][48][49][50][51][52][53] examined the effects of forest therapy on physiological health by evaluating heart rate (HR), heart rate variability (HRV), systolic blood pressure (SBP), diastolic blood pressure (DBP), salivary amylase (SA), the standard deviation of R-R intervals (SDRR), blood volume pulse (BVP), and skin conductance levels (SCL).
Four of these studies used POMS and HR/HRV to evaluate the psychological and physiological responses [45][46][47][48]. Tsutsumi, Nogaki, Shimizu, Stone, and Kobayashi [45] conducted a study to see if stimulation from watching one’s favorite video of the sea or the forest affected relaxing. Participants were instructed to watch DVDs for sea and forest with natural sounds for 90 min. The POMS scores were collected on every session, and Bispectral Index System value and HRV were monitored by the Bispectral Index System and MemCalc system. Each indication was compared between the two groups of six participants based on their sea or forest scenery choice. The heart rate, persistent arousal, and high frequency changed significantly as watching the favorite video. These findings suggested that the viewer’s favorite movie of the sea or forest had a calming impact. Yu, Lee, and Luo [46] investigated the physiological and psychological reactions to virtual reality forests and urban environments. This study used a cross-over and pretest-posttest approach to assess the VR environment’s impact on forests and urban restoration. The researchers gathered both physiological and psychological responses (POMS). The findings revealed that the subjects’ systolic blood pressure and heart rate reduced over time, regardless of contextual variables. In simulated urban contexts, an increased degree of weariness and a decreased level of self-esteem was observed as psychological responses. However, in simulated forest conditions, vigor levels increased, and negative feelings, such as perplexity, tiredness, anger-hostility, tension, and despair, decreased. Overall, the benefits of immersing in a forest environment have proved to be more significant. Another study was carried out by Hong, Joung, Lee, Kim, Kim, and Park [47] to examine the influence of VR forest video on adult stress relief using POMS, HRV, and HR measurements. Arithmetic tasks (1-digit by 2-digit numbers multiplication) were used to induce stress in participants before giving them five minutes to watch a virtual reality forests (VRF) video. This study revealed that stress index and HR decreased, confirming that VRF reduces stress in adults, stabilizes physiological state, and improves psychological state. Wang, Shi, Zhang, and Chiang [48] presented seven exemplary forest rest areas discovered during fieldwork in Beijing to participants using VR. Blood pressure, heart rate, salivary amylase, and the Brief POMS were physiological and psychological indicators, with stress level as the dependent variable. Each environment type was randomly allocated to 96 participants, and only a kind of forest resting setting was observed. According to this study, all seven forest rest environments may reduce stress effects to some level. The impact of different types of forest resting environments on stress relief is distinct, with the most natural settings having the greatest impact on stress relief.
Two studies [35][36] used STAI-S as a psychological indicator and HR/HRV or SCL as physiological indicators. For example, [35] studied the effect of natural noises and stress recovery in natural surroundings. The study investigated subjective stress (STAI-S) and physiological recovery (HR) in two virtual natural environments—(1) with exposure to natural sounds and (2) without exposure to natural sounds—and one control condition after producing stress with a virtual stress test. The results revealed parasympathetic activation in the group exposed to natural sounds in a simulated natural environment, implying increased stress recovery in such settings. The control group and the group that recovered in virtual nature without sound showed neither autonomic activation nor inactivation. The findings imply a possible mechanistic relationship between nature, natural sounds, and stress recovery, indicating the potential use of VR as a viable method to manage stress. Li, Sun, Sun, Yuan, and Li [36] investigated the influence of brightness levels on stress retrieval when watching VRF with simulated natural light. This study used pre-test and post-test strategies to examine the effect of different brightness levels on stress recovery using a virtual forest environment. A total of 120 participants were recruited to watch stimuli from six immersive virtual environments (IVEs) through a head-mounted display. The physiological and psychological responses, as well as perceived environmental characteristics, were assessed. This study showed that VRF scenes of bright sunlight reduced stress more effectively than scenes from the dark night.
In two more studies, HR was used with VAS [53] and PANAS [49] to evaluate the effectiveness of VR in reducing stress. Schebella, Weber, Schultz, and Weinstein [53] use IVEs comprised of visual, auditory, and olfactory stimuli to examine the impacts of biodiversity on stress recovery. Their study employed three natural and one urban environment (none, low, moderate, and high). A further IVE with high biodiversity was also added, but no auditory or olfactory stimulation. The study reported consistent reactions to well-being using physiological and self-reported measurements. However, biodiversity has been shown to have a non-linear effect on stress recovery, and is most effective in urban settings and most influential in moderately diverse environments. It was stated that multisensory (visual, auditory, and olfactory) stimulation improved stress recovery and did not impact the immersion sense of the participants when compared to visual-only encounters. In [49], the impact of VR technology on reducing stress and enhancing individuals’ moods was investigated using a pulse-oximeter and the PANAS. This study was conducted on 36 women with substance use disorder (SUD) for the first 10 min of their daily programs in a residential treatment program for four weeks, including two activities. A cross-over design was employed to compare seeing natural environments and performing mindfulness-based activities. As a result, there were statistically significant reductions in mean negative affect ratings and heart rate after seeing a nature scene and conducting mindfulness-based exercises. Additionally, general mood significantly improved for participants in both circumstances.
The other four studies used other psychological and physiological indicators, such as EDA and MRJPQ in [44]; GHQ12 and GSR in [50]; POMS, PSS, and GSR in [51]; and PANAS and SDRR in [52]. For instance, Anderson, Mayer, Fellows, Cowan, Hegel, and Buckey [44] used VR technology with immersive natural scenery to reduce stress levels and improve participants’ moods. They recruited 18 participants (9 men and 9 women), aged 32 to 44. The participants were required to watch three 360° views of an indoor control, rural Ireland, and remote beaches for 15 min. Before the scenes, the subjects were psychologically stressed with arithmetic tasks. Psychophysiological arousal was measured using EDA and heart rate variability. The mood and scene qualities were assessed using the positive and negative affect schedule and the 15-question MRJPQ. When comparing the natural sceneries to the control scenario, the reductions in EDA from baseline were larger at the end of the natural scenes. The natural settings reduced negative influence from baseline, whereas the control scene did not. The control scene had lower scores of MRJPQ than natural situations. The preferred scene in the two natural sceneries reduced the negative effect and increased MRJPQ scores than the second-choice scene. Their study revealed that natural VR could produce relaxation with the right selection of scenery, owing to its impact on assessing the mood and quality of the scenery. In [50], VR was integrated with bilateral stimulation for stress relief to evaluate EMDR. The authors conducted three relaxation training sessions on 28 healthy office workers who recorded their subjective stress (GHQ12), HR, mood, GSR, and muscle response prior to the session. The study revealed a significant reduction in stress levels and improved participant mood using VR based on their findings. Mostajeran, Krzikawski, Steinicke, and Kühn [51] studied the effects of exposure to a forest and an urban virtual environment on mood, stress, physiological responses, and cognition. The environments were shown as either traditional photo slideshows or 360-degree films on a head-mounted display. Their findings revealed that the forest environment had a favorable effect on cognition while the urban environment disrupted mood. Furthermore, images of an urban or forest setting could lower physiological stimulation than immersive 360-degree movies. A more recent study by [52], with 111 subjects recruited, highlighted the impact of buildings with vertical greenery on negative psychophysiological stress responses using VR technology. The vertical greenery covered the balconies, walls, and pillars of buildings in the plant state. The plants were replaced with equivalent hues of green in the color condition. The study suggested that vertical greenery prevented stress from increasing, as indicated by heart rate variability.
Two studies measured only physiological responses, such as SCL in [54], and NIRS, HRV, and SD in [55]. The effects of visual stimuli (virtual 360-degree images of forests, urban areas, and parks) on recovery from physiological stress have been compared by [54] to the effect of congruent olfactory stimuli (natural and urban smells) and acoustic stimuli (birdsong and noise). In their study, a total of 154 participants were randomly assigned to one of the three situations, urban area, forest, or park, and were then exposed to stress (operationalized by skin conductance levels). This study showed a significant reduction in stress in parks and forests but not in cities. Igarashi, Yamamoto, Lee, Song, Ikei, and Miyazaki [55] investigated the physiological effects on relaxation of 3D floral pictures compared to 2D images upon prefrontal cortex and autonomic nerve activity. Ninety male university students, aged 22 to 23, were given 90 s to see the water lily picture in 3D and 2D images. Their study detected prefrontal cortex (PFC) activity using near-infrared spectroscopy, whereas autonomic nerve activity was quantified using HRV. Besides, a modified SD approach was used to determine psychological impacts. The 3D visual stimulation, compared to 2D visual stimulation, resulted in significantly decreased hemoglobin concentration in the right PFC. Additionally, it caused lower sympathetic activity as measured by the low- and high-frequency ratio of the HRV component and substantially more realistic feeling, as evidenced by higher SD ratings.
The four final research used psychological indicators based on questionnaires and observations. Moyle, Jones, Dwan, and Petrovich [34] used the observed emotion rating scale (OERS) to assess the impacts of VRF on dementia patients’ engagement, apathy, and mood states, and learn more about staff, patients, and their families’ perspectives. Their study was conducted by the mixed method, consisting of ten individuals with dementia, ten family members, and nine care professionals from two residential aged care facilities by one care provider. Residents took part in a VRF session that was facilitated. The results showed that residents, family members, and staff agreed that the VRF had a favorable impact. Residents reported significantly higher levels of pleasure and attentiveness during the VRF session. They also felt more fear and anxiety during the forest encounter than the comparative normative sample. The VRF was considered to have a favorable impact on dementia patients, although a larger level of fear and anxiety has been observed during the VRF than the normative sample. Besides, Reese, et al. [56] used SSS and PANAS to evaluate participants’ condition following the VR experience irrespective of the control. This study recruited 64 participants who navigated by an experimenter or navigated across a VR environment. They claimed that lower stress could be experienced through a VR environment than actively navigating through it.
Scates et al. [57] used a Likert-type scale questionnaire to observe whether a VR nature could alleviate stress and discomfort in cancer patients in a treatment center. The authors recruited 50 patients having their regular chemotherapy treatment sessions. These patients were evaluated for two visits for stress and pain during their intravenous (IV). They watched a naturally inspired VR simulation during the second visit while getting their IV. The study found that cancer patients viewing naturally inspired VR were significantly less frustrated, more relaxed, and had peaceful feelings and positive distractions. Besides, Rozmi, et al. [58] highlighted several design aspects in terms of visual realism, navigation methods, and aids for users to be fully immersed in the virtual forest environment, thus reducing their stress levels. The design was based on a game concept and received positive feedback from users, and the study suggested using elements of nature, such as vegetation, natural habitat, and forests.
Table 1. Characteristics of included studies.
References Country Group Interventions Sex (M:F), Age Recovery
Duration		 Aim Outcome Measurement Technique Results
[35] Sweden EG: VR with nature sounds
CG: VR without nature sounds or No VR treatment		 EG: 10 (10:0), age 28.2 ± 10.3.
CG: 10 (10:0), age 28.1 ± 4.4; 10 (10:0), age 26.7 ± 3.4.		 40 min Explore physiological recovery in two distinct virtual natural settings, with and without interaction with natural sounds. The findings imply a possible mechanistic relationship between nature, natural sounds, and stress recovery. STAI-S, HRV, HR, TWA After the intervention, significant differences were discovered between groups (HR, p = 0.007; TWA, p < 0.001).
[55] Japan EG: 3D flower images
CG: 2D flower image		 EG & CG: 19 (19:0), age 22.2 ± 0.6. 90 s Evaluate physiological relaxation effects on autonomic nerve activity by viewing 3D versus 3D flower images. The study found that realistic 3D floral images boost physiological relaxation more effectively than 2D floral images. NIRS, HRV, SD Significant differences were found (NIRS, p < 0.01; HRV, p < 0.05; SD, p < 0.01) between the two groups.
[44] Lebanon EG: natural scenes (rural Ireland and remote beaches), and indoor control.
CG: -		 18 (9:9), age 32 ± 12. 15 min Promote nature exposure for those living in isolated, restricted settings. VR nature produced relaxation, and scene selection had a substantial impact on both mood and visual perception. EDA,
MRJPQ		 Significant differences were found (EDA, p = 0.002; MRJPQ, p < 0.014) between the natural scenes and indoor control.
[45] Japan EG: nature scence of sea or forest, and baseline
CG: -		 12 (12:0), age 22.2 ± 1.7. 90 min Evaluate the influence on people’s relaxation while viewing a video of the sea or a forest. The viewer’s favorite movie of the sea or forest had a calming impact. The findings also imply that watching a favorite scene of a natural setting could help to relieve stress and exhaustion. POMS, HR, low frequency, high frequency, BIS Significant stress reduction was found (POMS, p < 0.05) between the nature scenes (sea and forest) and their baselines.
[34] Australia EG: virtual reality forest
CG: -		 Residents with dementia: 10 (3:7), age = 89 ± 4.7; Family members: 10; Care staff: 9. 15 min Assess the apathy, engagement, and mood of dementia patients and to examine employees, dementia patients, and family experiences. The VRF positively affected dementia patients despite a higher level of fear/anxiety during the VRF compared to the normative group. OERS Residents reported higher levels of happiness (p = 0.008), attentiveness (p = 0.001), and anxiety/fear (p = 0.16).
[46] Taiwan Cross-over study: forest and urban VR environments. 30 (13:17), age 20–29. 9 min and 30 s Evaluate the effects of virtual forests on boosting people’s psychological well-being. Immersing in forests could provide benefits such as reduced negative emotions and enhanced vigor as compared to urban environments that lower self-esteem and raise fatigue levels. PASAT, POMS, BP, HRV Significant decrease in negative emotions (tension, p = 0, depression, p < 0.017) observed in forest environments.
[54] Sweden Pseudo-randomised study: VR forest, park and urban environments. Forest: 52 (24:28), age 27; park: 52 (26:22), age 28; park: 50 (22:28), age 27. 3 min Assess the potential for stress recovery using three different environments: urban areas, parks, and forests. According to the study, residing in an urban environment with no green space, traffic noise, and tar and diesel odors can expose people to a certain amount of stress compared to natural environments such as gardens and forests. SCL Significant differences were found between urban areas and both forest (p = 0.003) and park (p < 0.001), while no significant differences (p = 0.39) between forest and park.
[47] Korea EG: VR forest, baseline
CG: -		 40 (23:17), age 24.4 ± 2.8. 5 min Evaluate viewing forest videos in reducing stress in adults. The study revealed that watching videos of VR forests could affect individuals’ stress levels, regulate physiological conditions, and positively affect their mental conditions. HRV, HR, SI, POMS, SD, PANAS Significant decrease in stress was found (SI, p < 0.01; HRV, p < 0.05; HR, p < 0.01; SD, p < 0.01; POMS-TMD, p < 0.01).
[48] China Independent group design: Pre and post-VR forests. 96 (33:63), age 24.03 ± 5.29. 5 min Evaluate stress recovery after viewing VR videos of seven forest environments: (1) structure, (2) wood, (3) wood with bench, (4) wood with platform and bench, (5) platform with trees, (6) waterfall with trees, and (7) pool with plants. The study investigated seven forest resting environments. These environments showed a distinct impact on stress relief and proved to reduce stress to some level. SBP, DBP, HR, SA, POMS Significant differences were found in various environments with greatest impact in type 6: (SBP, p < 0.01; DBP, p < 0.05; HR, p < 0.05; SA, p < 0.05; POMS-TMD, p < 0.01)
[36] China Independent group design: six immersive virtual environments (IVE) (lightest to darkest). 120 (27:93), age 19.79 ± 1.90; 20 for each scene. 6 min Investigate how varied natural light brightness levels affect people’s stress recovery effects in the forest and provide some proof for stress reduction’s mental well-being benefits. This study confirmed that bright sunlight scenes (i.e., the lightest, lightest, lightest) in the virtual forest ease tension more effectively than the darkest night sceneries. Another discovery indicated that dark settings, such as sunrise without sunlight but with a hint of brightness, had the same effect. SCL, BVP, STAI-S Significant differences were found in natural light brightness (p < 0.001; SCL, p < 0.001; BVP, p < 0.001; STAI-S, p < 0.01).
[53] Australia Independent group design: four levels of biodiversity (urban IVE, none; natural IVE, low, moderate, and high). 52 (24:28), age 37.6 ± 10.6. Not stated the number of participants for each scene. 5 min Evaluate the effects of biodiversity IVEs on recovery from induced stress. The findings revealed similar well-being responses across self-reported and physiological measurements, implying that biodiversity had an impact on human happiness. In the urban IVE, stress recovery was the least effective for most well-being metrics. VAS, HR Significant differences in stress recovery for subjective stress, anxiety, and happiness were found between urban and low biodiversity IVEs (p < 0.05). For HR, no significant differences were found between the urban and either biodiversity IVEs.
[57] USA Repeated measures design: cancer patients with/without viewing VR during the intravenous procedure (IV). 50 (15:35), age > 65 (n = 29). During IV procedure for 30 consecutive days Investigate VR during IV procedures on reducing stress and pain among cancer patients. The participants felt significantly less frustrated and more relaxed while watching VR nature scenes throughout intravenous chemotherapy. Likert-type scale questionnaire Significant increases were found in positive distractions (p < 0.0001), relaxation(p < 0.05), feelings of peace (p < 0.01).
[49] USA Cross-over study: nature scene versus practicing mindfulness-based activities. 36 (0:36), age ≥ 18. 4 Weeks, 10 min daily Evaluate the effectiveness of VR in reducing stress among people with SUD. This study provided preliminary evidence that nature-viewing had similar benefits as a mindfulness therapy for treating stress and low mood associated with recovery from SUD. PANAS, HR Significant decreases in mean negative affect scores (p = 0.001) and heart rate (p ≤ 0.001) were found while viewing nature scenes and practicing mindfulness-based activities.
[58] Malaysia Observational study. Public respondents. - Use VR nature therapy as an alternative tool for stress relief. An early study found that VR had potential as an aid in therapy, with positive outcomes from users. Users’ feedback -
[50] Poland Cross-over study: VR immersion with visual, auditory, and tactile conditions. 23 (10:13), age 37.2 ± 9.7. 6.3 min VR combined with bilateral stimulation in EMDR as a stress-relieving tool. According to the study’s preliminary findings, VR-based bilateral stimulation may boost mood and reduce stress. GHQ12, GSR No significant differences were found between groups. For GSR, visual was most effective in subjective assessment ofstress level (pre, 80%; post, 100%).
[51] Germany Cross-over study: forest and urban VR environments. 34 (23:11), age 27.26 > 2.14. 6 min Demonstrate the health and well-being advantages of natural environments. The forest environment had a beneficial influence on cognition, while the urban setting had a negative effect on mood. Photos of an urban or forest scene succeeded better than 360 videos to reduce physiological arousals. POMS, PSS,
GSR		 Significant differences in participants’ mood (POMS, p < 0.05; PSS, no significant effects; GSR, p < 0.001)
[56] Germany EG: VR with active control and 30-s familiarization
CG: VR with no control.		 EG: 32 (8:24), age 23.31 ± 4.7.
CG: 32 (9:23), age 22.7 ± 2.85.		 5 min Identify the impact of control on the positive effects elicited by virtual nature environments. The study showed that participants reported reduced stress, and their positive affective states were raised following the VR experience. PANAS, SSS Significant positive effect was found after VR (PANAS, p < 0.001; SSS, p < 0.001)
[52] Singapore Independent group design: VR based plant or color conditions. 111 (40:71), age 21.63 > 1.81. 5 min Demonstrate the influence emotion and stress-buffering of vertical greenery outside buildings. The study suggested that vertical greenery on city buildings could help to mitigate the negative psychophysiological effects of stress. PANAS, SDRR Significant decreases were observed in SDRR (p = 0.01)and positive affect (p < 0.00) in color conditions. No significant main effect of the condition was found.

3. Effectiveness of VR Intervention to Relieve Stress

All eighteen studies stated in Table 1 examined the effectiveness of forest VR in treating physiological and psychological stress. These studies concluded that VR is a valuable tool for assessing and promoting relaxation among different population groups and found a statistically substantial reduction in stress levels, except for the study by [50], who evaluate VR immersion with visual, auditory, and tactile elements. According to the selected studies, realistic 3D views were found to have a more significant influence on physiological relaxation than 2D views [55]. Four studies [47][48][56][58] found that individuals exposed to forest VR experienced a more remarkable improvement in their stress levels than baseline or before the intervention. Another four studies [46][51][53][54] compared stress levels in virtual forests with urban areas following the VR intervention, revealing reduced negative emotions and stress levels in virtual forests. Even vertical greenery on urban buildings, as claimed by Chan, Qiu, Esposito, and Mai [52], might help minimize negative psychophysiological impacts of stress.
Additionally, elements of nature, such as sounds [35], were positively correlated with stress recovery after the VR intervention with sounds than without sounds. Similarly, bright sunlight scenes [36] were more effective in reducing stress than other natural light brightness levels. The effectiveness of nature was not a monopoly of forests, but beaches [44] and seas [45] provide similar positive effects to an extent. In health practice, VR has been proven to mitigate stress among patients with SUD [49], dementia [34], and cancer, during the intravenous procedure [57].

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