Design, Landscape, and Health - Horticultural Therapy

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<ul><li><p>8/4/2019 Design, Landscape, and Health - Horticultural Therapy</p><p> 1/8</p><p>ImplicationsVOL. 05 ISSUE 04</p><p>A Newsletter by InormeDesign. A Web site or design and human behavior research.</p><p></p><p>IN THIS ISSUE</p><p>cover image</p><p>goes here - ft</p><p>image to theblack box</p><p>using the</p><p>guidelines</p><p>According to Richard Jackson (2001</p><p>the Center for Disease Control (CDC):</p><p>The current design of our commun</p><p>has created new health problems. M</p><p>cine will not be adequate to deal with</p><p>health challenges of the 21st century,</p><p>even with the help of the sequenced</p><p>nome and advances in robotic surgEven though the United States spends</p><p>of every seven dollars on medical care</p><p>will not signifcantly improve health </p><p>the quality of life unless we pay more</p><p>tention to how we design our living e</p><p>ronments. Healthy living environments</p><p>clude not just a clean and heated kitc</p><p>bath or bedroom, but also the landsc</p><p>around us. Health for all, especially fo</p><p>young, aging, poor and disabled, requ</p><p>that we design healthfulness into our eronments as well.</p><p>In my experience as a primary care p</p><p>sician, I am continuously confron</p><p>with evidence that many of the dise</p><p>currently on the increase can be tra</p><p>back to the ways in which we have</p><p>signed our world. Diseases such as </p><p>betes, hypertension, and cardiovasc</p><p>disease, while multi-factorial in etiol</p><p>are all clearly linked to an increasisedentary population and with poor d</p><p>Reliance on automobiles for transpo</p><p>tion and sprawl of cities leads to po</p><p>air quality and an increase in asth</p><p>Design, Landscape, and HealthSteve Mitrione, MD, MLA</p><p>The World is Our Healthcare System</p><p>In the 21st century we have entered a</p><p>new phase in the challenges confronting</p><p>healthcare. The diseases that we face,</p><p>and that continue to consume an increas-</p><p>ing amount of our healthcare resources,</p><p>are related to the environments of our</p><p>own creation. There has been a dramatic</p><p>increase in chronic conditions, such as</p><p>obesity, diabetes, hypertension, and car-</p><p>diovascular disease, partly related to an</p><p>aging population, but increasingly related</p><p>to the designed environment.</p><p>These controllable yet currently incurable</p><p>diseases are contributing to an increas-</p><p>ing burden of disease within our soci-</p><p>ety. Recent trends have also shifted this</p><p>burden to the youngest members of our</p><p>society, who, if current trends continue,</p><p>may be the rst generation to witness a</p><p>decline in longevity. Disadvantaged and</p><p>minority populations also bear a dispro-</p><p>portionate burden of these diseases, fur-</p><p>ther compounded by their lack of access</p><p>to quality healthcare. These populations</p><p>are exposed to more pollution, have fewer</p><p>healthy food choices, and live in commu-</p><p>nities with less access to recreation and</p><p>green space.</p><p>Design, Landscape,</p><p>and Health</p><p>Healing and</p><p>Therapeutic Gardens</p><p>Case Study: A</p><p>Therapeutic Garden or</p><p>People Living With HIV</p><p>Related Research</p><p>Summaries</p></li><li><p>8/4/2019 Design, Landscape, and Health - Horticultural Therapy</p><p> 2/8</p><p>Implications</p><p>Where Research Inorms Design</p><p>particularly among inner city youth. Lack of walkable</p><p>and bikeable communities contributes to decreasedlevels of physical activity, which in turn increases the</p><p>prevalence of obesity.</p><p>Well-designed communities can foster social inter-</p><p>action, increasing social support and psychological</p><p> wellbeingtwo well-known determinants of health</p><p>status and recovery from illness. Organizations such</p><p>as the CDC, The Robert Woods Johnson Founda-</p><p>tion, and the Environmental Protection Agency have</p><p>all begun to examine and promote the development</p><p>of community design that fosters health. Insurancecompanies have also begun to recognize the impact</p><p>of design on community health.</p><p>Design has an important impact upon the places</p><p>where we provide healthcare. Hospitals, clinics, and</p><p>nursing homes are often designed for function, ef-</p><p>ciency, and style. We know little about what the effect</p><p>of these designed environments is upon peoples re-</p><p>covery from illness, though evidence has shown that</p><p>design factors can reduce infection rates and errors</p><p>in patient care and lead to shorter lengths of hospitalstays. There is also much to be learned in the design</p><p>of long term care facilitiespotentially leading to bet-</p><p>ter quality of life and lower hospitalization rates and</p><p>medication usage by residents. As our society ages</p><p>and the utilization of long term care accelerates, im-</p><p>proving the design of these facilities will be critical.</p><p>While conventional medicine and public health ha</p><p>much to contribute to our understanding and sho</p><p>term treatment of diseases and problems, they alo</p><p>cannot control and reverse the systemic conditio</p><p>that foster their development. Healthcare design is </p><p>emerging eld that seeks to address some of the</p><p>issues; it can be dened as the application of desi</p><p>in the provision of physical and mental services, p</p><p>ventative medicine, and treatments to individuals</p><p>the public.</p><p>However, for design to play a broad and signica</p><p>role in building and maintaining health, design a</p><p>research must be integrated despite differences </p><p>their premises, methods, and the language of th</p><p>outcomes. This issue ofImplicationsdescribes an </p><p>tegration of landscape design and research for t</p><p>purpose of optimizing user health.</p><p> The next section discusses healing and therapeu</p><p>gardens, outlining current therapeutic garden d</p><p>sign guidelines that are based on stress-respon</p><p>research, anecdotal evidence, and theories rega</p><p>ing stress reduction in well population groups. In t</p><p>case study that follows, these guidelines are utiliz</p><p>as a basis for the initial design of a therapeutic g</p><p>den for Clare Housing, an apartment building for p</p><p>tients with HIV disease. A methodology to test the</p><p>guidelines is also proposed.Pollution and sedentary lifestyles resulting from urban sprawl</p><p>contribute to a range of diseases.</p></li><li><p>8/4/2019 Design, Landscape, and Health - Horticultural Therapy</p><p> 3/8</p><p>Implications</p><p>Where Research Inorms Design</p><p>Healing and Therapeutic Gardens</p><p>Gardens have played a role in healthcare for centu-ries. With the advent of modern medicine in the be-</p><p>ginning of the 20th century, the curative potential of</p><p>gardens was lost. However, there has been renewed</p><p>interest in utilizing garden environments as thera-</p><p>peutic entities to enhance the process of healing that</p><p>occurs in healthcare environments.</p><p>Psychoneuroimmunology is an emerging eld of med-icine that examines the complex interplay between</p><p>the immune system, central nervous system, and en-</p><p>docrine system. It is generally accepted that chronic</p><p>stress leads to maladaptive changes that eventual-</p><p>ly impair our abilities to heal from illness. It is this</p><p>component of illness that is most amenable to inter-</p><p>vention by therapeutic gardens. By minimizing the</p><p>stress response, therapeutic gardens can promote re-</p><p>covery from illness or preserve health. One can theo-</p><p>rize that this effect is mediated by the sensory inputs</p><p>associated with gardens. These inputs can involveall sense organs, but it is not currently known which</p><p>is more important. For example, is viewing a garden</p><p>more important than the sounds of a garden? What</p><p>role do taste, touch and smell play, if any? In general,</p><p>there has been little research into the characteristics</p><p>of these gardens and their impact on the process of</p><p>healing.</p><p>What Makes a Garden Therapeutic?</p><p>Healing garden typically describes gardens designto promote healing from illness. Healing, within t</p><p>context of healthcare, is a broad term, seen as </p><p>improvement in overall well-being that incorpora</p><p>the spiritual as well as the physical. A healing gard</p><p>may provide relief from the psychological distress</p><p>disease and an improved sense of well-being, but</p><p>may or may not alter the disease outcome.</p><p>A therapeutic garden is more specically designed</p><p>produce a given outcome upon a disease process</p><p>can be thought of as similar to a medication thattaken for a specic disease or illness. The therapeu</p><p>garden is thus less focused on healing in a spiritu</p><p>context (although it may also have this effect) a</p><p>more akin to the disease model of illness as practic</p><p>by most allopathic medical systems.</p><p>At present, little data exists to guide the design</p><p>a therapeutic garden. Instead, general design guid</p><p>lines have been developed and are generally accept</p><p>based on theories of stress reduction, encompass</p><p>six principles.</p><p>1. Provide a sense of control by creating a vari-</p><p>ety of spaces. Spaces within a garden should b</p><p>easily accessible by all user groups, provide for</p><p>privacy, and include a variety of spaces that allo</p><p>individuals to seek out spaces that best suit the</p><p>2. Provide for social support. Social support is</p><p>associated with less stress than isolation, and h</p><p>been linked with improved outcomes after heart</p><p>attacks and cancer. Patient interviews highlight</p><p>talking as a primary activity in garden settings.Gardens should provide spaces to accommodate</p><p>various group sizes in a setting that encourages</p><p>conversation.</p><p>3. Provide for physical movement and exercise</p><p>Exercise is associated with reduced stress and</p><p>alleviation of depression in almost all population</p><p>groups, but especially those with chronic illness</p></li><li><p>8/4/2019 Design, Landscape, and Health - Horticultural Therapy</p><p> 4/8</p><p>Implications</p><p>Where Research Inorms Design</p><p>Gardens, because of their perceived pleasant-</p><p>ness, can encourage exercise and movement. Theyshould thus offer easy waynding and provide</p><p>destinations that encourage mild exercise.</p><p>4. Provide for access to nature and positive</p><p>distractions. Exposure to nature and natural</p><p>scenes is associated with decreased physiological</p><p>stress responses. This response is dose-related in</p><p>that the greater the percentage of greenery, as op-</p><p>posed to hardscape, the more likely the relaxation</p><p>response is to occur. This relaxation response is</p><p>believed to be hardwired into our nervous sys-</p><p>tems by evolutionary responses to environmentsthat favored survival.</p><p>5. Minimize ambiguity. Stressed individuals</p><p>respond negatively to ambiguity. Studies of inpa-</p><p>tients recovering from surgery showed increased</p><p>stress levels when exposed to abstract paintings</p><p>as compared with natural scenes. This is believed</p><p>to be due to the perception of ambiguous stimuli</p><p>as negative in stressed individuals, congruent</p><p>with their emotional state.</p><p>6. Minimize intrusive stimuli.To exert their effect,</p><p>therapeutic gardens need to minimize negativedistractions such as noise, odor, and bright lights.</p><p>Noise in particular can negate the positive effects</p><p>associated with viewing nature.</p><p>A water feature can mask undesired noises.</p><p>Case Study: A Therapeutic Garden</p><p>for People Living With HIVPrescribing with the Landscape</p><p>Creating a therapeutic landscape involves th</p><p>steps:</p><p>1. The evaluation of the disease and/or patient is</p><p>used to generate potential target symptoms or d</p><p>ease processes to be addressed by the design.</p><p>2. After attaining a thorough understanding of the</p><p>disease, disease processes, and social and psych</p><p>logical factors, the design is created based upon</p><p>the target symptoms that the designer wishes</p><p>to ameliorate. In addition, the methodology forevaluating the inuence of the garden on the pa</p><p>tient population is developed. This methodology </p><p>based upon the intent of the design and is used </p><p>measure its effectiveness.</p><p>3. Once the garden is installed and occupied, the</p><p>health, psychological, and social parameters de</p><p>termined in the previous step are evaluated. The</p><p>data collected are then used to determine the ef</p><p>fectiveness of the design based upon the intende</p><p>function of the garden. Undesired effects are als</p><p>evaluated.</p><p>The design of a therapeutic garden for Clare Housin</p><p>an apartment building for patients with HIV disea</p><p>illustrates the process by which therapeutic gard</p><p>spaces may be designed and scientically analyz</p><p>to determine their safety and effectiveness for a giv</p><p>user group.</p><p>1. Evaluating the Disease and the Patient</p><p>HIV Disease</p><p>Human immunodeciency virus (HIV) attacks timmune system. Untreated, HIV disease is progr</p><p>sive and fatal. Death takes place over a period</p><p>months to years. Recent changes in the drug thera</p><p>of HIV disease has, however, created the opportu</p><p>ty to greatly extend the lives of people infected w</p><p>HIV and, in some cases, lead to a remission of t</p><p>disease. This life extension has paradoxically led</p></li><li><p>8/4/2019 Design, Landscape, and Health - Horticultural Therapy</p><p> 5/8</p><p>Implications</p><p>Where Research Inorms Design</p><p>an increase in the number of individuals living with</p><p>HIV disease, even as the rate of new infections hasdeclined. For people living with HIV, it is known that</p><p>stress can lead to increased viral replication and de-</p><p>creased effectiveness of drugs used to treat the dis-</p><p>ease. Design considerations based upon the health</p><p>needs of people with HIV disease must therefore ac-</p><p>commodate the following:</p><p> Minimize exposure to potential infections. Chosen</p><p>plant material should be thornless and unlikely to</p><p>harbor potential bacterial and fungal pathogens. In</p><p>addition, standing water should not be present to</p><p>prevent transmission of mosquito-borne illnesses. The design should provide accessibility for people</p><p>with decreased mobility.</p><p> Waynding should be clear as dementia may</p><p>develop.</p><p> Shade should be provided as users may be sun-</p><p>sensitive due to medications used to treat HIV.</p><p>The Garden Users</p><p> To design a space that meets the needs of its in-</p><p>tended users, an investigation into the primary and</p><p>secondary users of the space was performed. Theprimary users of the site were the apartment</p><p>residents themselves. They were single adults, most-</p><p>ly HIV-positive, currently or previously homeless,</p><p>and varied in terms of mental health, employment,</p><p>and mobility. Social workers, case managers, and</p><p>housing administrative staff were also identied </p><p>secondary users. When surveyed, primary uers indicated desires for a water feature, areas </p><p>cook outdoors, ower gardens, opportunities </p><p>garden, and spaces to socialize as well as me</p><p>tate. Secondary users desired a space to hold st</p><p>meetings, events, and fundraisers, and to rel</p><p> The therapeutic garden design offered therapeu</p><p>spaces, each related to a specic theory and mech</p><p>nism for stress reduction and amelioration of the d</p><p>ease process.</p><p>2. Designing to Ameliorate Symptoms</p><p>Social Support: The Communal Area</p><p>The communal area functions to increase social su</p><p>port. Isolation is a major problem for those livi</p><p>with HIV disease, and can lead to depression, failu</p><p>to comply with medical regimens, and poorer o</p><p>comes. This patio area provides an informal area residents to gather and socialize. It is designed to </p><p>planted by the residentswho could choose plants</p><p>their likingto promote communal involvement, </p><p>encourage gardening as a form of relaxation, and</p><p>provide residents with a creative outlet and a chan</p><p>to interact during the planting. Wall seat plantin</p><p>are accessible.</p><p>The communal area.</p></li><li><p>8/4/2019 Design, Landscape, and Health - Horticultural Therapy</p><p> 6/8</p><p>Implications</p><p>Where Research Inorms Design</p><p>Decreasing Stress: The Natural Area and the</p><p>Meditative AreaThe viewing of nature is universally associated</p><p>with decreased stress and a...</p></li></ul>