A New Paradigm of Design and Health

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Alan Dilani, Ph.D.

Dr. Dilani is a founder and DirectorGeneral of the International Academyfor Design and Health. He has beenengaged by universities worldwidein the field of Design and Health for

developing ”Psychosocially Supportive DesignProgram”, both in Medical and Design institutions.He holds a Ph.D. in Health Facility Design from theRoyal Institute of Technology, Stockholm and aMasters of Architecture in Environmental Designfrom the Polytechnic of Turin, Italy. He is currentlyhead of the Research Center for Design and HealthStockholm, Sweden, supervising research rograms inthe areas of Design for Elderly, LearningEnvironments. Dr. Dilani is the author of numerousarticles and books in the field of Design and Healthincluding ” Design and Care in Hospital Planning”and editor of the book ”Design and Health - TheTherapeutic Benefits of Design”.

A New Paradigm of Design and Health

Alan Dilani

The problem of psychosocially supportivedesign or healthy workplace design is one of themost mysterious and meaningful challenges forarchitects and designer that create our dailyworkplace. This paper poses the question ofhealthy workplace design the very need of humanbeings that spend more than 80 % of their timein man-made indoor environments.

Earlier research in environmental psychologyhas shown that architectural dimensions such asstimulation (intensity, variety, complexity,mystery, novelty, noise, light, odor, color, crow-ding, visual exposure, proximity to circulation,adjacencies), coherence (legibility, organization,thematic structure, predictability, landmark,signage, pathway configuration, distinctiveness,

floor plan complexity, circulation alignment,exterior vistas), control (crowding, boundaries,climatic & light controls, spatial hierarchy, ter-ritoriality, symbolism, flexibility, responsive-ness, privacy, depth, interconnectedness, func-tional distances, focal point, furniture arrange-ment), and restoration (minimal distraction, sti-mulus shelter, attraction, solitude) are closelylinked to the perception of stress both in termsof positive and negative. The question is: Arethe positive characteristics from a stress-redu-cing point of view, of the above mentionedarchitectural dimension, possible to verify andimplement in current workplaces and the ove-rall built environment?

The traditional working environment – frommanagement systems and communication pat-terns to the physical layout – reflects theassumptions and thinking patterns of the pastindustrial era. We know that the physical andpsychosocial environment has a great impact onpeople’s motivation, creativity, state of mindand general well being. Yet, limited research isavailable on how the combination of workplacedesign factors affects health and well being in aholistic structural manner.

The physical workplace has often been control-led by the fact that the organisation of space wasfunctional. This means the workplace functio-nality and its measurable qualities are of greatimportance while the psychosocial aspects andthe individual’s needs and preferences, thatcould become a wellness factor to promotehealth and reduce stress, are largely neglected.

Holistic evaluation of workplaces from a multi-disciplinary perspective, considering psychosocial,physical and cultural as well as ergonomics factors

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A NEW PARADIGM OF DESIGN AND HEALTH

International Academy for Design and Health

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has so far been limited. Despite huge invest-ments on workplaces and their impact, therehas been a lack of evaluations and feedback.Through evaluations in an early stage we canavoid consequences of an unsuitable workingenvironment and limit added costs for the futu-re on both personal assets, in the form of sickdays and reduced production.

Health-promoting processes are becomingmuch more central as factors in the creation ofnew healthcare facilities. In this new paradigm,the focus is on the patients: along with theirphysical health needs the patients’ psychologi-cal and social health needs are given majoremphasis in the delivery of care activities and inthe design of health care environments.

Theoretical backgroundA salutogenetic perspective and Health

Salutogenetic is a word derived from the Latinword ‘salut’ that means health and well being. Ifthe designers and architects who create ourdaily environments are seeking to promote“health” through environmental qualities, it isnecessary that they should learn about thehealth and design factors that create healthyenvironments.

HealthThe concept of health is probably as complex aphenomenon as is the concept of illness.However, there is far less theoretical founda-tion, comparatively less theoretically basedresults and fewer experiences from practicalapplications of health than that of illness.

As early as 400 B.C. Hippocrates and Platodescribed health and illness with a holisticperspective in which the body was viewedas interacting with the environment surroun-ding the individual. It was believed thathealth could be retained by man living in co-existence with nature or by living in trueunity with nature and our senses(Alexandersson K, Medin J. 2000).

A generally accepted definition of Health accor-ding to WHO:

”Health is a state of complete physical, psycho-logical and social well being; not only theabsence of illness!”

State of the health is highly dependent on ourlifestyle. Therefore health cannot be explained,as freedom from disease but rather as a state ofbalance between health process and disease pro-cesses. According to Konarski, human beingsare creative, innovative and unpredictable.There are two parallel ongoing processes in ourdaily life; disease processes and health processes.These are composed on psychosocial factors, lifestyle, emotion and experience, that create healthprocesses. The placebo effect is an example of ahealth process. (Konarski, K. 1992, 1999).

The goal of increased public health cannot beachieved without 1. basic knowledge of thewellness factor phenomenon and 2. the unders-tanding of how the social, mental and physicalenvironment is shaped for public use. In reality,there is a great difference between reducingexposure to risk factors in the physical environ-ment and increasing the amount of wellness fac-tors within the building environment.

A risk factor is an aspect or a component of thephysical or urban room/space which constitutes aphysical, psychological or social risk for the indi-vidual. This in turn increases the risk for theescalation or the acceleration of the disease pro-cesses. The focus of the pathogenic perspective isto impede risk factors thereby preventing illness.Consequently, the qualities of architecture aremore functionally tailored and factors affectingemotions and experiences have been set aside.

A wellness factor is an aspect or component ofthe physical or urban environment which mayaffect emotions, experiences and sometimes alsobehaviour in a positive manner. In other words,these wellness factors increase the probability ofthe strengthening health process in somegroups of the population compared to othergroups who lack similar preconditions.



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Inviting entrance to reduce stress. Designed by Anshen and Allen.

Room for relaxation and thought. Designed by Anshen and Allen.




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A salutogenetic perspectiveand sense of coherence,Antonovsky has developed the term “salutonge-nes” that means causes of health as the oppositeto “pathogens” which means causes of sickness.He therefore wanted to try and persuade indivi-dual focus from sickness to health in order tostrengthen a healthy thinking. The Pathogenviewpoint questions and searches for new expla-nations on why some humans get sick, what riskfactors contribute to sickness and how the sick-ness can get cured. In comparison to this, thesalutogenetic perspective focuses on the originof health, where the greatest importance is tosee health as a resource. The salutogeneticinterpretation asks question of why some peoplesurvive when they are faced with hardship intheir life, while others do not and what factorsthat persuade humans to remain healthy.Antonovsky sees health as a continuum at whichthe individual often changes their position witha constant aim to maintain and improve theirhealth (Antonovsky, A. 1979, 1991).

What decides where people are placed on thishealth continuum is the individuals feeling ofconnection (Sense of Coherence) in their life.Sense of Coherence is the humans overallapprehension of life depending on how com-prehendible, manageable and meaningful it isto them.

Comprehendible;: describes to what extent theworld is experienced as understandable, in rela-tion to both outer and inner stimuli.Experiencing unpleasant situations may beunderstandable and describable to a greater orlesser degree. This is the controlling componentin “Sense of Coherence”.

Manageable;: pertains to the experienced abilityof having the resources to meet and manage sur-rounding stimuli. These resources may be in theform of personal qualities and individual know-ledge but may also include resources outside theindividual, such as human beings included inone’s social network.

Place for contemplation and relaxation. Designed by Niels Torp.



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Meaningful refers to the human perception thatlife has a meaning and that through life, whenproblems arise, life merits the investment ofhuman effort or energy.

Sense of Coherence is the overall human unders-tanding of life based on how Comprehendible,Manageable and Meaningful it is. If the individu-al has a good Sense of Coherence, it is easier tomanage tension/stress and thereby achieve betterhealth (Antonovsky, A. 1996). The physical envi-ronment creates the framework and the necessa-ry conditions to support a Sense of Coherence,thereby strengthening health processes. This isexplained by how the individual interprets theperception of stimuli and how one experiencesone’s environment.

Sense of Coherence is related to the ability tovalue and handle stress factors which may affectoverall health. Antonovsky means that with agood feeling of connections, individuals are ableto handle tensions better and therefore achievebetter health.

Antonovsky describes that health emerges fromthe human Sense of Coherence. Health and ill-ness are seen from the perspective of a conti-nuum where the individual often changes theirposition, and always strives to maintain orimprove health. Life is not a simple state ofbeing but a dynamic process in which the indi-vidual tries to understand, manage and findmeaning in life.

Stress and the physical environmentStress may be defined as a state tending todisturb our normal sensory and physical func-tions. It is an experience of discomfort in a situ-ation where the basic trust of an individual isthreatened. During the stressful experience, aseries of biological and physiological reactionsare released in the organism which in turn leadsto behavioural changes of the individual. Thisreaction may be of shorter or longer durationdepending of the individuals ability to masterthe experiences (De. La.Torre B. 1998).

The experience of being admitted to a hospital isa source of psychological stress, regardless of thereason for disease. Isolation from family and fri-ends, new and unknown environments, fear oftreatment and outcome, lack of control and pri-vacy, employment or financial concerns and una-vailable or lacking information can be mentionedas contributing factors of stress in the hospitalsetting (Dilani, A. 1998).

Humans are exposed to various demands whichmay lead to physiological and psychologicalreactions. The experience of demand, the reac-tions which follow and the consequences whicharise are all subjective. A stress reaction may becaused by noise, cold, heat or changes in thephysical environment which we cannot masteror control, such as a complex physical environ-ment made difficult in terms of orientations.

Place for social support. Designed by Niels Torp.




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In general the causes of stress are to work, oftenintensively, without time for relaxation; to havehigh responsibility (high demand) but withoutequivalent decision latitude (lack of control);inappropriate leadership and unclear goals inthe organization; lack of social support andfinally the lack of psychosocially supportivework environment - where people have notaccess to places for social interaction, contemp-lation, recreation, relaxation, and a place forsocial support (Theorell, T. 2000)

According to Levi, L. 1972, the stress theoryand his theoretical model for psychosociallymediated disease, the physical environment is apoint of departure that creates social organisa-tion, structure and function in the society thatleads a combined effect of psychosocial stimuliand psycho-biological programs which deter-

mines the psychological and physiological reac-tions. This process develops a mechanism thatwe call stress of each individual. This may undercertain circumstances, lead to precursors ofdiseases and disease itself. By providing wellnessfactors and creating a psychosocially supportiveenvironment can counteract the sequence ofthis process (Dilani, A. 2001).

Brain exposure to demands from the architectural environmentThe brain has as we know, two hemispheres,each with specialized functions to some degree.The left hemisphere has functions such as logic,mathematics, attention to details, language, etc.These are often known as “rational/logical”functions. The right hemisphere has specializedfunctions such as seeing entirety, intuition, art,musical experiences, generating ideas and many

Landmark within the complex building facilitate orientation. Designed by Anshen and Allen.



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other holistic functions. For most humans, oneor the other hemisphere is the dominant one;this is particularly the case in situations of lear-ning or of stress. The dominant hemispherethen takes command and we have to live withthe subsequent drawbacks (Emdad, R. 2002).

The brain neurons (the cells) build an innernetwork inside the brain which is called theneural network. These networks run our bodi-es, our speech, participate in our decision-making processes and carry out our decisions.These neural networks are strengthened eachtime we use them! For example, many adultshave a strong neural network for how to drive acar. The more we drive, the stronger the neuralnetwork and the more experienced and skilledwe become as drivers (IBID).

For the brain to function at full capacity, itneeds nourishment. The brain utilizes 20% ofthe total oxygen intake, yet the weight of thebrain is only 2-3% of the total body weight.Therefore it is important to breathe properlyand deeply. Besides oxygen, the brain requiresenergy, vitamins, minerals, etc. making itstronger and more functional. Between thebrain hemispheres, there is an area calledCorpus Callosum’, a canal in which there runsan enormous amount of cell connecting tissue.This area connects the right and the left brainhemispheres. The stronger and more developednetwork is in this area, the more ‘whole-brai-ned’ the individual can count on being. A per-son which has a balanced brain where bothhemispheres are equally dominating, communi-cating and cooperating with each other is refer-red to as “Wholebrained”. Such a person willtake an entire situation into account whenencountering a problem. They have full accessto logic and rational thinking, language, seeingit’s entirety, ideas, creativity and emotions.

It is well known that females have a built inconnective link with high transference capacitybetween left and right brain hemisphere func-tions. Since the two hemispheres in males areconnected by less nerve linking tissue then in

the female, the holistic ability suffers amongmen ( B. Habib, H.1998) .

This contributes to improved preparedness formanaging different types of situations at work.We can practise the integration of our brain tocreate more functional neural networks betwe-en the brain hemispheres.

We can with the help of experiences from thephysical environment, bypass verbal barriersand reactions by shifting back and forth betwe-en the two brain hemispheres. Architecturalexperiences may sometimes have a surprisingeffect which stimulates the parts of the braingoverning our emotions (Emdad, R. 2002).

In order to be creative and generate ideas, thecontext, i.e. the work environment, is pivotal.The process in our brain is central and is depen-dent on the hippocampus as the switchboardstation in the limbic system. The limbic systemis the “librarian of the brain” which sorts nerveimpulses thereby storing them as memory andknowledge in the library of the brain. Exposureto stress affects the function of the hippocam-pus which may need ample time to be repaired.Damage to hippocampus complicates storage ofnew memory. Harmonious and inspiring buil-dings and environments affect the storage ofinformation in hippocampus.

The hippocampus helps to encode memories, andthen helps in finding them when you want toremember something. When you remembersomething, it is not like finding a picture in yourbrain. Instead, your brain has to construct piecesof the memory from different clues. It is easier toremember events that you had strong feelingabout. The environmental quality has a strongeffect on our memorizing ability as well as streng-thening our memory itself (Emdad, R. 2002).

Good design will create a mental map whichmeans we can remember architectural environ-ments for long time in our life. Our memorywill be triggered to place and design when wesee a landmark or attractive design that attracts




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our attention and mental process. When youvisit Sydney once you will remember the buil-ding of the Sydney Opera House for all yourlife and you can associate the city with thearchitectural quality of the place.

More research into the working life, togetherwith applying the results of the research, inorder to promote health and increase the num-ber of healthy working days. The basic functionof workplaces should be to start a mental pro-cess by attracting human attention that can stopor reduce anxiety and bring about positivepsychological changes. Comprehensive evalua-tion of workplaces is needed from a saluto-genetic perspective in order to find out not onlythe causes of stress but also how we can imple-ment wellness factors to strengthen the healthyprocesses in the working life.

The basic function of design is to challenge ourminds and to start a mental process by attracting

human attention. This can stop or at least redu-ce anxiety and can thereby bring about positivepsychological changes. Psychosocially suppor-tive working environments should challengeour mind in order to create emotion, pleasure,stimulation, creativity, satisfaction, enjoymentand admiration (Dilani, A. 2001).

Hospital stays are inherently stressful, and poordecisions can increase that stress in ways thathave specific, measurable effects on patienthealth. Psychological results of stress on pati-ents include feelings of helplessness, anxietyand depression. Physiological symptoms suchas muscle tension, increased blood pressure andhigher levels of stress hormones are common.In addition, patients may exhibit behaviouralproblems: emotional outbursts, sleeplessness,withdrawal, substance abuse. Any one of thesecan be a serious hindrance to the healing pro-cess. These same stress factors affect membersof the health care staff. Studies have shown thathigh stress levels often result in high rates ofburn-out, low job satisfaction and excessiveabsenteeism (Beth Frankowski, J. 1996).

Noise, whether positive or negative, is definedas environmentally-generated sound with nospecific human purpose. High Noise levelshave been shown to enhance patient’s percep-tion of pain, resulting in increased need formedication, and certain antibiotics can add to apatient's vulnerability. Among the elderly,broad swings in noise levels are a significantsource of sleep deprivation and can cause con-fusion and disorientation (IBID).

Natural sounds, especially water, have a cal-ming, relaxing effect and effectively maskother undesirable noise. Music, which stimu-lates the body's release of endorphins andlowers heart rates, can have similar positiveresults. Classical music played in operatingsuites has been shown to lower patient anxie-ty and even reduce the need for anaesthesia,while certain types of New Age music, tunedto natural body rhythms, also have significantrelaxing effects (IBID).



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Colour is an essential element of visual stimula-tion with well-documented psychological andphysiological effects. Warm colours, especiallywhen accompanied by high illumination levels,have been found to encourage activity, whilecool colours promote more passive behaviour.These effects are so significant that, in Sweden,patients are assigned to hospital rooms in cer-tain colours based on the nature of their illness;as the healing process progresses, they aremoved to rooms with gradually higher levels ofcolour stimulation (IBID).

Colour also is vital in setting objects apart fromtheir backgrounds. Contrasts in hue, brightnessand saturation help the human eye defineobjects by distinguishing shapes and edges.This is an important scientific concept to bearin mind, especially when designing for thosewith impaired vision. Nursing homes and otherfacilities for the aging may require special

consideration. Many of the elderly have colour-related visual problems, among them reducedsensitivity to colours at the blue end of thespectrum and less ability to distinguish betweenclosely related colours.

Light is likewise essential to good vision, andalso has proven physiological effects. In addi-tion to its influence on the synthesis of certainvitamins, along with biochemical and hormonalbody rhythms can be influenced by the amountof light exposure.

Light and colour are inherently linked, in thatlight temperature significantly affects colourrendering. As a result, a designer's choices canhave a psychological influence, making a wellperson look sick or an ill person look healthier.

The elderly often have special needs, requiringup to three times the light needed by young




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adults for identical activities and tasks.Improperly directed light can cause glare,however, intensifying existing vision problemsand resulting in eye fatigue and loss of concent-ration, especially within this age group. Placefor socialization and relaxation are very impor-tant factor of social support and how we canexchange the ideas during daily work.

ConclusionPreventative work in the traditional publichealth field is suppressed by the increasing pat-hogenic orientation of the established healthcare system. The focus is too much on identify-ing risk factors, emphasizing small populationgroups and individuals, which are particularlyvulnerable while neglecting the factors involvedin maintaining good health.

Health care activities geared towards healthpromotion involve a shift of paradigm awayfrom the pathogenic perspective still domina-ting in the health care system today. The salu-togenetic perspective must replace this perspec-tive. Modern medical science increasinglyresembles the philosophy of industrialism and isin the process of changing into a “technoscien-ce” which lacks the humanistic profile.

The alternative to this currently dominatingview must shift away from the pathogen i.e. riskfactors to the salutogenic i.e. wellness factors cre-ating health in society. By mapping out the rea-sons why people maintain good health in spiteexposure to risk factors, we build the foundationfor a more health promoting view and therebymore healthy environment for our daily life.

The pattern of causality creating health consists of50 percent Activities within working, living, rec-reation and it is estimated that the qualities of theenvironment surrounding us at work, in the homeand in our recreational spaces make up 20 percentof health promoting conditions while the contribu-tion of health care system only create 10 percent.The other 20 percent consist of genetic factors,which are difficult to influence (Norling, I. 2001).

More research is needed along with applied studyresults in order to promote health and increaselife qualities by design. The concept of wellnessfactors should inspire planners to develop designcriteria, which stimulate wellness. An increase inthe consideration of wellness factors withindesign could have beneficial effects on well beingand health processes thereby creating environ-ments which are not only functionally efficientbut also highly psychosocially supportive.

ReferencesAlexandersson K, Medin J, 2000. Begreppen Hälsaoch hälsofrämjande- en litteraturstudie, Studentlitteratur, Lund

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 atheory to guide health promotion. Health promotioninternational, vol. 11, no 1, pp. 11-18.

Antonosky, A. 1991. Hälsans mysterium, Narur och Kultur, Köping

Bel Habib, H. 1998. Från diagnos till dialog,Salutogenes I teori och praktisk tillämpning,Dalarnas forskningsråd. Falun.

Beth Frankowski Jones 1996. Environments thatSupport Healing. Design works hand in hand withthe technology of healing

De. La.Torre B. 1998. “Stress” definitioner, mätmetoder, mekanismer, Karolinska Institutet,Stockholm

Dilani, A. 1998. Healthcare Building asSupportive Environments. KTH, Landstinget Härnösand.

Dilani, A. 2001. Psychosocial supportive design —Scandinavian Healthcare Design. In: Alan Dilani(2001) Design and Health-The TherapeuticBenefits of design, p. 31-38.



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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 Hospitalplanning, Karolinska Institutet, Institute forPsychosocial Factors and Health, Design and Health. Stockholm.Emdad, R. 2002. The EPOS- Emdad’s Pyramid ofstress (Demand, Effort, Satisfaction.Karolinska Institutet, Stockholm 2002

Konarski, K. 1999. Ideologiska överväganden,Arbetsmaterial till Nationella folkhälsokommitten(Report to National Health Committee). Kapitel 3, Karolinska Institutet, IPM. (in Swedish) Stockholm.

Konarski, K. 1992. Jordmån för ett gott liv,(Fertile soil for good life), Karolinska Institutet. (in Swedish) Stockholm.

Levi, L. 1972. Psychosocial Factors in PreventiveMedicine. In background papers to Healthy People:

The Surgeon General’s Report on HealthPromotion and Disease Prevention. Washington,D,C, US Public Health Service.

Norling, I. 2001. PNturens och trädgårdens betydelse för hälsa och livskvalitet. Göteborg botaniska trädgård. Göteborg.

Theorell, T. 2000. På jobbet, Stress ur ettMedicinsk Perspektiv (In working place, Stressfrom a medicine perspective). Karolinska Institute. (in Swedish) Stockholm.

Theorell, T. 2000. Hälsa på lika villkor- Nationella mål för folkhälsan.(Health for equal condition, the national goal forpublic health). Social department 2000:91 andKarolinska Institute. (in Swedish) Stockholm.

WHO, 1983. The principles of Quality Assurance.Euro reports and studies 94. Report of a WHOmeeting in Barcelona May 17-19, 1983.Copenhagen: World Health Organization.Technical Report on Quality 1983:1.


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A New Paradigm of Design and Health

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