This single-group observational before–after study evaluated short-term physiological and psychological changes associated with participation in a community-based Kurort Health Walking program conducted in a forest environment. The study was embedded within a public health program in Saikai City, Nagasaki, Japan. Adults who voluntarily attended certified Kurort courses between March 20, 2024, and March 30, 2025, were eligible. Written informed consent was obtained from all participants and the protocol received institutional ethics approval. The study followed STROBE reporting guidelines.
Two certified Kurort paths were used: the Shihondo Park course (1.83 km, cumulative altitude gain 74 m) and the Isanoura Park course (2.1 km, cumulative altitude gain 73 m). Both courses were supervised by two certified health and exercise trainers and followed the same session structure. Each session lasted approximately 120 minutes and included warm-up exercises, the walking session across sloped and natural terrain, and cool-down stretching. Participants monitored pulse rate by manual palpation at designated points to maintain target intensity (target PR approximated as 160 − age, reduced for participants on antihypertensive medication). Manual pulse checks were used for intensity control only and were not included in outcome analyses.
Ninety individuals initially enrolled; one participant who fell and could not complete the session was excluded, leaving 89 participants for analysis of blood pressure, pulse rate, and psychological measures. Autonomic nervous system data were available for 87 participants after excluding two with missing autonomic recordings. The analyzed cohort included 36 men (40.4%) and 53 women (59.6%), mean age 50.8 ± 16.5 years (range 18–83). Sixteen participants (18.0%) reported current use of antihypertensive medications. Sixty-one sessions (68.5%) were completed at Shihondo Park and 28 (31.5%) at Isanoura Park. Baseline characteristics did not differ significantly between the two course groups.
Systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse rate (PR) were measured before and after the walking session. Measurements were obtained with a wrist-type blood pressure monitor positioned at heart level. Baseline values were recorded after 10 minutes seated rest following registration; post-walk values were recorded after completion of cool-down stretching and an additional 10-minute seated rest.
Autonomic indices were measured at four standing points along the course: start, observation deck, waterside, and finish. The low-frequency/high-frequency (LF/HF) ratio and high-frequency (HF) power were calculated from facial RGB video using a non-contact vital sensing application that extracts pulse wave signals from subtle facial blood flow luminance changes. Each autonomic measurement lasted approximately 30 seconds with participants instructed to minimize movement and gaze at a fixed guide on an iPad screen. The application had prior validation reports indicating high agreement with contact-based electrocardiographic measurements under controlled conditions.
Psychological mood and emotion were assessed before and after the session using two validated instruments: the Profile of Mood States 2nd Edition (POMS2) Japanese adult short form and the Mood Check List-Short form.2 (MCL-S.2). POMS2 yields T-scores for seven subscales (anger-hostility, confusion-bewilderment, depression-dejection, fatigue-inertia, tension-anxiety, vigor-activity, and friendliness) and a Total Mood Disturbance (TMD) score. MCL-S.2 measures Pleasure, Relaxation, and Anxiety across 12 items scored on a 7-point scale. Internal consistency (Cronbach’s alpha) for POMS2 subscales was reported as 0.90 pre-walk and 0.84 post-walk; MCL-S.2 subscale alphas ranged from 0.79 to 0.92.
Data were summarized using means ± SD or medians and IQRs. Normality was assessed by the Kolmogorov–Smirnov test. Paired t-tests were used for normally distributed pre–post comparisons; Wilcoxon signed-rank or Friedman tests were used for non-normally distributed data or repeated measures. Effect sizes and 95% confidence intervals were calculated for primary outcomes. A sensitivity analysis evaluated blood pressure changes among participants not taking antihypertensive medication. Baseline values and pre–post changes were compared between the two courses to assess pooling appropriateness; principal outcomes did not differ materially, allowing pooled analysis.
SBP decreased significantly from 127.2 ± 15.9 mmHg to 120.6 ± 15.5 mmHg after the walking session (mean difference −6.6 mmHg, 95% CI −9.2 to −4.0, p < 0.001; Cohen’s d = 0.54). DBP decreased significantly from 81.2 ± 12.5 mmHg to 76.3 ± 13.8 mmHg (mean difference −4.9 mmHg, 95% CI −7.2 to −2.7, p < 0.001; Cohen’s d = 0.46). Pulse rate did not change significantly (mean difference 1.9 beats/min, 95% CI −0.2 to 3.9, p = 0.076).
Sensitivity analysis among participants not taking antihypertensive medications showed consistent reductions in SBP and DBP, with no significant change in PR.
Autonomic measurements of the LF/HF ratio and HF power recorded at the four standing time points during the walk did not show significant differences across measurement points by the Friedman test, indicating no detectable change in these indices during the session in this sample.
Psychological measures showed consistent improvements after the walking session. POMS2 T-scores demonstrated significant reductions in negative mood subscales: anger-hostility, confusion-bewilderment, depression-dejection, fatigue-inertia, tension-anxiety, and the Total Mood Disturbance score. Scores for vigor-activity and friendliness increased significantly. On the MCL-S.2, Pleasure and Relaxation subscale scores increased and Anxiety scores decreased significantly after the walk. Internal consistency metrics for the instruments supported reliable measurement in this sample.
The authors emphasize that this was a single-group pre–post study without a control group; therefore, the independent contributions of the forest environment, physical activity, social interaction, or other contextual factors cannot be disentangled. Autonomic indices were measured with a non-contact facial video system under field conditions; while prior validation exists, real-world measurement variability is a consideration. Participants were a self-selected volunteer sample with a wide age range and heterogeneous medication and health status; no restrictions were placed on prior participation or medication use. Missing data were excluded from relevant analyses.
Participation in a community-based Kurort Health Walking program in forest settings was associated with short-term reductions in systolic and diastolic blood pressure and with improvements in multiple psychological mood and emotion measures. No significant changes were observed in LF/HF ratio or HF power across standing measurement points. The lack of a control group limits causal attribution to specific elements of the intervention. The authors provide open access to the minimal dataset and report adherence to ethical and reporting standards.