Psychosocially Supportive Design As a theory and model to promote health

Introduction

The persistence of institutional and narrow functionally- oriented approaches in which high priority is given to operational efficiency, has largely neglected environmental qualities that could be considered psychosocially supportive. Modern disease concepts are no longer narrowly pathogenic. Instead, disease is seen as multifaceted, oriented to systems, with consideration given to a variety of psychosocial factors upon which the quality of physical environment has a great impact.

Psychosocially supportive design, as theory and a model, presents a new paradigm for health promulgation by design within the physical environment generally and, in particular, within healthcare facilities. The psychosocially supportive design approach is offered as a useful theory and framework to guide healthcare designers and planners who are considering how the physical environment impacts wellness factors in order to promote health. The main issue here is to emphasise that the qualities of the physical environment require both functional efficiency and psychosocially supportive design, aimed at enhancing and creating conditions for health processes to evolve.

To define the characteristic of psychosocially supportive design, a clearer understanding of health definitions is needed to establish the connection between the physical environment and health promotion.

Health and well being

In the 1930s, it was discovered that something in the mind could lead to somatic diseases, revealing that some diseases are psychosomatic and that exposure to the surroundings, as positive distraction, has a great impact on human health (Antonovsky, A. 1996). Human distress is highly affected by an integrated organism that has psychological, social and somatic aspects. Health promotion, as a conceptual platform for health, has been developed by the World Health Organization (WHO). Its vision states: “Health is a state of optimal physical, mental and social well-being, and not only the absence of disease.” WHO has emphasised a range of recommendations for people to engage in practices and behaviours which promote health, all of which are said to lead to a decrease in human suffering and a rise in human happiness. The consequences will be crucial for disease prevention. WHO contends that the successful promotion of health would have a major economic impact, because it would decrease the need for disease care expenditures and consequently allow people to be more economically productive, reducing absenteeism and increasing work efficiency.

The concept of health promotion as championed by WHO is an attractive proposition. The organisation advances original ideas about how health promotion should be developed and implemented in broader fields. Unfortunately, the economic consequences with respect to how health promotion can generate cost savings have not been well documented. Presumably, people who are healthy will live longer, thereby securing many more years of economic dependency.

According to Aaron Antonovsky, the best arguments for health promotion lie in value rather than in market oriented terms. He cites the paragon of museums in which no one challenges that the museum experience pays-off in cash.

Health promoters have not confronted the question of life style and the creation of appropriate social conditions that promote health. As a target for health promotion policy, “lifestyle” refers, for some, to the consciously chosen personal behaviour of individuals as it may relate to health. Another interpretation of “lifestyle” is a composite expression of the social and cultural circumstances which condition and constrain personal behaviour (McKinlay, J.B. 1993).

Environmental solutions that affect urban space and access to urban structure of the city have a great impact on lifestyle and human behaviours. The quality of urban space can support health promotion by providing wellness factors that stimulate social and mental wellbeing. There is a lack of empirical knowledge about the effect of more appropriate physical environments on health promotion, despite the fact that world scientists continue to emphasise the environmental quality of disease prevention.

The concept of lifestyles as it appears in the literature is well-documented. It includes a list of risk factors such as smoking, other substance abuse, over and under nutrition, drinking and driving, unsafe sex and exposure to injuries. The focus remains on the realm of disease prevention. However, lifestyle is somewhat broader, because it identifies risk factors that are often precursors to a variety of diseases. The physical environment provides a context for lifestyle and thereby affects our behaviour and, as a consequence, our health condition.

Salutogenic orientation as a basis for health promotion mandates both research and action towards developing psychosocially supportive design as a context for a healthy lifestyle and positive distractions. Design factors such as wellness that actively promote health, rather than only seeking to prevent risk factors aimed at avoiding injuries, should be developed.

The sutogenic perspective, which was developed by Aaron Antonovsky’s concern for health promotion factors emphasises wellness factors rather than risk factors. Antonovsky founded the concept of “salutogenes”. He describes health as a continuum and an incessant process in which the extremes are health and disease. The factor that determines where on the continuum a person finds himself is a question of high or low sense of coherence.

The stimuli bombarding an individual from inner and outer environments were perceived as information that affects our behaviors. This stimuli and thought led to the emergence of the sense of coherence (SOC).

In the following text, I will describe my observations regarding the salutogenic principles in a health promotion approach for the physical environment. My point of departure includes the factors, which in various ways, affect the sense of coherence in the physical environment that may stimulate our behaviour in a positive way. According to Antonovsky, the decisive factors driving the sense of coherence are comprehensibility, manageability and meaning.

The strength of everyone’s sense of coherence is a significant factor in facilitating the recognition of health promotion and confronting the stressor. Persons with a h4 sense of coherence will believe that a challenge is understandable (comprehensibility), believe that resources to cope are available (manageability) and finally, wish to be motivated to cope (meaningfulness).

Design that stimulates healthy behaviour

The implementation of a psychosocially supportive approach to design supports the sense of coherence that stimulates and engages individuals, both mentally and socially. The basic function of psychosocially supportive design is to start a mental process that, by attracting a person’s attention, may eliminate or, at least, reduce anxiety, bringing about positive psychological changes. Design from a salutogenetic perspective defines, not only the causes of stress, but introduces wellness factors that strengthen health processes. Psychosocially supportive design should challenge our mind in order to create pleasure, stimulation, creativity, satisfaction, enjoyment and admiration (Dilani, A. 2001).

During my past fifteen years of research, I focused on the effects of design on health and well being, developing a more profound understanding of the problem through the theoretical approach of the Salutogenic model for creating a healthy environment. Assuming the need for social support, a core problem faced by the elderly living alone is social isolation, yet it is through the physical environment that more access to social support can be provided. For example, a central setting could be built that facilitates a social structure for the community. Within the local community, it would be desirable to provide places where elderly persons could easily socialise, by attraction and stimuli from other activities such as at a children’s school close to elderly, as in the following photo (Norling, I. 2001).

With the ageing of the population and the increase in the incidence of neurodegenerative diseases, the medical costs of Alzheimer’s disease will increase steadily in the coming decades. It would be useful to know exactly how much care will cost, who will pay for it, and to what extent it is likely to grow. However, the specific medico-social costs of Alzheimer’s disease are difficult to distinguish from other costs because of physical dependence and multiple disorders that may affect elderly people generally. Currently, it is almost impossible to obtain reliable financial data. Through the physical environment, there are possibilities to reduce social costs, anxiety levels, and depression accompanied by the consumption of drugs (Zeisel, J. 2005).

The quality and character of the built environment has a profound influence on our health. During the last thirty years, architecture and design have been influenced by our industrial society. Public buildings like airports and hospitals were designed to function like factories. In hospitals, clinical practice formerly focused on treating illness while neglecting the psychological, social and spiritual needs of patients. Entering one of today’s older hospitals, signs are often difficult to interpret and the corridors, with people rushing about, appear endless. Such an environment can create a sense of dislocation and anxiety. If you weren’t ill before, you certainly might be after waiting for hours in a crowded, stuffy, featureless waiting room (Dilani, A. 2000). Contrast that with the welcoming environment of some of the best of the new hospitals where you may encounter water features, an orchestra playing pleasant music, natural daylight and works of art. The positive experience of this approach to the environment stimulates our senses, soothes our nerves and makes the whole hospital experience comprehensible, manageable and meaningful.

The Importance of Design for our Senses

Aesthetic enjoyment through wellbeing of the eyes, the ears, touch taste or smell, is a fundamental human need. Like other abilities, the senses need stimulation and practice to thrive. Sounds, for example, contribute to enlarging and reducing an architectural experience. Rooms and materials reflect sound in various ways. There are pleasant sounds and unpleasant sounds. Designers and architects sometimes spend a great deal of effort on the sound of environments, independent of their designing concert houses and theaters. One goal is to reduce or filter unwanted sound; another is to highlight beautiful and serene sounds such as rippling water and clicking sounds, informing us that a box or a door is closed. To find the right sound for a product has become an increasingly more important job for designers. If the sensory appeal is heightened with a pleasing handle, pleasurably tactile and smelling materials etc, it will increase people’s inclination to make the most of these environmental qualities. Personal insight is awakened, reflecting well on the value of a good environment. Medical research has shown how these sensory qualities stimulate patient recovery. The environment has a great positive influence on elderly patients, in particular.

Research and action

Despite the fact that the human being spends more than ninety-percent (90%) of their time in man-made indoor environments, the existing knowledge of how these environments affect human health is still insufficient (Evans G. W. 2003). Earlier research in environmental psychology has shown that architectural parameters such as stimulation (intensity, variety, complexity, mystery, novelty, noise, light, odor, colour, crowding, visual exposure, proximity to circulation, adjacencies), coherence (legibility, organization, thematic structure, predictability, landmark, signage, pathway configuration, distinctiveness, floor plan complexity, circulation alignment, exterior vistas), affordances (ambiguity, sudden perceptual changes, perceptual cue conflict, feedback), control (crowding, boundaries, climatic & light controls, spatial hierarchy, territoriality, symbolism, flexibility, responsiveness, privacy, depth, interconnectedness, functional distances, focal point, sociofugal furniture arrangement), and restoration (minimal distraction, stimulus, shelter, fascination, solitude) are closely linked to the perception of positive and negative stress.

The question is: Can the positive architectural characteristics required to reduce stress, as mentioned previously, be implemented in current workplaces and the overall built environment, thus strengthening the sense of coherence and its consequent promotion of health? To pursue this concept, we need to go one step further and seek to firmly link health promotion and design to reduced stress levels resulting from architectural design.

It is of critical importance that the field of design, as the creator of the physical context for health promotion, lacks a theoretical approach. As a basic foundation, the salutogenic approach should be considered to be the crucial point of departure in an attempt to develop a theoretical approach for psychosocially supportive design. It should be developed further as common ground for a design theory to promote health.

This theory has been proposed as a direction of travel that will allow the field to develop its commitment to deriving a greater understanding of all aspects of the human experience in relation to the physical environment. The theory suggests that we should not only design for stress reduction, but that we should focus on salutary rather than risk factors. Designers and planners should always focus on stimulating and rejuvenating the entire person’s mind and body, rather than only addressing risk and prevention factors. As one methodology, the sense of coherence linked to this design approach is a respectable way to apply health promotion by design. I have discussed a comprehensive source and guide for research and action. I believe that the salutogenic approach in design provides a common objective and is a particularly appropriate model for psychosocially supportive design.

Conclusion

The salutogenic approach, as a link and model to a design approach for health promotion, provides a basic theoretical framework for psychosocially supportive design. It provides a model and theory to promote health by design. There is a need to systematically investigate and conduct more empirical studies that verify this model. It is a model that posits that health outcomes are not only linked to stress reducing factors but are linked to environmental qualities that could measure the positive effects of health outcomes. Furthermore, this effort requires informed leadership to guide the organisation through the salutary approach process.

The issue of psychosocially supportive design is not a task for designers alone. It requires that the entire organisation understands the meaning of salutary organisation. Designers could support the effort by quantifying the benefit of such an approach. The organisation should measure the sense of coherence. At the same time, the staff should comprehend it and act on it. We believe that the staff resources to cope are available (manageability), but that they are waiting to be motivated (meaningfulness). Design qualities that could be included as wellness factors should be identified follow: access to nature; art; colours; sound of music and nature; lighting; access to pets; use of culture; familiarity; creating landmarks and references in buildings; aesthetics; harmonious and cheerful color; social interaction and neighborhoods; spatial composition and articulation; provision of inviting spaces for social support, all of which seek to engage mentally with positive stimulation that could strengthen people’s sense of coherence. This approach emphasises both psychological and social components that are crucial for health outcomes.

In this nascent stage of scholarship about design and health promotion, the most pressing need is for a better understanding of the psychological and social components that could potentially link a sense of coherence to the quality of wellness factors within the designed environment. Psychologically supportive design provides the theory, knowledge and models for advancing healthcare design.

References

• Antonosky, A. 1979. Health, Stress and coping: new perspectives on mental and physical well-being. Jossey-Bass, San Francisco
• Antonosky, A. 1996. The salutogenetic model as a theory to guide health promotion. Health promotion international, vol. 11, no 1, pp. 11-18.
• Antonosky, A. 1991. Hälsans mysterium, Natur och Kultur, Köping
• Dilani, A. 2005. A new paradigm of design and health in hospital planning. World Hospitals and Health Services, International Hospital Federation, Volume 41, Number 4.
• Dilani, A. 2001. Psychosocial supportive design — Scandinavian Healthcare
• Design. In: Alan Dilani (2001) Design and Health - The Therapeutic Benefits of design, p. 31-38.
• Dilani, A. 2000. Architecture and Design, Healthcare Buildings as Supportive Environments. World Hospitals and Health Services, IHF, Vol. 36, nr. 1.
• Dilani, A. 2000. Design and Care in Hospital planning, Karolinska Institutet, Institute for Psychosocial Factors and Health, Design and Health. Stockholm.
• Evans G. W. 2003. The Built Environment and Mental Health. Journal of Urban Health: Bulletin of the New York Academy of Medicine. Vol. 80. no 4. p. 536-555.
• Levi, L. 1972. Psychosocial Factors in Preventive Medicine. In background papers to Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. Washington, D,C, US Public Health Service.
• McKinlay, J. B. 1993. The promotion of health through planned socio-political change: Challenges for research and policy. Social Science and Medicine, 36, 109-117.
• Norling, I. 2001. Naturens och trädgårdens betydelse för hälsa och livskvalitet. Göteborg botaniska trädgård. Göteborg.
• Zeisel, J. 2005. Evidence-based Design as Health Treatment. In Alan Dilani (2004) Design & Health III – Health Promotion through Environmental Design, p. 35-43.

Professor Alan Dilani is the founder of the International Academy for Design and Health and head of the Research Centre for Design and Health at the Karolinska Institute in Stockholm, Sweden.

The International Academy for Design and Health is a non-profit organization with an inter-disciplinary network dedicated to the stimulation and practical application of research concerning the interaction between design, health and culture. To become a member of the network as either a researcher, a practitioner or a corporate member, contact: The Executive Board, Professor Alan Dilani, dilani@designandhealth.com or Marketing and Communications, Marc Sansom, marc@designandhealth.com