Introduction 

Spending time in nature to get benefits for physical and mental health has been practiced by society for centuries in different cultures. In 1982 the Japanese Ministry of Agriculture, Forestry, and Fisheries gave for the first time the definition of “Shinrin Yoku” (“Forest Bathing”). Since then, the concept became the subject of several studies demonstrating how and why “immersion” in natural environments provide benefits to psychophysical health and can contribute to tackling certain non-communicable pathologies ([42], [46], [4]). From Green Care to Forest Care Initiatives, there are many general terms indicating practices that improve physical, psychological, and social conditions with playful and/or recreational interaction with nature, even though nature-based therapy ([11]). In particular, the benefits of immersion in forest environments are associated with reduced levels of stress, anxiety, and depression ([32], [17], [36], [13]), increase in creativity ([55]), with positive effects also on the respiratory, cardiovascular and immune systems ([29], [21], [25], [12]). The role of forests for the contemporary society and their ecosystem services influencing human health ([44]) are crucial. According to an estimate of the European Strategy and Policy Analysis System ([14]), by 2030 at least two-thirds of the world’s population will live in urban areas (83% in Italy). The progressive moving away from nature has effects on people’s psycho-physical well-being, lifestyle-related disease and mental illnesses, and consequently on the relative health costs ([28], [27], [51], [52]). Spending time in forests has become increasingly valued by people living in urban settings, with high levels of stress and sedentary lifestyle ([1], [50]). Besides, there are evidence that forest immersion facilitates preventive and therapeutic measures for mental and physical health ([49], [54], [47]). In recent years an increase in the activities “labelled” as Forest bathing (FB) and Forest therapy (FT) in forest areas (often confused with each other) has been observed. This new trend responds to the growing demand for access to natural environments associate with the growing awareness of their importance, exacerbated by the climate crisis and the pandemic period, as mentioned in the State of the World’s Forests report ([16], [10], [40]). At present, FB and FT are developed in different countries, according to different locations, practices, and specific peculiarities ([56]). In Korea FT is recognized as a good practice for individuals and it has been promoted also for its positive effects on the development of local circular economy ([48]). In Japan FB and FT, promoted by the Forest Therapy Society and other institutions, are recognized as medical practices, and are supported by the Ministry of Agriculture, Forestry and Fisheries ([22]). Also, Japan has a certification system for FT sites (since 2005, 65 forests have been approved) and forest therapists, that also has a positive effect on the development of circular economy ([30], [57]). In Italy, FB and FT can be considered an evolution of initiatives that have already been conducted for over a century in search of psychophysical wellbeing, such as those promoted by the Italian Alpine Club (CAI) and various environmental associations. The topic of FT and FB has been addressed by an increasing number of research projects and studies conducted at national level, e.g., the Green for Care project (⇒ https:/­/­www.­greenforcare.­eu/­) or the collaboration between CAI and the National Research Council of Italy ([31], [37]). All these initiatives have been developed in very different sites without public recognizing of the suitability and qualified therapists with personalised therapy program. Indeed, although the Italian National Forestry Strategy ([38]) recognizes the importance of FT initiatives among the socio-cultural services of forests, actually there is not a specific regulatory framework, neither common public standards for FT sites evaluation (e.g., forest composition, accessibility, etc.) and for the training of the medical and technical staff involved in FT. In particular, the characteristics of forests where FT is carried out are often not sufficiently analysed to establish if the site is suitable for the FT/UFT activities in terms of safety and effectiveness, considered as key requirements by recent studies ([19], [23]). There are only some private associations and certification bodies which have proposed standards to certify suitable areas for “forestry wellbeing” or sites called “forests of wellbeing”, with the purpose of FB activities or generic “improving wellbeing and health of people” ([20], [5]). The present and future challenges of the growth of the national forestry sector impose a regulation and a framework identifying suitable FT sites and releasing the suitability qualification to protect users as well as the natural environments ([43]). Such recognition could potentially enhance the competitiveness and multifunctionality of enterprises ([26]) and territories, mainly mountainous and marginal or rural areas. Then, FT represents an important entrepreneurial and employment opportunity for the Italian forestry sector and for many rural areas ([7], [8], [45]). It could also lead to a health system of “green prescriptions” ([6], [36]) for preventive and therapeutic purposes with benefits for the National Health System. Recognizing a site suitable to be used for FT and assess its specific characteristics is the focus of this paper. Although some studies have found no significant differences in the results of activities carried out between natural and urban environments ([35]), the work distinguishes between FT in natural sites and Urban Forest Therapy (UFT). They are both important but very different because of their locations, which entail different environmental features and management methods ([33]). Urban forestry sites are exploited especially by people living in the city, who can access them more quickly and frequently ([53]). “Natural sites”, far from urban areas, are less exposed to noise and visual disturbance, and to air pollution, but they require longer time to be reached. This study proposes: (i) a standard procedure (“iter”) for the validation of a FT/UFT site by the competent authority to obtain the official “environmental recognition” of site suitability; (ii) the technical and objective criteria to assess the stationary and environmental parameters that a potential area must possess to be qualified and recognized as a FT/UFT site.

  Materials and methods 

Iter

The procedure to validate the FT site suitability is mainly based on methodologies adopted in Italy for the institutional recognition of Monumental Trees ([34]) and of Old Growth Forests ([24]). In particular, the procedure for the identification of monumental trees starts with an identification form where all the characteristics of the candidate tree must be reported. The form is filled by an agricultural or forestry technician of the Municipality, which proposes the candidature to the Region. The competent regional office checks and validates the information reported and, if these meet the monumental criteria, the tree is included in the National List of Monumental Trees. The inclusion requires some management activities to guarantee the maintenance of the good health and conditions of the Monumental Tree. A similar procedure is used for the identification and the official recognition of Old Growth Forests. The candidature is presented to the competent regional office through an identification form, where the scientific information relating to the characteristics of the site are reported. The regional office checks and validates the information reported and if these meet the scientific criteria needed for the forest to be considered an Old Growth Forest, the site is added to the National Network of Old Growth Forests.

The Technical Information Sheets (TIS)

To realize the procedure described above, four Technical Information Sheets (TIS) are proposed with 90 parameters representing the minimum criteria to be assessed to consider the site suitable or not for FT. The sheets are related to; (1) Identification registry; (2) Management; (3) Accessibility and use; and (4) Protection and regulation. The TIS include key information about the site need to be reported by the applicant. The list of criteria comes from the scientific literature available on the web on the broad topic of forest care, using combinations of key words, e.g., forest therapy, wellness, activities, etc. Several works were retrieved from grey literature, including conference proceedings, scientific papers in print, and from information gathered through the research group’s contacts with Universities and research institutes. This explorative research shows a mosaic of information and data revealing the heterogeneity of forest care sites and initiatives in Italy. The literature collected was subsequently filtered selecting FT initiatives and discarding generic leisure, recreational and sports forest bathing activities, which do not involve the support of therapists. The selected criteria reflect the essential features of the forest environment for the development of forest therapy activity and services, such as location, landscape features, characteristics of forests, forest management, accessibility, anthropogenic conditions, etc. An important guideline in this selection has been a study carried out in Bulgaria ([9]) that considers 22 indicators to characterise the forest, environmental and anthropic features of the sites where FT projects can be implemented. Fourteen of these indicators have been proposed in this study, some of which were modified or broken down into a larger number of indicators, based on the characteristics of Italian forests. For example, the indicator “Composition of forest stand (tree species, number and type - coniferous and deciduous)” has been split into a larger number of items to capture more aspects (Vegetation species, Percentage of forest cover, Distribution of the tree component, Large live trees, Deadwood and decaying wood, etc). Moreover, several other parameters have been added to characterise areas where FT initiatives could be implemented (information on site location, management activities, silvicultural systems, facilities, equipment, environmental constraints, risks, etc.). Regarding the FT sites in Italy, several studies have been considered. Based on Doimo et al. ([11]), 12 sites from the 232 forest-based care site initiatives have been identified including 9 declared as FT site and 3 declared Social Inclusion (Physiological and Psychological, in Motivation-Effects) sites. Further 6 cases including FT initiatives have been added from Meneguzzo et al. ([36]). Based on these 18 cases, two types of contexts where FT initiatives can take place are identified: (i) Site: a delimited, demarcated forest area, equipped and managed, with circuits with tracks, generally with irregular ring, that is closed circuit; (ii) Pathway: a track that develops in an open area through a natural wooded environment or a mixed one (from wooded to grazing, etc.), which may be equipped, where the start point is other than the end point.

Depending on the environment where FT initiatives are carried out two site typologies can be distinguished: (i) Forest therapy (FT) sites in a natural forest environment context; (ii) Urban forest therapy (UFT) sites of environmental of anthropogenic origin with characteristics that can be traced back to a forest but located in peri-urban or urban contexts (parks, botanical gardens, green areas of hospital, schools, etc.).

All selected parameters were sorted by themes, fields, and items, as shown and explained in detail in the result section.

  Results 

As mentioned above, the aim of the work is to propose a possible institutional iter for the assessment and validation of the FT/UFT site suitability through the submission of Technical Information Sheets (TIS) containing the necessary information on the sites’ characteristics. TIS must be provided by applicants and assessed by competent authority.

The site suitability validation iter

This process begins when the proponent of a FT or UFT site wishes to obtain the official recognition of site suitability, i.e., the therapeutic environment status and provides the basic information useful for carrying out an objective assessment of the candidate site. To this purpose, the proponent must submit the request through an application form to the Italian competent authority (regional or national), by filling out the TIS (see above) with all the detailed information necessary for the complete analysis of the environment. After receiving the filled TIS, the designated authority would process the application on a stepwise basis (Fig. 1). The first step is the preliminary analysis of the information given in the TIS, together with a remote check, to verify the reliability of the data carried out by bibliography information’s and with the help of auxiliary data of thematic digital maps (DEM, topography, protection regulation, etc.). In case of negative outcome, the application is rejected with motivation. Here two possibilities are considered, depending on the reasons of rejection and the possibility of modifying/adjustment. If the reasons for the rejection are “adjustable” (e.g., unsuitable routes in terms of length or width, missing services, etc.), the proponent can submit a new assessment request after the changes have been implemented. Otherwise, if the unsuitability of the site or pathway is due to structural conditions that cannot be modified (e.g., excessive noise or excessive slope, etc.), the request will be definitely rejected, and the location is excluded. Fig. 2 is a representation of the site suitability validation iter. In case the application form is deemed eligible, the authority may proceed to the second step. This entails specific on-site investigations, through a special technical-scientific evaluation undertaken by independent experts with proven experience in forestry. Here there are two possible outcomes again. If the evaluation is positive, the site or path will be declared suitable for all purposes. If the assessment is negative and the grounds for exclusion can be changed, a new application may be requested, and the needed adjustment should follow. Otherwise, the location must be definitively excluded.

Fig. 1 - (a) Site, with ring track and station to stop; (b) Pathway.

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Fig. 2 - Flow chart of the iter (or process) of the accreditation of a site suitability of a Forest / Urban Forest Therapy project by the submission of application forms. Based on our own elaboration.

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At the end of this second step, in case of positive assessment, the area can be officially recognized as suitable to host a FT initiative, and a monitoring system can be provided within the management plan of the site area (e.g., Forest Assessment Plan) to verify the maintenance of the recognized suitability over time.

Site information and requirements in the Technical Information Sheets

The TIS are drawn up to identify and qualify sites on the basis of technical and scientific parameters regarding features and characteristics of the station (site or pathway), the landscape, the ecology, the vegetation, and the anthropic traits. These depend on location, morphology, the specific composition of the forest stand, its age, structure, stage of development, type of forest management, including the presence and characteristics of the road network for the use of the area. The TIS are divided in four themes: (1) Identification; (2) Management; (3) Accessibility and Use; (4) Protection regulation. The first sheet (Identification - Tab. 1) summarises all the information (32 items) needed to identify the property and to classify the proposed therapeutic initiative (FT or UFT). The first block of information needs to be provided in any case, the other information depending on whether it is a “Site” or a “Pathway”.

The second sheet (Management - Tab. 2 and Tab. 3) collects most of the data needed and is broken down into two different parts or themes of investigation: “A. Geomorphologicaland Landscape Features” and “B. Ecological and Vegetation Features”. These sheets include information about the characteristics of the project area and its surroundings that may affect its usability from a visual and acoustic point of view, and information about air and/or water. The characteristics proposed as technical-scientific criteria for the two themes provide the most important information for an evaluation which is objective and guarantees the good quality of the initiative. The compilation of this section implies technical knowledge that can only be obtained by professional experts (e.g., agricultural or forest scientists) through field analyses and the study of the Forest Assessment Plan. The theme A (Geomorphologicaland Landscape Features) investigates five specific fields: Morphology, Naturalistic elements, Anthropic elements, Territorial context, and Disturbing elements. The 28 items refer to the elements visible both externally and internally to the perimeter of the site or pathway. In particular, it is important to know the average distance (in metres) from possible important anthropogenic polluting structures, such as built-up areas, busy highways, industrial and craft workshops, sewage treatment plants, etc. These elements could influence the quality of the proposed services and their distance from the site or pathway have to be considered in relation to prevailing wind regimes that might transport pollutants to the site. However, the presence of forest belts, placed to create an adequate barrier of several km between the site of interest and the sources of pollutants, can represent an effective obstacle for pollutants before they reach the site. In the Theme B (Ecological and Vegetation Features) 25 items are included, grouped in 12 fields: Vegetation species, Percentage of forest cover, Distribution of the tree component, Large live trees, Deadwood and decaying wood, Phytopathologies, Vegetation mapping, Management/assessment plan, Additional historical information, Silvicultural systems, Main forest category, Main forest type, Fauna. Here there are the most important parameters (type of tree, shrub and herbaceous species, specific composition, age of the trees, etc.) for the evaluation and identification for the therapeutic services that can potentially be provided. In this context, the availability of a georeferenced tree census for the candidate area is particularly useful. Such a tool is part of modern Forest Management Plans and can be carried out through remote sensing LiDAR or ground tree inventory for trees with a diameter of more than 50 cm, conducting a hypsometric survey and recording the projection of tree crowns on the ground. All this makes it possible to assess the tree cover density, which could be a discriminating element depending on the purpose of the activity. In general, regardless of the quantity of species, sufficiently open and bright forests are recommended. It is also important to detect the presence of any “alien species”, extraneous to the ecological context of the area. For an exhaustive list of alien species, the database of the Italian Botanical Society’s Invasive Species Working Group and its publications could be considered (Ministry of Ecological Transition). The recent EU Regulation on the management of newly invasive species (Reg. No. 1143/2014/ EC - [15]) should also be considered. In addition, the presence of species that are toxic to touch or have poisonous parts must be considered. It is important to know the vegetation evolution of the species (tree and shrub species) as well as the emission into the air of volatile compounds and pollen, depending on the season. The protection of personal health cannot ignore considerations about respiratory well-being, and therefore the control of “best periods of forest use”, in relation to individual sensitivities to allergenic pollens. Then the evaluator should consider the potential allergenic index of the most representative species with medium to high allergenicity. Based on the possible presence of forest cover data, the Index of Urban Green Zones Allergenicity (IUGZA) of the forest phytocoenosis will be calculated, where possible, assuming a standard cover, in order to establish a gradient of potential allergenicity of the various phytocoenosis. A seasonal pollen calendar must be drawn up, based on available data collected by the Italian Aerobiology Association and the Regional Environmental Agencies, for the main allergenic families including native Italian tree species (Betulaceae, Corylaceae, Oleaceae, Cupressaceae). Of particular importance is also the presence and level of spread of plant diseases, which must be periodically verified and monitored, as they could compromise health and create potential safety hazards for individuals. Finally, information is required on the current silvicultural system, categories and types of forest. This information can be found in scientific bibliography or reported in the Forest Management Plans of the area. Particularly important is the availability of the Forest Management Plan for forest sites and the Management and Maintenance Plan for sites in areas such as gardens, botanical gardens, etc. The management plan is critical for a site designated to FT or UFT to plan the operations needed to guarantee good health and usability of the site over time. Forest management for a proper site maintenance can improve the resilience of the environment, by overcoming possible natural or anthropic disturbance factors, that could alter the ecosystem services it provides.

The third sheet (Accessibility and Use - Tab. 4) proposes five specific fields: Accessibility, Practicability, Usability, External Facilities and Additional Information. The 13 items relate to the transport and logistics infrastructures, to the actual accommodation and any other infrastructures facilitating the use of the site or pathway, as well as the opportunities for developing therapeutic initiatives. A site needs be easily accessible, therefore distances longer than 500 metres and paths with a high degree of difficulty should be avoided. Slope, difference in altitude between departure and arrival points, length, accessibility from the main road and exposure can influence the pathways, which should not require significant physical effort. Ad hoc experiences for people with disabilities can also be planned within a site or pathways, which can also be enjoyed by the able-bodied, in an overall time not exceeding one hour. Longer distances can also be provided for the pathways, including at least one overnight stay in a refuge or equipped accommodation in the forest.

The fourth sheet (Protection regulation - Tab. 5) includes two specific fields: Protected areas, and Risks and Constraints. Here there are 9 items and it is required to indicate if the area is subject to specific environmental constraints. This information represents an important point of reference for understanding the management and improvement limits that have to be respected (e.g., protected areas), as well as the risks that the constrained area might suffer from, or that users might encounter.

  Discussion and conclusion 

In Italy, as well as in most other countries, there is a lack of regulatory framework relating FT and relative activities, which lead the proliferation of locations and non-professional initiatives. This study contributes to fill this gap, proposing the development of standards for the recognition of FT/UFT sites. The official recognition by public institutions is critical to provide a public health service to the society, which considers disease prevention as increasingly important. The standard procedure described in the study is based on the analysis of technical and site-specific criteria required to evaluate when a site is suitable for FT/UFT as treatment sites. The proposed iter can represent the base for a regulation of sites where FT/UFT activities are carried out, so that high quality health services through FT/UFT can be provided. This procedure builds upon the use of TIS to assess forests and their environmental characteristics. Indeed, each area has its own specific forestry features and properties, accommodating and performing specific functions suitable for target subjects/groups or activities ([2]). In this paper the distinction between FT and UFT have been stressed. Forests in urban environments are very important but they have different advantage and disadvantages to the locations in extra-urban and more natural environments. Forests in urban context suffer from a greater number of stresses for vegetation and disturbing factors (noise, pollution, etc.), but they are more easily accessible and can therefore be more frequently enjoyed by a larger share of population. This is particularly important considering the ongoing urbanization process, which brings to the increase in psychophysical stress and other non-communicable diseases in the urban-dwelling population related to sedentary lifestyles and mental illness, and consequently an increase in health costs that FT/UFT initiatives can contribute to reducing. The evaluation and recognition of site suitability needs be carried out by local authorities, accordingly to the national political-legal framework oversees forests and the overall forestry sector. Indeed, any productive or recreational projects on forest land always need to be authorized by the regional administration to comply with regulation relating to environmental protection, risks areas (e.g., hydraulic or landslide risk). Of course, the recognition of FT site suitability must be updated and verified periodically: it is essential that all the requirements are met not only at the time of submission of the application for eligibility but also over time, according to the provisions defined in the regional forest management programme and planning tools. For this purpose, a Site Management Plan (or equivalent instrument) must be produced to identify how the forest and stationary characteristics, which are relevant to the intended therapeutic activity, will be maintained in the short and long term. This is ensured by the definition and planning of silvicultural interventions, that also aimed at protecting the natural capital and enhancing ecosystem services, according to the current environmental regulation. The present study is part of the activities envisaged by an agreement signed by a broad partnership (memorandum of understanding between the parties) composed of research institutions, universities, and public administrations, including the Italian Ministry of Agriculture, Food Sovereignty and Forests (⇒ https:/­/­www.­reterurale.­it/­terapiaforestale/­contatti). The project partners are currently developing an online platform as a reference for the census of all the FT/UFT sites in Italy (⇒ https:/­/­www.­reterurale.­it/­terapiaforestale/­retenazionale). This is another contribute to supporting FT initiatives in Italy, making them more visible and institutionalized. A public database could be useful to collect all the information of the FT suitable sites at national level, adding data regarding the most important features of the site (type of sites, use, etc.). Another important output of this agreement is the definition of specific methodologies to be used for the analysis and classification of the therapeutic characteristics in each site and their benefits for users. In fact, once the site is recognised as suitable from a forest perspective, other two more steps are necessary. Firstly, an on-field evaluation of the quality atmosphere (e.g., concentration of volatile organic pollutants) and properties (e.g., concentration of monoterpenes emitted by plants) of the site is required. This inspection should be performed by authoritative scientists and specialists belonging to governmental research bodies and validated by the Superior Health Institute. The characterization of the forest atmosphere determines the specific vocation of different forest types and the “therapeutic specialization” of the site. Moreover, it is necessary to consider that the therapeutic function cannot ignore the connection between silvicultural and medical sciences ([41]). Secondly, the site would be related to different disorders or diseases (anxiety, depression, etc.) in order to provide an effective therapeutic service, and become the base for guidelines according to an institutional regulation. The site should be used for target groups on the basis of a medical prescription by therapist scientists (psychologists, psychiatrists).

FT and UFT initiatives can be considered amongst the new frontiers of preventive and curative medicine in the same way as thermal treatment. The recognition of the Italian sites and the activities could lead to future “green prescriptions”, as it happens in few other countries such as Korea ([39]). Furthermore, it might represent a concrete and useful means of relieving the National Health System in terms of costs. Last but not least, it could be an interesting opportunity for the local development and employment, in both inland rural areas and urbanised contexts. The main business opportunities are related to the creation of new professional profiles (such as guides for the sites), the increasing of hospitality, and to the sustainable forest management of dedicated sites ([3], [9]). This is especially true in a country like Italy where forests cover more than 36% of its land area ([18]), where under 15% of the national population live and only 16% of the forest area has a Forest Management Plan. Finally, FT can also represent a chance to revitalize the forestry sector, which is increasingly focused on multifunctionality and the provision of ecosystem.

  Acknowledgements 

We want to thank Lorenzo Crecco and Antonio Pepe who, during their scholarship at Policies and Bioeconomy Centre of CREA, contributed to the first idea of the manuscript draft. Thanks also to Sonia Marongiu for final revision.

Raoul Romano (RRo) conceived the idea of the study with Rosa Rivieccio (RRi), and together they drafted the manuscript. Tables are designed and by RRo and RRi. Figures are drawn up by RRi. Stefano Orsini (SO) gave effective suggestions in its improvement. The manuscript was reviewed by RRo, RRi, and SO, and edited by RRi, and SO.

  References