Implications

VOL. 05 ISSUE 04

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A Newsletter by InformeDesign. A Web site for design and human behavior research.

Design, Landscape, and Health

Steve Mitrione, MD, MLA

The World is Our Healthcare System cover image goes here - fit image to the black box using the guidelines

In the 21st century we have entered a new phase in the challenges confronting healthcare. The diseases that we face, and that continue to consume an increasing amount of our healthcare resources, are related to the environments of our own creation. There has been a dramatic increase in chronic conditions, such as obesity, diabetes, hypertension, and cardiovascular disease, partly related to an aging population, but increasingly related to the designed environment. These controllable yet currently incurable diseases are contributing to an increasing burden of disease within our society. Recent trends have also shifted this burden to the youngest members of our society, who, if current trends continue, may be the first generation to witness a decline in longevity. Disadvantaged and minority populations also bear a disproportionate burden of these diseases, further compounded by their lack of access to quality healthcare. These populations are exposed to more pollution, have fewer healthy food choices, and live in communities with less access to recreation and green space.

IN THIS ISSUE
Design, Landscape, and Health Healing and Therapeutic Gardens Case Study: A Therapeutic Garden for People Living With HIV Related Research Summaries

According to Richard Jackson (2001), of the Center for Disease Control (CDC): The current design of our communities has created new health problems. Medicine will not be adequate to deal with the health challenges of the 21st century, not even with the help of the sequenced genome and advances in robotic surgery. Even though the United States spends one of every seven dollars on medical care, we will not significantly improve health and the quality of life unless we pay more attention to how we design our living environments. Healthy living environments include not just a clean and heated kitchen, bath or bedroom, but also the landscape around us. Health for all, especially for the young, aging, poor and disabled, requires that we design healthfulness into our environments as well. In my experience as a primary care physician, I am continuously confronted with evidence that many of the diseases currently on the increase can be traced back to the ways in which we have designed our world. Diseases such as diabetes, hypertension, and cardiovascular disease, while multi-factorial in etiology, are all clearly linked to an increasingly sedentary population and with poor diet. Reliance on automobiles for transportation and sprawl of cities leads to poorer air quality and an increase in asthma,

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particularly among inner city youth. Lack of walkable and bikeable communities contributes to decreased levels of physical activity, which in turn increases the prevalence of obesity. Well-designed communities can foster social interaction, increasing social support and psychological wellbeingtwo well-known determinants of health status and recovery from illness. Organizations such as the CDC, The Robert Woods Johnson Foundation, and the Environmental Protection Agency have all begun to examine and promote the development of community design that fosters health. Insurance companies have also begun to recognize the impact of design on community health. Design has an important impact upon the places where we provide healthcare. Hospitals, clinics, and nursing homes are often designed for function, efficiency, and style. We know little about what the effect of these designed environments is upon peoples recovery from illness, though evidence has shown that design factors can reduce infection rates and errors in patient care and lead to shorter lengths of hospital stays. There is also much to be learned in the design of long term care facilitiespotentially leading to better quality of life and lower hospitalization rates and medication usage by residents. As our society ages and the utilization of long term care accelerates, improving the design of these facilities will be critical.

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While conventional medicine and public health have much to contribute to our understanding and shortterm treatment of diseases and problems, they alone cannot control and reverse the systemic conditions that foster their development. Healthcare design is an emerging field that seeks to address some of these issues; it can be defined as the application of design in the provision of physical and mental services, preventative medicine, and treatments to individuals or the public. However, for design to play a broad and significant role in building and maintaining health, design and research must be integrated despite differences in their premises, methods, and the language of their outcomes. This issue of Implications describes an integration of landscape design and research for the purpose of optimizing user health. The next section discusses healing and therapeutic gardens, outlining current therapeutic garden design guidelines that are based on stress-response research, anecdotal evidence, and theories regarding stress reduction in well population groups. In the case study that follows, these guidelines are utilized as a basis for the initial design of a therapeutic garden for Clare Housing, an apartment building for patients with HIV disease. A methodology to test these guidelines is also proposed.

Pollution and sedentary lifestyles resulting from urban sprawl contribute to a range of diseases.

Where Research Informs Design

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Healing and Therapeutic Gardens
Gardens have played a role in healthcare for centuries. With the advent of modern medicine in the beginning of the 20th century, the curative potential of gardens was lost. However, there has been renewed interest in utilizing garden environments as therapeutic entities to enhance the process of healing that occurs in healthcare environments.

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What Makes a Garden Therapeutic?

Healing garden typically describes gardens designed to promote healing from illness. Healing, within the context of healthcare, is a broad term, seen as an improvement in overall well-being that incorporates the spiritual as well as the physical. A healing garden may provide relief from the psychological distress of disease and an improved sense of well-being, but it may or may not alter the disease outcome. A therapeutic garden is more specifically designed to produce a given outcome upon a disease process. It can be thought of as similar to a medication that is taken for a specific disease or illness. The therapeutic garden is thus less focused on healing in a spiritual context (although it may also have this effect) and more akin to the disease model of illness as practiced by most allopathic medical systems. At present, little data exists to guide the design of a therapeutic garden. Instead, general design guidelines have been developed and are generally accepted based on theories of stress reduction, encompassing six principles. 1. Provide a sense of control by creating a variety of spaces. Spaces within a garden should be easily accessible by all user groups, provide for privacy, and include a variety of spaces that allow individuals to seek out spaces that best suit them. 2. Provide for social support. Social support is associated with less stress than isolation, and has been linked with improved outcomes after heart attacks and cancer. Patient interviews highlight talking as a primary activity in garden settings. Gardens should provide spaces to accommodate various group sizes in a setting that encourages conversation. 3. Provide for physical movement and exercise. Exercise is associated with reduced stress and alleviation of depression in almost all population groups, but especially those with chronic illness.

Psychoneuroimmunology is an emerging field of medicine that examines the complex interplay between the immune system, central nervous system, and endocrine system. It is generally accepted that chronic stress leads to maladaptive changes that eventually impair our abilities to heal from illness. It is this component of illness that is most amenable to intervention by therapeutic gardens. By minimizing the stress response, therapeutic gardens can promote recovery from illness or preserve health. One can theorize that this effect is mediated by the sensory inputs associated with gardens. These inputs can involve all sense organs, but it is not currently known which is more important. For example, is viewing a garden more important than the sounds of a garden? What role do taste, touch and smell play, if any? In general, there has been little research into the characteristics of these gardens and their impact on the process of healing.

Where Research Informs Design

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Gardens, because of their perceived pleasantness, can encourage exercise and movement. They should thus offer easy wayfinding and provide destinations that encourage mild exercise. 4. Provide for access to nature and positive distractions. Exposure to nature and natural scenes is associated with decreased physiological stress responses. This response is dose-related in that the greater the percentage of greenery, as opposed to hardscape, the more likely the relaxation response is to occur. This relaxation response is believed to be hardwired into our nervous systems by evolutionary responses to environments that favored survival. 5. Minimize ambiguity. Stressed individuals respond negatively to ambiguity. Studies of inpatients recovering from surgery showed increased stress levels when exposed to abstract paintings as compared with natural scenes. This is believed to be due to the perception of ambiguous stimuli as negative in stressed individuals, congruent with their emotional state. 6. Minimize intrusive stimuli. To exert their effect, therapeutic gardens need to minimize negative distractions such as noise, odor, and bright lights. Noise in particular can negate the positive effects associated with viewing nature.

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Case Study: A Therapeutic Garden for People Living With HIV

Prescribing with the Landscape
Creating a therapeutic landscape involves three steps: 1. The evaluation of the disease and/or patient is used to generate potential target symptoms or disease processes to be addressed by the design. 2. After attaining a thorough understanding of the disease, disease processes, and social and psychological factors, the design is created based upon the target symptoms that the designer wishes to ameliorate. In addition, the methodology for evaluating the influence of the garden on the patient population is developed. This methodology is based upon the intent of the design and is used to measure its effectiveness. 3. Once the garden is installed and occupied, the health, psychological, and social parameters determined in the previous step are evaluated. The data collected are then used to determine the effectiveness of the design based upon the intended function of the garden. Undesired effects are also evaluated. The design of a therapeutic garden for Clare Housing, an apartment building for patients with HIV disease, illustrates the process by which therapeutic garden spaces may be designed and scientifically analyzed to determine their safety and effectiveness for a given user group. 1. Evaluating the Disease and the Patient HIV Disease Human immunodeficiency virus (HIV) attacks the immune system. Untreated, HIV disease is progressive and fatal. Death takes place over a period of months to years. Recent changes in the drug therapy of HIV disease has, however, created the opportunity to greatly extend the lives of people infected with HIV and, in some cases, lead to a remission of the disease. This life extension has paradoxically led to

A water feature can mask undesired noises.

Where Research Informs Design

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an increase in the number of individuals living with HIV disease, even as the rate of new infections has declined. For people living with HIV, it is known that stress can lead to increased viral replication and decreased effectiveness of drugs used to treat the disease. Design considerations based upon the health needs of people with HIV disease must therefore accommodate the following: Minimize exposure to potential infections. Chosen plant material should be thornless and unlikely to harbor potential bacterial and fungal pathogens. In addition, standing water should not be present to prevent transmission of mosquito-borne illnesses. The design should provide accessibility for people with decreased mobility. Wayfinding should be clear as dementia may develop. Shade should be provided as users may be sunsensitive due to medications used to treat HIV. The Garden Users To design a space that meets the needs of its intended users, an investigation into the primary and secondary users of the space was performed. The primary users of the site were the apartment residents themselves. They were single adults, mostly HIV-positive, currently or previously homeless, and varied in terms of mental health, employment, and mobility. Social workers, case managers, and

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housing administrative staff were also identified as secondary users. When surveyed, primary users indicated desires for a water feature, areas to cook outdoors, flower gardens, opportunities to garden, and spaces to socialize as well as meditate. Secondary users desired a space to hold staff meetings, events, and fundraisers, and to relax. The therapeutic garden design offered therapeutic spaces, each related to a specific theory and mechanism for stress reduction and amelioration of the disease process.

The communal area.

2. Designing to Ameliorate Symptoms Social Support: The Communal Area The communal area functions to increase social support. Isolation is a major problem for those living with HIV disease, and can lead to depression, failure to comply with medical regimens, and poorer outcomes. This patio area provides an informal area for residents to gather and socialize. It is designed to be planted by the residentswho could choose plants to their likingto promote communal involvement, to encourage gardening as a form of relaxation, and to provide residents with a creative outlet and a chance to interact during the planting. Wall seat plantings are accessible.

Where Research Informs Design

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Decreasing Stress: The Natural Area and the Meditative Area The viewing of nature is universally associated with decreased stress and a sense of psychological restoration. A natural area provides a place for small groups to view an area planted in a more natural form. The plantings are loosely arranged but clumped to create visual impact. Plants that attract wildlife were prioritized as they would increase the sense of wilderness that the site is intended to impart. The meditative area also functions to decrease arousal and stress. Meditative states are associated with positive physiological states of lowered blood pressure, pulse, and circulating stress hormones. A water feature was designed to enhance this state by providing a focus, positive distraction, and screening out intrusive visual and auditory stimuli. Conifer plantings were designed to provide a quiet and restful complement to the space. Their density would create a calm, enclosed space to facilitate a meditative experience.

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dementia. The garden walkway plantings were selected to be bold and colorful, to stimulate the senses in a positive way, and to encourage movement to see what lies ahead. The plantings were designed for four season interest, shade and respite, and sheltered views to the street for people watching. 3. Determining the Effectiveness of the Design The therapeutic garden can be evaluated through several disease-specific, biological markers of disease activity (such as viral loads and CD4 counts), and measures of mental health status, social functioning, and quality of life. Additionally, it may be useful to ascertain which areas of the garden are frequented most often by residents to determine if certain spatial qualities prove more successful than others in accomplishing the goals of the design. The hypothesis is that the installation of the garden will lead to an improvement in medical, psychiatric, and social indicators among the residents. Measurements of these health indicators should be made before and after installation of the garden to determine what effect, if any, the garden has upon the health of the residents.

Toward a New Paradigm of Therapeutic Gardens

As the interest in the field of therapeutic gardens continues to expand, system for research must be developed. The chairs of the American Society of Landscape Architects (ASLA) Therapeutic Garden Design Professional Interest Group have stated: We propose a renewed effort to encourage academic research that is useful to practitioners, and to provide publicity for the new research to get the word out. Research is important to validate intuition and to motivate policy change...We need research approaches that address current problems. These same sentiments are echoed throughout the literature and writings of landscape architects interested in this field. And yet, there appears to be little progress in the answer to these calls.

The garden walkway.

Exercise: The Garden Walkway Exercise is associated with relaxation and induces a relaxation response. The site was designed to encourage walking within the site and positive distraction. The walkways are circular in layout to provide easy wayfinding for those residents who may suffer from

Where Research Informs Design

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Perhaps what is missing is a paradigm that allows research to develop out of the design process. Landscape architecture is first and foremost a design profession, and landscape architects are primarily designers. The language of research and the language of design are different. What is needed is a process to translate design into research and research into design. The two must become linked for any progress to be made. An effective process will be cyclical and seamless, with research, design, and analysis forming a continuous loop that ultimately leads to the development of design guidelines. These guidelines themselves are constantly in flux as new information is collected, new designs are created, and analysis leads to new insights.

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scape, city, and regional design is a hypothesis about what is best for a given problem. Human subjects then interact with the design with a resulting impact upon them. What is missing in the design professions is a means to evaluate the results and use this data to inform future design. Research needs to inform design and design needs to inform research.

About the Author:

Steve Mitrione, MD, MLA, is a family physician with 20 years of clinical experience. Dr. Mitrione recently received his MLA from the University of Minnesota and is one of only two individuals in the United States to hold both degrees. His focus is on the ways in which landscape and the designed environment can improve health and aid in the recovery from illness.

Conclusion
Design has always been important to health. How we shape our homes, neighborhoods, towns, cities, and regions ultimately impacts our ability to stay healthy. When we become ill, the design of our clinics, hospitals, and nursing homes impacts our ability to get well. Design issues related to health and healthcare are, however, complex. There is a distinct need for collaboration between design professionals and members of the scientific and healthcare professions, such as, public health professionals, epidemiologists, physicians, and nurses, to name a few. It is my belief that the solutions to reverse the deterioration in our nations health and spiraling healthcare costs lie at the intersection of disciplines. It is only when all of those involved in creating and understanding healthy and healing environments are working collaboratively, can meaningful solutions be found. Designers are, perhaps unknowingly, already involved in creating experiments through design. Every building, land-

References
Cole, S., Naliboff, B., Kemeny, M., Griswold, M., Fahey, J., & Zack, J. (2001). Impaired response to HAART in HIV-infected individuals with high autonomic nervous system activity. Proceedings of the National Academy of Sciences, USA, 98, 1269512700. Epstein, M., & Sachs, N. (2005, Summer). Therapeutic Garden Design newsletter, 4. Mace, L., Bell, P., & Loomis, R. (1999). Aesthetic, affective and cognitive effects of noise on natural landscape assessment. Society and Natural Resources, 12, 225-242. Paine, R., Francis, C., Marcus, C. & Barnes, M. (1998). Hospital outdoor spaces. In Marcus, C. & Francis, C. (Eds.), People places: Design guidelines. (pp. 311-343). New York: Wiley.

Where Research Informs Design

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Ruuskanen, J., & Parketti, T. (1994). Physical activity and related factors among nursing home residents. Journal of the American Geriatrics Society, 42, 987-991. Speigel, D., Kraemer, H., Bloom, J., & Gottheil, E. (1989). Effects of psychosocial treatment on survival of patients with metastatic breast cancer. The Lancet 2, 888-891. Ulrich, R. (1999). Effects of gardens on health outcomes: Theory and research. In Marcus, C. & Barnes, M. (Eds.), Healing gardens: Therapeutic benefits and design recommendations (pp. 27-86). New York: Wiley. Ulrich, R., Lunde, O., & Eltinge, J. (1993). Effects of exposure to nature and abstract pictures on patients recovering from heart surgery. Psychophysiology, 30, suppl. 1, 7. Ulrich S., Simons, R., Losito, B., Fiorito, E., Miles, M., & Zelson, M. (1991). Stress recovery during exposure to natural and urban environments. Journal of Environmental Psychology, 11, 201-230.

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Health Benefits of Including Nature Within HospitalsJournal of Environmental Psychology Pediatric Healing Gardens Landscape and Urban Planning Alleviating Mental Fatigue in Urban and Natural SettingsJournal of Environmental Psychology Creating Facilities for AIDS Patients Journal of Architectural and Planning Research Window Views Affect Well-Being and Residential SatisfactionEnvironment and Behavior Tranquil and Pleasing Natural Environments Journal of Environmental Psychology A Review of Health Effects and Urban Design Landscape and Urban Planning Designing for the Health Process World Hospitals and Health Services End of Life CareThe Journal of Alternative and Complementary Medicine

Related Research Summaries

The InformeDesign Web site has many Research Summaries on design, landscapes, and health. This knowledge will be valuable to you as you consider your next design solution and is worth sharing with your clients and collaborators.

Photos Courtesy of:

The Metropolitan Design Center, Regents of the University of Minnesota (pp. 1-4). Steve Mitrione (remainder).

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The Mission of InformeDesign is to facilitate designers use of current, research-based information as a decisionmaking tool in the design process, thereby integrating research and practice.

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