Design, Landscape, and Health: Volume 5, Issue 4 - InformeDesign

Implications
VOL. 05 ISSUE 04
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IN THIS ISSUE
Design, Landscape,
and Health
Healing and
Therapeutic Gardens
Case Study: A
Therapeutic Garden for
People Living With HIV
Related Research
Summaries
Design, Landscape, and Health
Steve Mitrione, MD, MLA
The World is Our Healthcare System
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.
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
wellbeing—two 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 people’s 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 facilities—potentially 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.
Pollution and sedentary lifestyles resulting from urban sprawl
contribute to a range of diseases.
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.
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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.
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.
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.
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.
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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.
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.
A water feature can mask undesired noises.
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
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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.
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 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
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 residents—who could choose plants to
their liking—to 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.
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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.
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
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.
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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.
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
nation’s 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, landscape,
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.
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, 12695-
12700.
—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.
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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.
“Health Benefits of Including Nature Within
Hospitals”—Journal of Environmental Psychology
“Pediatric Healing Gardens”
—Landscape and Urban Planning
“Alleviating Mental Fatigue in Urban and Natural
Settings”—Journal of Environmental Psychology
“Creating Facilities for AIDS Patients”
—Journal of Architectural and Planning Research
“Window Views Affect Well-Being and Residential
Satisfaction”—Environment and Behavior
“Tranquil and Pleasing Natural Environments”
—Journal of Environmental Psychology
“A Review of Health Effects and Urban Design”
—Landscape and Urban Planning
—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.
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.
“Designing for the Health Process”
—World Hospitals and Health Services
“End of Life Care”—The Journal of Alternative and
Complementary Medicine
Photos Courtesy of:
The Metropolitan Design Center, Regents of the
University of Minnesota (pp. 1-4).
Steve Mitrione (remainder).
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