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ImplicationsVOL. 05 ISSUE 04

A Newsletter by InormeDesign. A Web site or design and human behavior research.

www.inormedesign.umn.edu

IN THIS ISSUE

cover image

goes here - ft

image to theblack box

using the

guidelines

According to Richard Jackson (2001

the Center for Disease Control (CDC):

The current design of our commun

has created new health problems. M

cine will not be adequate to deal with

health challenges of the 21st century,

even with the help of the sequenced

nome and advances in robotic surgEven though the United States spends

of every seven dollars on medical care

will not signifcantly improve health

the quality of life unless we pay more

tention to how we design our living e

ronments. Healthy living environments

clude not just a clean and heated kitc

bath or bedroom, but also the landsc

around us. Health for all, especially fo

young, aging, poor and disabled, requ

that we design healthfulness into our eronments as well.

In my experience as a primary care p

sician, I am continuously confron

with evidence that many of the dise

currently on the increase can be tra

back to the ways in which we have

signed our world. Diseases such as

betes, hypertension, and cardiovasc

disease, while multi-factorial in etiol

are all clearly linked to an increasisedentary population and with poor d

Reliance on automobiles for transpo

tion and sprawl of cities leads to po

air quality and an increase in asth

Design, Landscape, and HealthSteve 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 increas-

ing 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 car-

diovascular disease, partly related to an

aging population, but increasingly related

to the designed environment.

These controllable yet currently incurable

diseases are contributing to an increas-

ing burden of disease within our soci-

ety. Recent trends have also shifted this

burden to the youngest members of our

society, who, if current trends continue,

may be the rst generation to witness a

decline in longevity. Disadvantaged and

minority populations also bear a dispro-

portionate burden of these diseases, fur-

ther compounded by their lack of access

to quality healthcare. These populations

are exposed to more pollution, have fewer

healthy food choices, and live in commu-

nities with less access to recreation and

green space.

Design, Landscape,

and Health

Healing and

Therapeutic Gardens

Case Study: A

Therapeutic Garden or

People Living With HIV

Related Research

Summaries


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Implications www.inormedesign.umn.edu

Where Research Inorms Design

particularly among inner city youth. Lack of walkable

and bikeable communities contributes to decreasedlevels of physical activity, which in turn increases the

prevalence of obesity.

Well-designed communities can foster social inter-

action, 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 Founda-

tion, and the Environmental Protection Agency have

all begun to examine and promote the development

of community design that fosters health. Insurancecompanies 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, ef-

ciency, and style. We know little about what the effect

of these designed environments is upon peoples re-

covery from illness, though evidence has shown that

design factors can reduce infection rates and errors

in patient care and lead to shorter lengths of hospitalstays. There is also much to be learned in the design

of long term care facilitiespotentially leading to bet-

ter quality of life and lower hospitalization rates and

medication usage by residents. As our society ages

and the utilization of long term care accelerates, im-

proving the design of these facilities will be critical.

While conventional medicine and public health ha

much to contribute to our understanding and sho

term treatment of diseases and problems, they alo

cannot control and reverse the systemic conditio

that foster their development. Healthcare design is

emerging eld that seeks to address some of the

issues; it can be dened as the application of desi

in the provision of physical and mental services, p

ventative medicine, and treatments to individuals

the public.

However, for design to play a broad and signica

role in building and maintaining health, design a

research must be integrated despite differences

their premises, methods, and the language of th

outcomes. This issue ofImplicationsdescribes an

tegration of landscape design and research for t

purpose of optimizing user health.

The next section discusses healing and therapeu

gardens, outlining current therapeutic garden d

sign guidelines that are based on stress-respon

research, anecdotal evidence, and theories rega

ing stress reduction in well population groups. In t

case study that follows, these guidelines are utiliz

as a basis for the initial design of a therapeutic g

den for Clare Housing, an apartment building for p

tients with HIV disease. A methodology to test the

guidelines is also proposed.Pollution and sedentary lifestyles resulting from urban sprawl

contribute to a range of diseases.


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Healing and Therapeutic Gardens

Gardens have played a role in healthcare for centu-ries. With the advent of modern medicine in the be-

ginning of the 20th century, the curative potential of

gardens was lost. However, there has been renewed

interest in utilizing garden environments as thera-

peutic entities to enhance the process of healing that

occurs in healthcare environments.

Psychoneuroimmunology is an emerging eld of med-icine that examines the complex interplay between

the immune system, central nervous system, and en-

docrine system. It is generally accepted that chronic

stress leads to maladaptive changes that eventual-

ly impair our abilities to heal from illness. It is this

component of illness that is most amenable to inter-

vention by therapeutic gardens. By minimizing the

stress response, therapeutic gardens can promote re-

covery from illness or preserve health. One can theo-

rize that this effect is mediated by the sensory inputs

associated with gardens. These inputs can involveall 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.

What Makes a Garden Therapeutic?

Healing garden typically describes gardens designto promote healing from illness. Healing, within t

context of healthcare, is a broad term, seen as

improvement in overall well-being that incorpora

the spiritual as well as the physical. A healing gard

may provide relief from the psychological distress

disease and an improved sense of well-being, but

may or may not alter the disease outcome.

A therapeutic garden is more specically designed

produce a given outcome upon a disease process

can be thought of as similar to a medication thattaken for a specic disease or illness. The therapeu

garden is thus less focused on healing in a spiritu

context (although it may also have this effect) a

more akin to the disease model of illness as practic

by most allopathic medical systems.

At present, little data exists to guide the design

a therapeutic garden. Instead, general design guid

lines have been developed and are generally accept

based on theories of stress reduction, encompass

six principles.

1. Provide a sense of control by creating a vari-

ety of spaces. Spaces within a garden should b

easily accessible by all user groups, provide for

privacy, and include a variety of spaces that allo

individuals to seek out spaces that best suit the

2. Provide for social support. Social support is

associated with less stress than isolation, and h

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 pleasant-

ness, can encourage exercise and movement. Theyshould thus offer easy waynding 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 op-

posed to hardscape, the more likely the relaxation

response is to occur. This relaxation response is

believed to be hardwired into our nervous sys-

tems by evolutionary responses to environmentsthat favored survival.

5. Minimize ambiguity. Stressed individuals

respond negatively to ambiguity. Studies of inpa-

tients 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 negativedistractions such as noise, odor, and bright lights.

Noise in particular can negate the positive effects

associated with viewing nature.

A water feature can mask undesired noises.

Case Study: A Therapeutic Garden

for People Living With HIVPrescribing with the Landscape

Creating a therapeutic landscape involves th

steps:

1. The evaluation of the disease and/or patient is

used to generate potential target symptoms or d

ease processes to be addressed by the design.

2. After attaining a thorough understanding of the

disease, disease processes, and social and psych

logical factors, the design is created based upon

the target symptoms that the designer wishes

to ameliorate. In addition, the methodology forevaluating the inuence of the garden on the pa

tient population is developed. This methodology

based upon the intent of the design and is used

measure its effectiveness.

3. Once the garden is installed and occupied, the

health, psychological, and social parameters de

termined in the previous step are evaluated. The

data collected are then used to determine the ef

fectiveness of the design based upon the intende

function of the garden. Undesired effects are als

evaluated.

The design of a therapeutic garden for Clare Housin

an apartment building for patients with HIV disea

illustrates the process by which therapeutic gard

spaces may be designed and scientically analyz

to determine their safety and effectiveness for a giv

user group.

1. Evaluating the Disease and the Patient

HIV Disease

Human immunodeciency virus (HIV) attacks timmune system. Untreated, HIV disease is progr

sive and fatal. Death takes place over a period

months to years. Recent changes in the drug thera

of HIV disease has, however, created the opportu

ty to greatly extend the lives of people infected w

HIV and, in some cases, lead to a remission of t

disease. This life extension has paradoxically led


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an increase in the number of individuals living with

HIV disease, even as the rate of new infections hasdeclined. For people living with HIV, it is known that

stress can lead to increased viral replication and de-

creased effectiveness of drugs used to treat the dis-

ease. Design considerations based upon the health

needs of people with HIV disease must therefore ac-

commodate 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.

Waynding should be clear as dementia may

develop.

Shade should be provided as users may be sun-

sensitive due to medications used to treat HIV.

The Garden Users

To design a space that meets the needs of its in-

tended users, an investigation into the primary and

secondary users of the space was performed. Theprimary users of the site were the apartment

residents themselves. They were single adults, most-

ly HIV-positive, currently or previously homeless,

and varied in terms of mental health, employment,

and mobility. Social workers, case managers, and

housing administrative staff were also identied

secondary users. When surveyed, primary uers indicated desires for a water feature, areas

cook outdoors, ower gardens, opportunities

garden, and spaces to socialize as well as me

tate. Secondary users desired a space to hold st

meetings, events, and fundraisers, and to rel

The therapeutic garden design offered therapeu

spaces, each related to a specic theory and mech

nism for stress reduction and amelioration of the d

ease process.

2. Designing to Ameliorate Symptoms

Social Support: The Communal Area

The communal area functions to increase social su

port. Isolation is a major problem for those livi

with HIV disease, and can lead to depression, failu

to comply with medical regimens, and poorer o

comes. This patio area provides an informal area residents to gather and socialize. It is designed to

planted by the residentswho could choose plants

their likingto promote communal involvement,

encourage gardening as a form of relaxation, and

provide residents with a creative outlet and a chan

to interact during the planting. Wall seat plantin

are accessible.

The communal area.


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Decreasing Stress: The Natural Area and the

Meditative AreaThe viewing of nature is universally associated

with decreased stress and a sense of psychologi-

cal 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 at-

tract 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 arous-al and stress. Meditative states are associated with

positive physiological states of lowered blood pres-

sure, pulse, and circulating stress hormones. A water

feature was designed to enhance this state by provid-

ing a focus, positive distraction, and screening out in-

trusive visual and auditory stimuli. Conifer plantings

were designed to provide a quiet and restful comple-

ment to the space. Their density would create a calm,

enclosed space to facilitate a meditative experience.

Exercise: The Garden Walkway

Exercise is associated with relaxation and induces a

relaxation response. The site was designed to encour-

age walking within the site and positive distraction.

The walkways are circular in layout to provide easy

waynding for those residents who may suffer from

dementia. The garden walkway plantings were

lected to be bold and colorful, to stimulate the senes in a positive way, and to encourage movement

see what lies ahead. The plantings were designed

four season interest, shade and respite, and shelter

views to the street for people watching.

3. Determining the Effectiveness of the Design

The therapeutic garden can be evaluated throu

several disease-specic, biological markers of disea

activity (such as viral loads and CD4 counts), a

measures of mental health status, social functionin

and quality of life. Additionally, it may be usefulascertain which areas of the garden are frequent

most often by residents to determine if certain sp

tial qualities prove more successful than others

accomplishing the goals of the design. The hypo

esis is that the installation of the garden will lead

an improvement in medical, psychiatric, and soc

indicators among the residents. Measurements

these health indicators should be made before a

after installation of the garden to determine what

fect, if any, the garden has upon the health of t

residents.

Toward a New Paradigm of Therapeutic Garden

As the interest in the eld of therapeutic gardens co

tinues to expand, system for research must be dev

oped. The chairs of the American Society of Lan

scape Architects (ASLA) Therapeutic Garden Desi

Professional Interest Group have stated:

We propose a renewed effort to encourage academ

research that is useful to practit ioners, and to prov

publicity for the new research to get the word out. R

search is important to validate intuition and to mvate policy change...We need research approaches t

address current problems.

These same sentiments are echoed throughout

literature and writings of landscape architects int

ested in this eld. And yet, there appears to be lit

progress in the answer to these calls.

The garden walkway.


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Perhaps what is missing is a paradigm that allows

research to develop out of the design process. Land-scape architecture is rst 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 ux as newinformation 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 ulti-

mately impacts our abil-

ity to stay healthy. Whenwe become ill, the design

of our clinics, hospitals,

and nursing homes im-

pacts 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 mem-

bers of the scientic and healthcare professions, such

as, public health professionals, epidemiologists, phy-

sicians, and nurses, to name a few. It is my belief

that the solutions to reverse the deterioration in ournations 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 collaborative-

ly, can meaningful solutions be found. Designers are,

perhaps unknowingly, already involved in creating

experiments through design. Every building, land-

scape, city, and regional design is a hypothesis abo

what is best for a given problem. Human subjethen interact with the design with a resulting impa

upon them. What is missing in the design professio

is a means to evaluate the results and use this da

to inform future design. Research needs to info

design and design needs to inform research.

About the Author:

Steve Mitrione, MD, MLA, is

family physician with 20 years

clinical experience. Dr. Mitrio

recently received his MLA frthe University of Minnesota a

is one of only two individuals

the United States to hold both d

grees. His focus is on the ways

which landscape and the designed environment c

improve health and aid in the recovery from illnes

References

Cole, S., Naliboff, B., Kemeny, M., Griswold, M.,

Fahey, J., & Zack, J. (2001). Impaired response

to HAART in HIV-infected individuals with highautonomic nervous system activity. Proceedings

the National Academy of Sciences, USA, 98, 1269

12700.

Epstein, M., & Sachs, N. (2005, Summer). Thera

peutic Garden Designnewsletter, 4.

Mace, L., Bell, P., & Loomis, R. (1999). Aesthetic,

affective and cognitive effects of noise on natura

landscape assessment. Society and Natural Re-

sources, 12, 225-242.

Paine, R., Francis, C., Marcus, C. & Barnes, M.

(1998). Hospital outdoor spaces. In Marcus, C. &

Francis, C. (Eds.), People places: Design guide-

lines. (pp. 311-343). New York: Wiley.


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2002, 2005 by the Regents of the University of Minnesota.

Creator: Founding Sponsor:

The MissionThe Mission of InformeDesign is to facilitate designers

use of current, research-based information as a decision-

making tool in the design process, thereby

integrating research and practice.

Ruuskanen, J., & Parketti, T. (1994). Physical

activity and related factors among nursing homeresidents. Journal of the American Geriatr ics Soci-

ety, 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 Lancet2, 888-891.

Ulrich, R. (1999). Effects of gardens on health

outcomes: Theory and research. In Marcus, C. &

Barnes, M. (Eds.), Healing gardens: Therapeuticbenefts 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. Psycho-

physiology, 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.

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.

Health Benets 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 ResidentialSatisfactionEnvironment 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

Photos Courtesy of:

The Metropolitan Design Center, Regents of

University of Minnesota (pp. 1-4).

Steve Mitrione (remainder).

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