Stella Chukwu Dissertation by PDF Uploads

HEALTHY HOSPITALS

How are the principles of Salutogenic design articulated in the healthcare sector?

Student Name: Stella Chukwu Student Number: 180233670 Dissertation Title: Healthy Hospitals Dissertation Tutor: John Kamara Word Count: 8917 Footnotes/Quotations Wordcount: 1,351

Acknowledgements Throughout the process of writing of this dissertation I have benefitted tremendously from the support, experience and knowledge of many. I would first like to thank my tutor, John Kamara, whose assistance was essential in refining and developing my research topic and ensuring my research was comprehensive. In addition, I would like to thank my parents and siblings for their support, advice and encouragement not only in the writing of this dissertation, but in all things, and through this difficult year particularly. Finally, thanks go to my friends and fellow students, whose support and shared experience have been invaluable.

Abstract This dissertation will examine salutogenic design principles through a review of key researchers in the field and then examine the application of these principles in a case study of Akershus Hospital in Oslo to answer the central research question of how the principles of this theory are applied in healthcare environments. This discussion will be rooted in a review of healthcare design throughout history, in order to understand how hospital design is reactively linked with public health and to consider changing perspectives on holistic approaches to health, followed by a literature review of salutogenic design principles, and a case study of Akershus Hospital to inform the theories surveyed with an example in practice.

Covid Research Adaptation Account My initial research plan for this paper relied on the ability to interview hospital staff about the impact they saw salutogenic design to have on patient well-being and recovery, if any, in order to offer a form of quantified research on its effectiveness, an area where there is not substantial information presently in academic literature. I also hoped to visit the hospital. However, the onset of a global pandemic made contacting a health institution for this project seem incredibly inappropriate, and travel became impossible.

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TABLE OF CONTENTS Acknowledgements

Abstract

Covid Research Adaptation Account

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INTRODUCTION

CHAPTER ONE: A HISTORY OF HEALTHCARE DESIGN

CHAPTER TWO: SALUTOGENIC DESIGN

CHAPTER THREE: ANALYSIS OF CASE STUDY/AKERSHUS HOSPITAL

Daylighting Spatial Division Access to Nature Street-Like Layout & Community Use Key Findings Considerations & Critique

CHAPTER FOUR: CONCLUSION

27 29 30 32 35 37

“We are coming to understand health not as the absence of disease, but rather as the process by which individuals maintain their sense of coherence (i.e. sense that life is comprehensible, manageable, and meaningful) and ability to function in the face of changes in themselves and their relationships with their environment.”

---Aaron Antonovsky

Introduction

The role of the built environment in contributing to health and well-being is a clear concern today as obesity, sedentary habits and poor nutrition contribute to rising rates of cardiovascular disease, diabetes, stroke and cancer, each currently among the world’s greatest killers.1 As pointed out by Noa Pinter-Wollman, Andrea Jelic and Nancy M. Wells writing for the Royal Society, the trajectory of these lifestyle diseases can be tracked alongside urban development and the built environment, with separation of use brought about by zoning and the invention of the automobile being key influencers of inactivity and obesity, and thus, lifestyle-related diseases in the 21st Century.2 Further, chronic disease, and depression particularly, has been linked to dimensions of the built environment through factors such as isolation, crowding, pollution and the absence of green spaces.3 The WHO acknowledges the role the built environment plays in well-being, defining health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” and, significantly, including the built environment as a contributing factor.4 Working from this definition, this dissertation will explore how the principles of salutogenic design are articulated in healthcare environments, particularly hospitals, today. For the purposes of this dissertation, well-being driven healthcare design is

Wendy Collins Perdue, Lesley A. Stone and Lawrence O. Gostin, "The Built Environment And Its Relationship To The Public’S Health: The Legal Framework", American Journal Of Public Health, 93.9 (2003), 1390-1394. 2 Noa Pinter-Wollman, Andrea Jelić and Nancy M. Wells, "The Impact Of The Built Environment On Health Behaviours And Disease Transmission In Social Systems", Philosophical Transactions Of The Royal Society B: Biological Sciences, 373.1753 (2018), 20170245 <https://doi.org/10.1098/rstb.2017.0245>. 3 ibid 4 "Constitution", Who.Int, 2020 <https://www.who.int/about/who-we-are/constitution> [Accessed 23 April 2020].

defined as that which takes a humanistic view of the patient, acknowledging that illness brings with it significant psychological social and cultural effects which can be mitigated by the built environment by supporting not just the physical needs of the patient, but their emotional, social and spiritual needs as well.5 While there are several schools of well-being-driven architecture, this dissertation will focus particularly on salutogenic design, which espouses the idea that the built environment can be designed to actively promote health rather than simply treat disease,6 mirroring the WHO’s contention that health encompasses far more than merely the absence of disease. Salutogenics as a discipline positions itself in opposition to what is known as the pathogenic model of healthcare.7 While the former focusses on the what creates and maintains health, the latter begins with considering disease and how to treat and eliminate it.8 While no one would argue against disease treatment and elimination, some suggest that this approach with regard to medical architecture creates buildings made for technology and equipment to attack diseases rather than to foster good health and well-being in patients. Salutogenic design suggests that medical technology and cutting-edge treatments can and should sit alongside a designed environment which fosters health and recovery with a focus on the well-being of the whole person, not just the elimination of disease. As we examine the role of architecture in promoting health, it is important to acknowledge that public health and the corresponding built environment have always been reactively linked, with Pinter-Wollman, Jelic and Wells contending that illness “was the raison

Leila Valizadeh and others, "A Concept Analysis Of Holistic Care By Hybrid Model", Indian Journal Of Palliative Care, 23.1 (2017), 71. 6 Aaron Antonovsky, Health, Stress, And Coping (San Francisco: Jossey-Bass Publishers, 1991). 7 Christopher J. Fries, "Healing Health Care: From Sick Care Towards Salutogenic Healing Systems", Social Theory & Health, 18.1 (2019), 16-32. 8 ibid

d'être for the advent of urban planning in Europe and the USA, and one of the central motifs that shaped the architecture of modernism” in their 2018 article, The Impact of the Built Environment on Health Behaviours and Disease Transmission in Social Systems. During the 19th and 20th centuries, cities like London and New York had dense populations living in close proximity to animal yards and factories, with people inhabiting tenement housing with low airflow and poor access to light.9 Cholera, tuberculosis and typhoid were rampant, and disease and transmission poorly understood: theories like ‘miasma theory’—the idea that bad air vapours transmitted disease—were widespread.10 This helped fuel the sense that urban congestion, pollution and lack of access to nature led to illnesses, which encouraged the growth of zoning by usage and lower-density development strategies.11 Healthcare-related architecture and city planning responded to the perceived causes of these crises with the mid-nineteenth century public health movements, and the rebuilding of European and North American cities began, with the goal of addressing overcrowding and poor sanitary conditions.12 Ironically, efforts to design the built environment to stem the spread of infectious diseases in the late 1800s and early 1900s can be seen today as contributing factors for chronic diseases in the twenty-first century, brought to prevalence by obesity, stress and lack of physical activity. Today, architecture and design clearly face a new challenge of how to address these chronic and lifestyle-driven threats to public health, which in addressing risks to health and

Noa Pinter-Wollman, Andrea Jelić and Nancy M. Wells, "The Impact Of The Built Environment On Health Behaviours And Disease Transmission In Social Systems", Philosophical Transactions Of The Royal Society B: Biological Sciences, 373.1753 (2018), 20170245 <https://doi.org/10.1098/rstb.2017.0245>. 10 ibid 11 ibid 12 ibid

well-being in a previous age have inadvertently caused others in modern times. Perhaps this discussion is nowhere more important than in regard to healthcare environments, where this dissertation will examine salutogenic design’s attempt to promote holistic well-being within a medical facility. To place this research in context, Chapter One of this dissertation will provide an overview of healthcare design throughout history, before moving to a thorough grounding in the theory of salutogenic design, and analysing salutogenic design in practice through a case study of The Akershus University Hospital, designed in 2008 by CF Moller in Oslo.13 Modelled on a town, the building embraces salutogenic principles for patients, visitors and employees.14 These impacts will be examined in detail to inform the conclusion of this research.

"Akershus University Hospital (New Ahus)", C.F. Møller, 2020 <https://www.cfmoller.com/p/AkershusUniversity-Hospital-New-Ahus-i269.html> [Accessed 14 October 2020]. 14 "Healthy Buildings, Healthy People", Bulletin Of The World Health Organization, 96.3 (2018), 151-152 .

Chapter One: A History of Healthcare Design Historically, the holistic well-being of patients in healing environments was much more widely recognised than it is in much of today’s modern medical architecture.15 As we saw in the introduction to this dissertation, the degree to which architecture and planning are linked with disease and prevention cannot be understated, and this is certainly a factor worthy of consideration. As a 2016 article in the International Encyclopedia of Public Health notes, until the discovery of germ theory, hospitals were effectively “non-medical institutions…to improve the spirits of patients rather than to impact their physical wellbeing.”16 While these ideas were clearly informed by the medical and cultural awareness of their time, many critics of healthcare design, such as Heathcote and Dilani, argue that hospitals are now more designed for the technology they hold than the patients they treat, and call for a more holistic approach, meaning that the built environment should respond to the patients’ well-being as well as their illness. Looking back at history, the Ancient Egyptians believed that illness and cure were intertwined with spirit, religion and psyche, as well as linked to the community.17 In ancient Greece, the Asclepeion at Epidaurus was a medical centre that included a sanctuary with a guest house and mineral spring as well as a theatre and gardens.18

Edwin Heathcote, "The Architecture Of Health: How Buildings Are Designed For Wellbeing", Ft.Com, 2018 <https://www.ft.com/content/0249c3be-bce0-11e8-8dfd-2f1cbc7ee27c> [Accessed 26 September 2020]. 16 Stella R Quah, International Encyclopedia Of Public Health, 2nd edn (Saint Louis: Elsevier Science, 2016). 17 Edwin Heathcote, "The Architecture Of Health: How Buildings Are Designed For Wellbeing", Ft.Com, 2018 <https://www.ft.com/content/0249c3be-bce0-11e8-8dfd-2f1cbc7ee27c> [Accessed 26 September 2020]. 18 Charles Jencks, The Architecture Of Hope, 1st edn (London: Frances Lincoln Ltd, 2015).

Figure 1: Model of the Asclepeion at Epidaurus

Figure 2: View of the Site today.

During the 19th Century, Florence Nightingale emphasized the importance of environmental elements on human health, taking into account the impact noise, illumination and daylight had on mood.19 Until the early 20th Century, hospital design was still heavily influenced by the ideas of the Enlightenment, with natural surroundings, peaceful environs and clean air still seen as essentials20 (Figures 3-5).

Figure 3: Purkersdorf Sanatorium, 1905

Figure 4: Chapel Hospital at am Steimhof, Otto Wagner, built 1904-1907

Alan Dilani, "Psychosocially Supporative Design - As A Theory And Model To Promote Health (A Letter To Editor)", Journal Of Zankoy Sulaimani - Part A, 10.1 (2007), 165-179 <https://doi.org/10.17656/jzs.10172>. 20 Edwin Heathcote, "The Architecture Of Health: How Buildings Are Designed For Wellbeing", Ft.Com, 2018 <https://www.ft.com/content/0249c3be-bce0-11e8-8dfd-2f1cbc7ee27c> [Accessed 26 September 2020]. 19

Figure 5: London’s Royal Hospital for Neuro-disability is set on extensive grounds allowing views of and access to nature.

However, As Lindstrom points out, the Industrial Revolution and Modernity prioritized mass production and progress over the individual, while simultaneously the cultural image of man was altered by Darwin’s theory of evolution in 1857.21 The view of mankind as an evolved species rather than a creation of God gave power to the idea that humankind could of its own power correct the ills of the world, which was supported at the same time by the growth of industry and mass production.22 Thus, as Giddens (1991) point out, revolutionary machinedriven progress brought with it the capacity for “actions to be taken without considering the effects on the individual.”23 Criticism of the loss of the personal and individual from development, innovation and society were stark, with Durkheim’s idea of anomia, or man being misplaced and isolated within the momentum of development, emerging during this

B. Lindstrom, "Contextualizing Salutogenesis And Antonovsky In Public Health Development", Health Promotion International, 21.3 (2006), 238-244 <https://doi.org/10.1093/heapro/dal016>.

Anthony Giddens, Modernity And Self-Identity (Cambridge: Polity Press, 1991).

B. Lindstrom, "Contextualizing Salutogenesis And Antonovsky In Public Health Development", Health Promotion International, 21.3 (2006), 238-244 <https://doi.org/10.1093/heapro/dal016>.

period.24 As Lindstrom points out, this was one of the reasons offered for the high incidence of suicide at the time.25

Figure 6: Modern medical environments often reflect purely technical needs rather than human needs.

It is important to note that Darwin’s theory of Evolution emerged at the same time as the acceptance of germ theory in the 1860’s, which transformed hospitals into centres of technical innovation rather than places that healed the spirit and promoted the well-being of the ill.26 This understanding of the mechanisms that cause disease and the importance of sterile environments brought radical change, meaning that communicable illnesses became far less lethal, making individuals more likely to die at older ages from non-communicable

illnesses, vastly increasing life-spans and quality of life around the world. As medical advancement continued during this period, competition for the most sophisticated infrastructure and technology led to what Porter and Teisberg term “the medical arms race.”27 As hospitals became more technical and clinical in the race to house the latest medical technology based on a pathogenic model of health, the WHO’s vision for health widened, including the built environment and spiritual well-being in the 1980’s.28 While advancement in medical science offers ever more efficient treatment and better prognoses, proponents of well-being driven design suggest that the hospital of today is built for the machines it houses rather than the people it seeks to heal, resulting in what Heathcote refers to as the “ghettoization of architecture” in hospitals, and a view of health exclusively in terms of the absence of disease.29 As hospitals become ever more focussed on technology to heal disease, there is evidence that environments that consider patient well-being as well as disease treatment actively aid the recovery process. In 1986, a then ground-breaking study by Dr Robert Ulrich found that hospitalised surgery patients whose rooms had a bedside window with a view of nature recovered better than those with a view of a brick wall, healing faster, requiring less medication and having improved relationships with hospital staff.30 In 2005, Dijkstra, Piaterse and Pruyn evaluated 30 peer-reviewed articles to test the impact of environmental interventions, which found, for example, 30.8% faster recovery rate and 38% lower mortality

Michael E Porter and Elizabeth Olmsted Teisberg, Redefining Health Care (Boston, Mass.: Harvard Business School Press, 2006). 28 ibid 29 Edwin Heathcote, "The Architecture Of Health: How Buildings Are Designed For Wellbeing", Ft.Com, 2018 <https://www.ft.com/content/0249c3be-bce0-11e8-8dfd-2f1cbc7ee27c> [Accessed 26 September 2020]. 30 R. Ulrich, "View Through A Window May Influence Recovery From Surgery", Science, 224.4647 (1984), 420421.

among psychiatric patients given sunlit rooms.31 Overall, the study pointed out that only 30 of 1100 peer reviewed journal articles met the criteria to be included in the review, and that more rigorous research was required, but that their study did show that the physical hospital environment does have an impact on patient recovery.32 Further, studies have shown the relationship between blood pressure levels and exposure to natural light, the use of stairs to combat cardiovascular disease, and the impact of spaces on human connections to name just a few.33 There is also evidence that access to nature can enhance coping capacity in patients with diagnoses. Cimprich’s study of women recently diagnosed with breast cancer found that patients randomly assigned to a nature intervention showed substantial improvements “in attentional capacity in the weeks following surgery, compared to those in the nonintervention group.”34 The study made the distinction between two types of attention: “directed attention” and “involuntary attention.”35 The former becomes fatigued with use, causing focus difficulties, distraction and irritability.36 By engaging involuntary attention through access to nature, the neural pathways of directed attention are allowed to rest and recover.37 It is thought that this switching of attention sources that occurs through observing

Karin Dijkstra, Marcel Pieterse and Ad Pruyn, "Physical Environmental Stimuli That Turn Healthcare Facilities Into Healing Environments Through Psychologically Mediated Effects: Systematic Review", Journal Of Advanced Nursing, 56.2 (2006), 166-181. 32 Ibid. 33 Stephen R Kellert, Judith Heerwagen and Martin Mador, Biophilic Design: The Theory Science And Practice Of Bringing Buildings To Life, 1st edn (Hoboken: Wiley, 2008). 34 Bernadine Cimprich and David L. Ronis, "An Environmental Intervention To Restore Attention In Women With Newly Diagnosed Breast Cancer", Cancer Nursing, 26.4 (2003), 284-292. 35 ibid 36 Bernadine Cimprich and David L. Ronis, "An Environmental Intervention To Restore Attention In Women With Newly Diagnosed Breast Cancer", Cancer Nursing, 26.4 (2003), 284-292. 37 ibid

nature “enhances attentional capacity and the ability to cope and manage life's demands, including coping with illness.”38 As Golembiewski points out, research into biological science further supports the idea that our environment directly influences our well-being, showing that many neurotransmitters in the brain react to design.39 Acetylcholine controls balance and many factors associated with comfort, such as touch, warmth and hunger, while light is thought to affect serotonin and related hormones such as melatonin.40 Dopamine has been found to be highly reactive to environmental stimuli, and this neurotransmitter is most closely associated with emotion and the intensity with which one experiences stories.41 It is also closely implicated in mental illness.42 There is also significant evidence that the urban environment itself negatively impacts neurotransmitters in a way that contributes to mental illness, and that one’s mental state impacts healing generally, pointing to the power of design and natural interventions to mitigate this effect. 43

38 39

ibid

Jan A. Golembiewski, "The Designed Environment And How It Affects Brain Morphology And Mental Health", HERD: Health Environments Research & Design Journal, 9.2 (2015), 161-171 <https://doi.org/10.1177/1937586715609562>. 40 ibid 41

ibid ibid 43 ibid 42

Chapter Two: Salutogenic Design Salutogenics was developed as a discipline in the 1970s by Dr Aron Antonovsky, placing focus on health promotion rather than disease prevention.44 Antonovsky sought to answer the question of why some people, in spite of challenges and difficulties, stay healthy and respond constructively to their inability to control their lives, while others do not.45 The central claim of Antonovsky’s work is that how individuals relate to the world around them has an impact on their health, chiefly measured by two factors the researcher called a sense of coherence and general resistance resources46. For Antonovsky, one’s sense of coherence, or the idea that things that happen to an individual make sense to them, is based on manageability, meaningfulness, and comprehensibility47. Manageability is the sense that one has the capacity to deal with a given demand; meaningfulness refers to viewing one’s life events as important or significant; comprehensibility refers to the sense that individuals understand why things are happening48. According to Antonovsky, meaningfulness is the most significant factor and is innately linked to one’s desire to overcome challenges, chiefly found in connectedness, causes and spirituality.49 Thus, the key sources of coherence come from psychological sources, social structural sources, the capacity to deal with practical demands, and cultural-historical sources.50 General resistance factors, on the other hand, refer to personal resources such as

B. Lindstrom, "Contextualizing Salutogenesis And Antonovsky In Public Health Development", Health Promotion International, 21.3 (2006), 238-244 <https://doi.org/10.1093/heapro/dal016>. 45 M. Eriksson and B. Lindstrom, "Antonovsky's Sense Of Coherence Scale And Its Relation With Quality Of Life: A Systematic Review", Journal Of Epidemiology & Community Health, 61.11 (2007), 938-944 <https://doi.org/10.1136/jech.2006.056028>. 46ibid.. 47 Alan Dilani, "Psychosocially Supportive Design - As A Theory And Model To Promote Health (A Letter To Editor)", Journal Of Zankoy Sulaimani - Part A, 10.1 (2007), 165-179 <https://doi.org/10.17656/jzs.10172>. 48 Ibid. 49 Maurice B Mittelmark and others, The Handbook Of Salutogenesis, 1st edn (New York: Springer International Publishing). 50 Aaron Antonovsky, Health, Stress, And Coping (San Francisco: Jossey-Bass Publishers, 1991). 44

financial means, positive self-regard and intellectual ability, which allow people to better cope with challenges.51 Together, these factors reflect one’s general quality of life, which in turn impacts their physical mental and social health. In 1986, at the first International Conference of Health Promotion, the concept of health promotion was formally defined as the enabling of individuals to “increase control over and to improve their health” thus achieving well-being mentally, physically and socially, which reflects a high quality of life.52 Effectively, this requires that people must be able to set and achieve their goals, meet their needs, and cope with the stresses of life with adaptability.53 As Erikson and Lindstrom point out, this definition is highly reflective and reliant on the work of Antonovsky, and his work serves as a framework for supporting this goal. In the 1990’s architect Alan Dilani suggested that these ideas could be applied to architecture, particularly in the healthcare sector, calling for the discipline to not only define stressors and seek to reduce them, but also introduce aspects of design to actively promote health54. He translated Antonovsky’s theory as follows: comprehensibility through wayfinding, nature, perception, landmark, and pleasure; manageability through natural light, green environments, ergonomic design, and interior design; and meaningfulness and social support through activity, music, art, and positive distractions55.

M. Eriksson and B. Lindstrom, "Antonovsky's Sense Of Coherence Scale And Its Relation With Quality Of Life: A Systematic Review", Journal Of Epidemiology & Community Health, 61.11 (2007), 938-944 <https://doi.org/10.1136/jech.2006.056028>. 52 M. Eriksson and B. Lindstrom, "Antonovsky's Sense Of Coherence Scale And Its Relation With Quality Of Life: A Systematic Review", Journal Of Epidemiology & Community Health, 61.11 (2007), 938-944 <https://doi.org/10.1136/jech.2006.056028>. 53 ibid 54 Ellen Ziegler, "Application Of A Salutogenic Design Model To The Architecture Of Low-Income Housing" (University of British Columbia, 2020). 55 Alan Dilani, "Psychosocially Supportive Design - As A Theory And Model To Promote Health (A Letter To Editor)", Journal Of Zankoy Sulaimani - Part A, 10.1 (2007), 165-179 <https://doi.org/10.17656/jzs.10172>. 51

Heerwagen worked from a similar point of view in developing a theory of salutogenic design which relies heavily on the work of Antonovsky.56 She claims that the key characteristics for creating coherence in the built environment are social cohesion through both formal and informal meeting points, individual control over lighting and access to daylight levels, temperature and sound levels, private areas within a space, and restorative and relaxing environments through quiet areas, soft lighting and access to nature and pleasant views of the outside environment.57 Stokols similarly contended that salutogenic environments could be achieved by addressing mental, physical and social needs. In this articulation of the theory, physical health is promoted through ergonomic and non-toxic buildings, while mental health is promoted through individual control over one’s environment and predictability, as well as the introduction of a consistent aesthetic that embraces symbols, nature and spiritual elements, and social health is promoted through access to networks and involvement in the design process58. In each of these articulations of salutogenic design theory, the reader will see the common thread of Antonovsky’s sense of coherence and its various components. As Golembiewski points out, the typical standard for evaluating the effectiveness of architecture, the degree to which it provides functionality and shelter, is particularly important with regard to healthcare, given that hospitals must support patient management, infection control, technology, and clinical procedures.59 However, through this traditional lens, the approach is

Emmanuel Tsekleves and Rachel Cooper, Design For Health, 1st edn (New York: Routledge, 2017). ibid. 58 ibid. 59 Jan A. Golembiewski, "Salutogenic Architecture In Healthcare Settings", The Handbook Of Salutogenesis, 2016, 267-276 <https://doi.org/10.1007/978-3-319-04600-6_26>. 56 57

pathogenic in nature, focussing solely on eliminating disease, without acknowledging the personal stressors of being hospitalised. Golembiewski points out that salutogenic design in healthcare has “the capability to also support enhanced patient manageability, comprehensibility and meaningfulness, and coherence… to help a person through the natural process of recovery.”60 Golembiewski further points out that healthy people in normal circumstances typically have a surplus of resistance resources, or methods of coping with stress, making aesthetic improvements to one’s environment less necessary.61 However, illness, in addition to its obvious impact on health, brings with it additional stressors, making the built environment all the more important. He further points out that the impositions of the built environment are by their nature restrictive. However, improvements in health of patients in hospital can be linked to aesthetic factors, and the psychological rather than the physical, suggesting that salutogenic

design

healthcare

environments

can

enhance

manageability,

comprehensibility, and meaningfulness to create coherence for patients and aid them in healing.62 According to Golembiewski, each of these elements has an important role to play in supporting patient experience and recovery in a hospital setting. The author first notes how the role of patient manageability is essential to hospital design, but that this factor is often centralised for the convenience of healthcare staff in traditional hospital design, effectively removing that aspect of coherence from patients themselves and thus disempowering them63

ibid. ibid. 62 ibid. 60 61

Jan A. Golembiewski, "Salutogenic Architecture In Healthcare Settings", The Handbook Of Salutogenesis, 2016, 267-276 <https://doi.org/10.1007/978-3-319-04600-6_26>.

(Figure 7). To counter this phenomenon, salutogenic design looks to create alternative and discrete ways for patients to be monitored by implementing informal areas where nurses can monitor their units (Figure 8).

Figure 7: Conventional ward design centralises monitoring stations.

Figure 8: This model provided by Golembiewski provides an alternative to the staff stations seen in traditional medical environments, allowing patients to monitored discreetly.

Regarding comprehensibility, the author points out that medical environments often leave information in the hands of experts while patients encounter a state of not knowing what is happening or when64. Intuitive wayfinding is an essential part of comprehensibility in medical environments, which allows patients to “help themselves” inasmuch as they are able by having a basic understanding of their place within the hospital environment and how to navigate it.65 This is extended by salutogenic architectural principles to include outdoor views, outdoor spaces, street patterns in architectural layouts, and distinctive landmarks and sculptures within the buildings.66

64 65

ibid. ibid.

Jan A. Golembiewski, "Salutogenic Architecture In Healthcare Settings", The Handbook Of Salutogenesis, 2016, 267-276 <https://doi.org/10.1007/978-3-319-04600-6_26>.

Figure 9: The lobby of Lady Cilento Children’s hospital in Queensland uses colour, sculpture and lighting as well as open views to enhance patient and visitor comprehensibility

The second contributing factor to comprehensibility is meaning, which, as Golembiewski observes, is not an emotion typically found in hospital settings67, where confusion, fear and uncertainty are common. Isolation from the things that often give one’s life meaning – such as religious services, family, home, cooking and pets – is in fact standard in hospitals. However, as the researcher points out, salutogenic design principles can help to bolster a sense of meaningfulness in myriad ways.

ibid.

At Khoo Teck Puat Hospital, there are lush planted areas in public areas designed to attract wildlife, as well as a butterfly registry.68 At the Royal Children’s Hospital, a meerkat enclosure has been installed to engage patients and visitors.69

Figure 10: Khoo Teck Puat Hospital in Singapore has vast planted areas which are visible from patient rooms and attract nature.

Wilicannia Hospital in Australia serves an indigenous tribal population, and offers patient rooms on its ground floor with expansive patios looking out on the natural landscape and allowing visits from one’s tribe70, reflecting the values of the tribal indigenous culture the hospital serves. Similarly, the community was involved in the design of the facility, which is reflected throughout, and thus connects visitors and patients to the culture and community it resides within71. The newly built annex follows the curve of the Darling River which is on the property, with outdoor spaces between buildings created as landscaped “rooms”.72

Jan A. Golembiewski, "Salutogenic Architecture In Healthcare Settings", The Handbook Of Salutogenesis, 2016, 267-276 <https://doi.org/10.1007/978-3-319-04600-6_26>. 69 ibid.. 70 Governmentarchitect.Nsw.Gov.Au, 2020 <https://www.governmentarchitect.nsw.gov.au/resources/ga/media/files/ga/case-studies/case-study-wilcanniahealth-service-2020-06-04.pdf?la=en> [Accessed 14 October 2020]. 71 Governmentarchitect.Nsw.Gov.Au, 2020 <https://www.governmentarchitect.nsw.gov.au/resources/ga/media/files/ga/case-studies/case-study-wilcanniahealth-service-2020-06-04.pdf?la=en> [Accessed 14 October 2020]. 72 ibid. 68

Courtyards integrate mature trees and invite visitors and patients into the external landscape, with outdoor spaces given as much importance and indoor spaces73.

Figure 11: Wilicannia Hospital in Australia’s architecture follows the curve of the Darling River and its verandas allow for large numbers of visitors from the local tribe.

Figure 12: Wilicannia Hospital’s site was configured to incorporate mature trees that existed on the site, as well as community input, which is reflected in this installation (right).

ibid.

As we can see from these examples, salutogenic design offers several interventions to confer a sense of coherence by injecting comprehensibility, manageability, and meaning into healthcare settings, which can have a significant impact in supporting patients in recovery and contribute to mental, social and physical health. To understand these concepts more thoroughly, Chapter Three will engage in a case study of one of the leading examples of salutogenic design, Oslo’s Akershus Hospital, designed by CF Moller Architects.

Chapter Three: Case Study Analysis of Akershus Hospital, Oslo

Figure 13: Akershus Hospital is the largest hospital in Norway, and was designed around salutogenic principles by architects CF Moller.

Oslo’s Akershus Hospital was designed by CF Moller Architects, a firm which specialises in salutogenic healthcare buildings, between 2008-2015.74 The project spanned such a long period of time because it comprised two phases, a reconfiguration of existing facilities as well as new structures. The facility was designed to replace a smaller hospital to better serve the population of Oslo. The hospital combines salutogenic principles with green design to create a building that not only fosters well-being and health in its inhabitants, but protects and conserves the environment as well. 85% of the building’s

"Akershus University Hospital (New Ahus)", C.F. Møller, 2020 <https://www.cfmoller.com/p/AkershusUniversity-Hospital-New-Ahus-i269.html> [Accessed 14 October 2020].

heating and over 40% of the total energy is generated from renewable geo-thermal energy.75 The firm’s website acknowledges the project’s human-centred perspective, commenting that “The Akershus University Hospital is not a traditional institution building; it is a friendly, informal place with open and comprehensible surroundings oriented towards the patients and their relatives,” referencing the central tenet of Antonovsky’s theory of salutogenics, which the firm sought to achieve through wayfinding, daylighting and access to landscape.76 To understand salutogenic design more thoroughly in practice, we will now review the ways in which this project reflects Antonovky’s concept of coherence, through the mechanisms of comprehensibility, manageability and meaning. Beginning with the site plan (Figure 14), which comprises 137,000 square meters,77 one can see salutogenic principals at work.

Figure 14: Akershus Hospital is surrounded by a park-like setting in spite of its location in Oslo, giving patients and visitors access to natural surroundings.

Peters, Terri, "Design For Health: Sustainable Approaches To Therapeutic Architecture [Special Issue]", Architectural Design, 87 (2017)

76 77

ibid.

"Akershus University Hospital (New Ahus)", C.F. Møller, 2020 <https://www.cfmoller.com/p/AkershusUniversity-Hospital-New-Ahus-i269.html> [Accessed 14 October 2020].

We will focus our attention to the winged design of the complex, highlighted in red (Figure 14). This configuration of the building serves several salutogenic purposes which contribute the sense of coherence experienced by patients. What is noticeable firstly is the amount of green space and access to nature apparent on the site. However, particular attention has also been given to the organisation of space and their orientation. The model shown in Figure 15 shows the level of attention to detail regarding separation of functions, with wards, treatment rooms, emergency treatments, and youth patients given separate areas in the hospital.

Figure 15: Akershus Hospital is organised along an atrium that runs from the glass gate entrance to the back of the building, dividing the functions of the hospital.

Figures 16 and 17 further show that this separation is achieved through a glass atrium extending from the main entrance to the building throughout the facility, shown highlighted by the orange line in Figure 15. As we will see through the analysis to follow, the atrium serves several salutogenic purposes. Seeing the execution of this design choice in figure 16 and 17 will serve as the starting point of this discussion.

Figure 16: Akershus Hospital’s winged design and atrium is integrated into the building’s entrance.

Figure 17: Akershus Hospital’s atrium fills the centre of the hospital with light, and is the central organising principle of the design.

Figures 17 and 18 show the atrium’s prominent position within the building, serving not only to divide hospital functions, but also to flood the central path through the hospital with light and a recognisable wayfinding method through the architectural language of the building, conveying manageability to patients and visitors. However, it is not only that the atrium makes the central thoroughfare of the building easier to recognise in and of itself, contributing to comprehensibility through wayfinding. This organisation has several other features that contribute to a coherent experience overall, through daylighting and the breaking up of a rational medical complex into small patient-centred wings, control over one’s environment through spatial division, access to nature and views of green spaces, a street-like layout and spaces for community use. Each of these will now be addressed separately.

Daylighting

As we have seen in the images above, the central atrium (highlighted in red in Figure 18) is the chief organising principle of Akershus Hospital. However, it is not just the atrium itself, but also the building’s orientation that contributes to its salutogenic properties. The atrium is oriented on the north/south axis, while the patient wings are oriented on the east/west axis78. This orientation means that the southern façade receives sunlight at a steep angle, making it easier to control, while the inpatient wards receive sunlight in the afternoon. The building is also largely naturally ventilated, with patients being able to open their windows as well, which contributes to access to nature and control over one’s

"Akershus University Hospital (New Ahus)", C.F. Møller, 2020 <https://www.cfmoller.com/p/AkershusUniversity-Hospital-New-Ahus-i269.html> [Accessed 14 October 2020].

environment, contributing to meaningfulness and manageability respectively, as we see in Figure 19.

Figure 18: Akershus Hospital’s atrium fills the centre of the hospital with light, and is the central organising principle of the design.

All patient rooms also have views of the natural surroundings given the building’s orientation which again contributes to a sense of meaningfulness.

Figure 19: Akershus Hospital’s patient rooms have large windows that open, and every room has a view to the campus’s natural surroundings, as seen in this image from CF Moller Architects.

Spatial Division Another significant salutogenic effect of the building’s dividing atrium is the extent to which it breaks the traditional rational and immense hospital space into smaller, more easily navigatable areas. As Peters points out, while patients, families, staff and visitors are in fact existing in a highly technical and vast environment, their experiences are moderated by the fact that at Akershus Hospital, each area feels distinct, small and manageable. Looking again at the model below (Figure 20), we can see that the narrow wards are distinct from one another, allowing nurses and staff to discretely monitor small areas, while the treatment facilities are on the other side of the atrium, providing a greater sense of peace and separation to patients when in their rooms, as well as a sense of belonging and recognition in their ward. Indeed, a head nurse at the hospital referred to the firm’s decision to place the neo-natal ward on the top floor, saying, “When you give birth and something goes wrong, it can be very stressful. There are bedrooms and a shared living room for the parents, who may stay for days, even weeks.”79

Figure 20: Akershus Hospital is organised along an atrium that runs from the glass gate entrance to the back of the building, dividing the functions of the hospital.

"Healthy Buildings, Healthy People", Bulletin Of The World Health Organization, 96.3 (2018), 151-152 <https://doi.org/10.2471/blt.18.020318>.

Access to Nature As we have discussed previously, the orientation of the site maximises access to nature for all patient areas. This includes views, ventilation and the use of materials. Looking again at the model above, we can see that each area of the hospital has direct access to views of lush landscaping, courtyards, and green spaces. This creation of enclosed green spaces throughout a large complex helps to address anxieties and recognise the individual in the hospital experience. This can be seen in the site plan shown in Figure 21.

Figure 21: Akershus Hospital’s design breaks departments and outdoor spaces into smaller more personal areas, all distinct from each other.

Looking at this site plan, we can see that each area of the hospital, whether the entrance, wards, treatment facilities, children’s area or the emergency department, has 30

access to courtyards of green space and landscaping. This not only provides access to natural views wherever one is in the hospital, it also effectively scales the view for the individual, giving a patient the sense that they are in a small personal space both inside and out rather than a vast hospital complex. As we see in Figure 22, natural materials used in the hospital’s construction also help it to reflect the natural landscape surrounding it.

Figure 22: Akershus Hospital’s design provides smaller courtyards within its vast landscape, making the scale of internal and external spaces more personal.

Figure 23: The site itself is constructed with natural materials including wood and glass, extending the connection to the planted grounds which include mature trees and seasonal plantings.

Thus, Akershus Hospital connects patients and visitors to nature in every way possible, from the glass-roofed atrium that divides the building, to the lush landscape divided into smaller spaces, and through the natural materials seen throughout the site, all of which diminish the sense of the building as a vast and sterile environment and put the individual and their needs first. Street-Like Layout & Community Use One of the most significant salutogenic concepts articulated in the design of Akershus Hospital is its street-like design, with the central atrium effectively functioning as a town high street. This not only aids in way-finding and spatial division, as discussed previously; it also engenders a sense of familiarity and normality which is often missing in sterile medical environments. Within the glass-roofed atrium, referred to within the hospital as the promenade, there is a centre devoted to community learning about health issues like obesity and diabetes, in addition to the kinds of shops one would find in the centre of town, such as 32

a florist, hair dresser, pharmacy, coffee shop and wig seller.80 Speaking of this intentional design choice, the principal architect on the project, Dahle, commented, “The hospital is a bit like a town with squares and meeting points.”81

Figure 24: Akershus Hospital’s central atrium or promenade functions much a like a neighbourhood high street, with community resources and shops.

This idea of the atrium or promenade functioning as a high street is also reflected in the connection the space has to the outside and natural light and ventilation, making it resemble a stroll down a local street more than a walk through a hospital’s main corridor. Responding to this, Dahle said that the style of the hospital was one of “inside out and outside in” through “abundant fresh air, the use of natural materials inside and the ability to see nature outside” which all help “create a healing environment” in the hospital.82

"Healthy Buildings, Healthy People", Bulletin Of The World Health Organization, 96.3 (2018), 151-152 <https://doi.org/10.2471/blt.18.020318>.

ibid.

"Healthy Buildings, Healthy People", Bulletin Of The World Health Organization, 96.3 (2018), 151-152 <https://doi.org/10.2471/blt.18.020318>.

The larger community of Oslo was also an essential part of the salutogenic design of the hospital, as part of the goal of changing the hospital environment from a reactive one, where it is a place people only visit as a response to illness or crisis, to a proactive one, where people may visit it proactively to learn, exercise or meet.83 Accordingly, CF Moller integrated spaces for fitness, rehabilitation, and learning for children and adults.84 These spaces effectively serve two purposes in addressing the association of healthcare buildings with isolation and illness. With regard to patients and families, the hospital is seen as a place where community gathers and “normal life” goes on around them. Regarding the community at large, the hospital becomes a destination for wellness and exists within the city of Oslo outside of the crisis of illness. However, the idea of community engagement began with the design of the hospital and one if its key user groups: the staff, doctors and patient and community groups.85 The project’s principle architect Dahle reflected on the firm’s close working relationship with user groups to develop a design concept and plan which would reflect the “needs and values” of the people most closely connected to the project, commenting that, “…working with them on the concept gave the users a sense of ownership and the feeling that it’s their hospital.”86

Terri Peters, "Design For Health: Sustainable Approaches To Therapeutic Architecture [Special Issue]", Architectural Design, 87.2 (2017). 84 ibid. 85 "Healthy Buildings, Healthy People", Bulletin Of The World Health Organization, 96.3 (2018), 151-152 <https://doi.org/10.2471/blt.18.020318>. 83

ibid.

Key Findings As we learned earlier, project architects CF Moller translated their salutogenic goals through three key mechanisms: wayfinding, daylighting and access to landscape.87 Each of these in turn correspond to Dilani’s translation of Antonovky’s theories as comprehensibility through wayfinding, nature, perception, landmark, and pleasure; manageability through natural light, green environments, ergonomic design, and interior design; and meaningfulness and social support through activity, music, art, and positive distractions. We will now summarise each one of these separately as it relates to Akershus Hospital. Comprehensibility Comprehensibility is achieved at Akershus Hospital most prominently by the orientation of the building’s atrium, which mimics the feeling of a high street. Not only is the area immediately recognisable as the building’s centre and thus a landmarking device, it is deeply connected to nature with views of the landscape, natural light, and fresh air. The use of glass and natural woods in the space’s materiality also allow it to blend with the natural environs outside. This provides easy wayfinding, nature, the perception or recognition of the space as recalling a local street, and the pleasure of familiarity. This thread is carried through with the scaling of the building’s wards and wings, which divide what could be a vast medical maze into small easy to navigate areas with scaled courtyards offering views of nature.

Terri Peters, "Design For Health: Sustainable Approaches To Therapeutic Architecture [Special Issue]", Architectural Design, 87.2 (2017).

Figure 25: Akershus Hospital creates a sense of comprehensibility through its easily navigatable townlike layout, access to nature, and sense of pleasure through natural materials.

Manageability Dilani translated manageability as access to natural light, green environments, ergonomic design, and interior design, all of which can be clearly seen at Akershus Hospital. This is reflected in all choices regarding the planning and design of the hospital, from the access to natural light in the atrium as well in all rooms of the hospital, to the views accessible from all areas, and the choice of natural materials to reflect the outside environment within. This is further reflected in the nurse’s statement cited previously in this dissertation that living spaces and common areas were available in the neo-natal ward, to reflect a home-like feeling.

Figure 26: Interior design choices and access to nature contribute to manageability at Akershus Hospital.

Meaningfulness Meaningfulness is considered by Antonovsky to be the key driver of coherence, as we learned earlier in this dissertation. It is evidenced at Akershus Hospital through several key features. The division of the separate wards and departments to more individual scales gives the patient a sense of belonging, while the connection to the outside environment yields a spiritual dimension. Meaningfulness is also articulated through the sense of connection to place, the engagement with stakeholders that was part of the design process and the community activities the hospital hosts, forging a connection with its wider area beyond illness. The street-like arrangement of the areas of the hospital also forges small communities out of wards with social interactions encouraged through designated areas. Considerations and Critique Through this case study of Akershus Hospital, we have seen one example of how salutogenic principals and design can be interpreted in the built environment. While perhaps not comprehensive in its iteration of salutogenic design principles, comments from both staff and the project’s architects clearly show that the design mission was to integrate patient, family and staff well-being into a modern medical environment through translating Antonovsky’s theory of salutogenics into bricks and mortar. There have not yet been studies on the degree to which the hospital’s design impacts recovery and patient experience, which presents an obvious lacuna in this dissertation. Indeed, the design and implementation of studies into the effectiveness of salutogenic design is an area that presents significant methodological difficulties due to the holistic nature of the intended effects and the multi-disciplinary origins of the theories on which it is based. Further, the project was only completed in 2015, so any findings could only be preliminary at this stage.

The research gap regarding the effectiveness of salutogenic architecture becomes all the more stark when one considers that the hospital cost over 1 billion euros to build and took seven years to complete.88 With a capacity to treat over 50,000 patients and hosting 4,600 staff members,89 its focus on scale and comprehensibility seems all the more pertinent, as features such as the atrium, courtyards and street-like placement of kiosjs and community resources help to create manageable spaces out of a vast and complex environment. However, if it is to become a beacon for reform in medical architecture, and salutigenic design is to gain popularity, the impacts and effects if its implementation must be measurable to be meaningful when compared with balance sheets in boardrooms. The supporting literature and academic study into salutogenic design’s impacts seem to rely heavily on the truisms of design – certainly thoughtfully designed architecture feels better, but whether it helps people get better is hardly conclusively proven, and as noted earlier, the studies which exist are often too small to be broadly applicable. While rooted in Antonovsky’s academic work on health and resilience, more rigorous explorations and evaluations are required to establish an objective framework for evaluation. During my research, it became clear that no quantitative or qualitative studies which conclusively compare outcomes between well-being driven architecture and its pathogenically-based counterparts were found, presenting an obvious weakness in the research. Particularly, it would be interesting to compare medical outcomes as well as

"Akershus University Hospital, Oslo", Artigo, 2021 <https://www.artigo.com/en/portfolio/akershusuniversity-hospital-oslonorway/#:~:text=Akershus%20University%20Hospital%20%E2%80%93%20Oslo%2C%20Norvegia,University%20hospital%20surfacing&text=The%20complex%20that%20covers%20a,M%C3%B8ller% 20.> [Accessed 25 January 2021]. 89 ibid

surveys of patients’ experiences regarding factors such as stress, recovery and rest with those of a more conventionally designed medical environment. This might allow a more comprehensive understanding of both the capacity of salutogenic design to speed recovery, a thus far thinly-supported but often repeated claim, as well as to impact Antonovsky’s sense of coherence in real terms.

Chapter Four: Conclusions and Looking Forward This dissertation began with the central research question of how the principles of salutogenic design are articulated in healthcare environments. To place this discussion in context, we looked at the significant distance health architecture has travelled away from the holistic individual throughout history, and how this change has kept pace with cultural, medical and technical advancement. This revealed the finding that medical architecture was and remains closely linked with cultural ideals of its time as well as the medical knowledge available, with ideas of the Enlightenment being dismissed in favour of the power of production over problems with the advent of Darwin’s theory of evolution and the development of germ theory as well as the Industrial Revolution. This led to the pathogenic understanding of health and an architectural point of view which responded to disease rather than wellness, which still dominates today, perhaps displacing the well-being of the individual in favour of a singular focus on the absence of disease. This has been the prevailing force driving modern medicine and hospital design forward for over a century. While treatments and technologies have improved vastly and yielded exponential improvements in life expectancy, our research has shown that the perspective of these advancements is still directed exclusively at treating illness rather than promoting health in all its various aspects. However, we now live in a time when, while the standards set by a pathogenic model of health, such as sterile environments and technical advancements, should certainly be maintained and continue to be a focus, our greatest threats to health are now from chronic conditions that stem from modern lifestyles and in many cases are linked to psycho-social issues such as stress, depression and lack of activity. If the reactive relationship between public health issues and the architecture of health are to

continue as they have through the centuries, it seems likely that a movement to a more holistic view of healthcare and its architecture is imminent. Salutogenic design is only one of many theories of how architecture can support and impact health and well-being. Rooted in Antonovsky’s social science theory, it suggests that health promotion is as important as disease prevention, looking instead at how to maintain and promote health and well-being, beginning from a consideration of health rather than a responsiveness to disease, and taking into account psycho-social factors to understand wellbeing. It is interesting to note that the WHO’s definition of health took a similar holistic stance in 1948, expressing clearly that health was more than the absence of disease and encompassed other aspects of personal experience, while medical architecture became ever more focussed on the former. By 1989, when the WHO expanded the definition again, to include the built environment and spirituality, the “medical arms race” was in full swing, moving the architecture of health further away from a holistic view. While the historical development of medical architecture can be traced in line with existing medical knowledge, particularly regarding the development of germ theory, this writer notes that perhaps such a singular focus on pathogens is outdated today, as many of the healthcare crises in modern times are linked to lifestyle choices and mental health. If health is to be seen as more than the absence of disease, then healthcare and the buildings which house it should, it seems, hold more than the means to treat illness, and embrace a broader understanding of what it is to be healthy as well. This points to the interesting question of what events and knowledge gave rise to salutogenic design in the 1990’s as well as the other schools of well-being driven design, which would be an interesting point for further study.

Salutogenic design offers an alternative which more closely aligns with the dimensions of the WHO’s definition of health. Through examples and our case study, Akershus Hospital, we saw these theories effectively put into practice by leading architects seeking to place the patient back at the centre of the healing experience, effectively balancing the technological needs of medical care with the holistic needs of the patient, postulating that stress reduction through architecture has a positive impact on patient experience. Uniquely, each of the projects profiled in this dissertation responded to their particular environment and the patients they helped, whether children, tribal populations, or a busy metropolitan constituency, pointing out just how important it is to reflect the particular environment and population at hand. While the effects of salutogenic design and other branches of well-being driven architecture need more study for their impacts to be fully understood, the multi-disciplinary nature of salutogenics and its cohorts (encompassing psychology, the social sciences, planning, and architecture) make such reviews complex, and this is an obvious difficulty in quantitatively evaluating their effectiveness. This is a weakness a more pathogenic model does not suffer from simply because the number of patients cured of an illness is far easier to count than the psycho-social and medical effects of well-being driven architecture. Perhaps it goes without saying that the former of these two is far easier to monetise, and justify expenditure towards as well. This will remain a complication in advancing salutogenic design in mainstream medical design until a singular framework for its evaluation can be developed, perhaps pointing to the inherent difficulty of applying a theory of social science to the world of architecture.

However, as we look to the future of healthcare architecture, it is clear that the pathogenic model of hospital design may be incomplete in its capacity to respond to the chronic diseases of today. Just as the advent of sterile surfaces followed medical knowledge of their time and improved patient outcomes exponentially when communicable diseases were the world’s greatest health risk, our healthcare environments of today should continue to reflect our healthcare concerns and our knowledge about factors which reduce the threat of chronic diseases, such as stress reduction, the impact of mental health, and the benefits of exercise, just to name a few. If medical architecture is to continue to respond to the dominant health concerns of the day, a shift from a purely pathogenic foundation to one which also encompasses the role psychology and prevention play in the prevention of the chronic illnesses which are now the fastest growing causes of mortality seems appropriate. Just as the WHO’s definition of health has not remained stagnant, but has adapted with growing understanding, salutogenic design provides one framework of many to create healthier buildings and in turn healthier people. Recognising the psycho-social aspects of illness, as well as the capacity of the built environment to help ameliorate the causes of chronic disease provides an opportunity to impact not just patient experience but also public health in general over the longer term, as hospitals like Akershus seek to have a presence in their community outside of treating health concerns through publicly accessible education programmes. By designing a hospital as a community wellness resource, in an architectural environment that challenges the common notions of what hospitals feel like to visit, medical centres like Akershus have the potential to create healthier populations overall as well as treat patients who are ill. This places the whole community, not just patients in urgent medical situations, at the centre of the healthcare paradigm, representing a transition in what hospitals do as well as how they feel to visit. 43

According to the architects who designed the hospital, Akershus was designed through a salutogenic framework to put human experience at the centre of the and the hospital experience while also offering an exceptional standard of medical care. While these impacts are difficult to quantify, one can imagine that this lacuna may close as chronic diseases take on ever greater urgency in the healthcare landscape. While data is scant today, salutogenic design and Akershus itself offer a clear message of the capacity of the design and build industry to bring together medical progress and personal experience, creating spaces which not only render a better experience for users, but also foster the sense of place and identity that leads to a greater sense of care for architecture and the environment as a whole. These factors may aid healing and provide better medical outcomes. Today, salutogenic design is becoming more widely recognised, perhaps matching pace with our current understanding of issues such as the impacts of mental health and well-being. This writer hopes this area of healthcare design will continue to grow, creating a landscape of buildings that respond to health and help to foster it, rather than simply treat disease.

Bibliography Governmentarchitect.Nsw.Gov.Au, 2020 <https://www.governmentarchitect.nsw.gov.au/resources/ga/media/files/ga/casestudies/case-study-wilcannia-health-service-2020-06-04.pdf?la=en> [Accessed 14 October 2020] "Akershus University Hospital (New Ahus)", C.F. Møller, 2020 <https://www.cfmoller.com/p/Akershus-University-Hospital-New-Ahus-i269.html> [Accessed 14 October 2020] "Akershus University Hospital, Oslo", Artigo, 2021 <https://www.artigo.com/en/portfolio/akershus-university-hospital-oslonorway/#:~:text=Akershus%20University%20Hospital%20%E2%80%93%20Oslo%2C%20Norv egia,University%20hospital%20surfacing&text=The%20complex%20that%20covers%20a,M%C3% B8ller%20.> [Accessed 25 January 2021] Antonovsky, Aaron, Health, Stress, And Coping (San Francisco: Jossey-Bass Publishers, 1991) Carrington, Damian, "Two-Hour ‘Dose’ Of Nature Significantly Boosts Health – Study", The Guardian, 2020 <https://www.theguardian.com/environment/2019/jun/13/two-hour-dosenature-weekly-boosts-health-study-finds> [Accessed 21 April 2020] Cimprich, Bernadine, and David L. Ronis, "An Environmental Intervention To Restore Attention In Women With Newly Diagnosed Breast Cancer", Cancer Nursing, 26 (2003), 284292 <https://doi.org/10.1097/00002820-200308000-00005> "Constitution", Who.Int, 2020 <https://www.who.int/about/who-we-are/constitution> [Accessed 23 April 2020] Dijkstra, Karin, Marcel Pieterse, and Ad Pruyn, "Physical Environmental Stimuli That Turn Healthcare Facilities Into Healing Environments Through Psychologically Mediated Effects:

Systematic Review", Journal Of Advanced Nursing, 56 (2006), 166-181 <https://doi.org/10.1111/j.1365-2648.2006.03990.x> Dilani, Alan, "Psychosocially Supporative Design - As A Theory And Model To Promote Health (A Letter To Editor)", Journal Of Zankoy Sulaimani - Part A, 10 (2007), 165-179 <https://doi.org/10.17656/jzs.10172> Eriksson, M., and B. Lindstrom, "Antonovsky's Sense Of Coherence Scale And Its Relation With Quality Of Life: A Systematic Review", Journal Of Epidemiology & Community Health, 61 (2007), 938-944 <https://doi.org/10.1136/jech.2006.056028> Fries, Christopher J., "Healing Health Care: From Sick Care Towards Salutogenic Healing Systems", Social Theory & Health, 18 (2019), 16-32 <https://doi.org/10.1057/s41285-01900103-2> Giddens, Anthony, Modernity And Self-Identity (Cambridge: Polity Press, 1991) Golembiewski, Jan A., "Salutogenic Architecture In Healthcare Settings", The Handbook Of Salutogenesis, 2016, 267-276 <https://doi.org/10.1007/978-3-319-04600-6_26> Golembiewski, Jan A., "The Designed Environment And How It Affects Brain Morphology And Mental Health", HERD: Health Environments Research & Design Journal, 9 (2015), 161171 <https://doi.org/10.1177/1937586715609562> Golembiewski, Jan, "Salutogenic Design: The Neural Basis For Health Promoting Environments", World Health Design Scientific Review, 5 (2012), 62-68. <https://www.researchgate.net/publication/255971085_Salutogenic_design_The_neural_b asis_for_health_promoting_environments/citation/download> [Accessed 23 April 2020] "Healthy Buildings, Healthy People", Bulletin Of The World Health Organization, 96 (2018), 151-152 <https://doi.org/10.2471/blt.18.020318>

Heathcote, Edwin, "The Architecture Of Health: How Buildings Are Designed For Wellbeing", Ft.Com, 2018 <https://www.ft.com/content/0249c3be-bce0-11e8-8dfd-2f1cbc7ee27c> [Accessed 26 September 2020] Heerwagen, Judith, Stephen R Kellert, and Martin Mador, Biophilic Design (Hoboken, N.J.: Wiley, 2013) Jencks, Charles, The Architecture Of Hope, 1st edn (London: Frances Lincoln Ltd, 2015) Kellert, Stephen R, and Edward O Wilson, The Biophilia Hypothesis, 1st edn (Washington, DC: Island Press, 2013) Kellert, Stephen R, Judith Heerwagen, and Martin Mador, Biophilic Design: The Theory Science And Practice Of Bringing Buildings To Life, 1st edn (Hoboken: Wiley, 2008) Kellert, Stephen, "Beyond LEED: From Low Environmental Impact To Restorative Environmental Design", in Greening Rooftops For Sustainable Communities Conference (Portland Oregon: Greening Rooftops for Sustainable Communities Conference, 2004) <http://www.selba.org/GEDSEsp/Ecologica/EnfoqueSistemico/kellert-2004.pdf> [Accessed 27 April 2020] Lawson, L., "Restorative Commons: Creating Health And Well-Being Through Urban Landscape", Ecological Restoration, 30 (2012), 244-245 <https://doi.org/10.3368/er.30.3.244> Lindstrom, B., "Contextualizing Salutogenesis And Antonovsky In Public Health Development", Health Promotion International, 21 (2006), 238-244 <https://doi.org/10.1093/heapro/dal016> Mittelmark, Maurice B, Shifra Sagy, Monica Eriksson, Georg F Bauer, Jürgen M Pelikan, and Bengt Lindström and others, The Handbook Of Salutogenesis, 1st edn (New York: Springer International Publishing)

Perdue, Wendy Collins, Lesley A. Stone, and Lawrence O. Gostin, "The Built Environment And Its Relationship To The Public’S Health: The Legal Framework", American Journal Of Public Health, 93 (2003), 1390-1394 <https://doi.org/10.2105/ajph.93.9.1390> Peters, Terri, "Design For Health: Sustainable Approaches To Therapeutic Architecture [Special Issue]", Architectural Design, 87 (2017) Petrie, Keith J, Borge Sivertsen, Mari Hysing, Elizabeth Broadbent, Rona Moss-Morris, and Hege R Eriksen and others, "Thoroughly Modern Worries", Journal Of Psychosomatic Research, 51 (2001), 395-401 <https://doi.org/10.1016/s0022-3999(01)00219-7> Pinter-Wollman, Noa, Andrea Jelić, and Nancy M. Wells, "The Impact Of The Built Environment On Health Behaviours And Disease Transmission In Social Systems", Philosophical Transactions Of The Royal Society B: Biological Sciences, 373 (2018), 20170245 <https://doi.org/10.1098/rstb.2017.0245> Porter, Michael E, and Elizabeth Olmsted Teisberg, Redefining Health Care (Boston, Mass.: Harvard Business School Press, 2006) Quah, Stella R, International Encyclopedia Of Public Health, 2nd edn (Saint Louis: Elsevier Science, 2016) Satorius, Norman, "The Meanings Of Health And Its Promotion", Croation Medical Journal, 47 (2006), 662-664 Tsekleves, Emmanuel, and Rachel Cooper, Design For Health, 1st edn (New York: Routledge, 2017) Ulrich, R., "View Through A Window May Influence Recovery From Surgery", Science, 224 (1984), 420-421 <https://doi.org/10.1126/science.6143402> Ulrich, Roger, Biophilia, Biophobia And Natural Landscapes, 1st edn (Washington DC: Island Press, 1993), pp. 73-137

Valizadeh, Leila, Madineh Jasemi, Vahid Zamanzadeh, and Brian Keogh, "A Concept Analysis Of Holistic Care By Hybrid Model", Indian Journal Of Palliative Care, 23 (2017), 71 <https://doi.org/10.4103/0973-1075.197960> Wilson, Edward O, Biophilia, 2nd edn (Cambridge, Mass.: Harvard Univ. Press, 2003) Ziegler, Ellen, "Application Of A Salutogenic Design Model To The Architecture Of LowIncome Housing" (University of British Columbia, 2020)

Image Citations Figure 1: Model Of The Asklepion At Epidaurus, 2020 <https://collection.sciencemuseumgroup.org.uk/objects/co83272/model-of-the-asklepionat-epidaurus-greece-1936-model> [Accessed 14 October 2020] Figure 2: View From The Site Today, 2020 <http://www.visitgreece.gr/en/culture/archaeological_sites/sanctuary_of_asklepios_at_epi daurus> [Accessed 14 October 2020] Figure 3: Purkersdorf Sanatorium, 1905, 2020 <https://www.ft.com/content/0249c3bebce0-11e8-8dfd-2f1cbc7ee27c> [Accessed 14 October 2020] Figure 4: Chapel Hospital At Am Steimhof, Otto Wagner, Built 1904-1907, 2020 <https://www.ft.com/content/0249c3be-bce0-11e8-8dfd-2f1cbc7ee27c> [Accessed 14 October 2020] Figure 5: London’S Royal Hospital For Neurodisability Is Set On Extensive Grounds Allowing Views Of And Access To Nature., 2020 <https://www.rhn.org.uk/> [Accessed 14 October 2020] Figure 6: Modern Medical Environments Often Reflect Purely Technical Needs Rather Than Human Needs., 2020 <https://healthcaresnapshots.com/projects/2756/st-andrews-hospitalclinical-development/> [Accessed 14 October 2020] Figure 7: Tradition Ward Design, 2019.< https://www.researchgate.net/figure/The-generallayout-of-the-inpatient-ward_fig1_282457720> [Accessed 14 October 2019]. Figure 8: This Model Provided By Golembiewski Provides An Alternative To The Staff Stations Seen In Traditional Medical Environments, Allowing Patients To Monitored Discreetly., 2020 <https://www.researchgate.net/publication/307513474_Salutogenic_Architecture_in_Healt hcare_Settings> [Accessed 14 October 2020] Figure 9: The Lobby Of Lady Cilento Children’S Hospital, 2020 <https://www.arts.qld.gov.au/aq-blog/health-and-wellbeing/the-healing-power-of-artsand-health> [Accessed 14 October 2020]

Figure 10: Khoo Teck Puat Hospital In Singapore Has Vast Planted Areas, 2020 <. https://earthbound.report/2020/01/31/building-of-the-week-khoo-teck-puat-hospital/> [Accessed 14 October 2020] Figure 11: Wilicannia Hospital In Australia’S Architecture Follows The Curve Of The Darling River, 2020 <https://www.governmentarchitect.nsw.gov.au/resources/ga/media/files/ga/casestudies/case-study-wilcannia-health-service-2020-06-04.pdf?la=en> [Accessed 14 October 2020] Figure 12: Wilicannia Hospital’s Site Incorporates Mature Trees, as Well as Community Input, 2020 <https://www.governmentarchitect.nsw.gov.au/resources/ga/media/files/ga/casestudies/case-study-wilcannia-health-service-2020-06-04.pdf?la=en> [Accessed 14 October 2020] Figure 13: Akershus Exterior Materials, 2020 https://aasarchitecture.com/2015/01/akershus-university-hosptial-c-f-mollerarchitects.html/akershus-university-hosptial-by-c-f-moller-architects-18/ [Accessed 14 October 2020] Figure 14: Akershus Model, 2020 https://tigerprints.clemson.edu/all_theses/1120/ [Accessed 14 October 2020] Figure 15: Akershus Entrance Exterior, 2020 https://aasarchitecture.com/2015/01/akershusuniversity-hosptial-c-f-moller-architects.html/akershus-university-hosptial-by-c-f-mollerarchitects-18/ [Accessed 14 October 2020] Figure 16: Akershus Atrium, 2020 https://aasarchitecture.com/2015/01/akershus-universityhosptial-c-f-moller-architects.html/akershus-university-hosptial-by-c-f-moller-architects-18/ [Accessed 14 October 2020] Figure 17: Akershus Aerial View, 2020 https://tigerprints.clemson.edu/all_theses/1120/ [Accessed 14 October 2020] Figure 18: Akershus Site Plan, 2020 https://aasarchitecture.com/2015/01/akershusuniversity-hosptial-c-f-moller-architects.html/akershus-university-hosptial-by-c-f-mollerarchitects-18/ [Accessed 14 October 2020] 51

Figure 19: Akershus Model, 2020 https://tigerprints.clemson.edu/all_theses/1120/ [Accessed 14 October 2020] Figure 20: Akershus Site Plan, 2020 https://aasarchitecture.com/2015/01/akershusuniversity-hosptial-c-f-moller-architects.html/akershus-university-hosptial-by-c-f-mollerarchitects-18/ [Accessed 14 October 2020] Figure 21: Akershus Courtyards, 2020 https://aasarchitecture.com/2015/01/akershusuniversity-hosptial-c-f-moller-architects.html/akershus-university-hosptial-by-c-f-mollerarchitects-18/ [Accessed 14 October 2020] Figure 22: Site Exterior, 2020 https://aasarchitecture.com/2015/01/akershus-universityhosptial-c-f-moller-architects.html/akershus-university-hosptial-by-c-f-moller-architects-18/ [Accessed 14 October 2020] Figure 23: Comprehensibility, 2020 https://aasarchitecture.com/2015/01/akershusuniversity-hosptial-c-f-moller-architects.html/akershus-university-hosptial-by-c-f-mollerarchitects-18/ [Accessed 14 October 2020] Figure 24: Interior Design Choices, 2020 https://aasarchitecture.com/2015/01/akershusuniversity-hosptial-c-f-moller-architects.html/akershus-university-hosptial-by-c-f-mollerarchitects-18/ [Accessed 14 October 2020] Figure 25: Akershus, 2020 https://aasarchitecture.com/2015/01/akershus-universityhosptial-c-f-moller-architects.html/akershus-university-hosptial-by-c-f-moller-architects-18/ [Accessed 14 October 2020] Figure 26: Akershus, 2020 https://aasarchitecture.com/2015/01/akershus-universityhosptial-c-f-moller-architects.html/akershus-university-hosptial-by-c-f-moller-architects-18/ [Accessed 14 October 2020]