Conceptualizing Health Promotion in Relation to Outpatient Healthcare Building Design: A Scoping Review

Abstract

Objective:

This review explored different conceptualizations of health promotion in the context of, and in relation to, outpatient building design.

Background:

Today’s healthcare organizations are implementing holistic healthcare approaches such as health promotion, while simultaneously increasing their outpatient services. These health promotion approaches, focused on empowering people to take control of their health, are expected to have implications for the outpatient healthcare building design. Yet there is limited knowledge what these may be. A review of the literature on the current state of the art is thus needed to enable and support dialog on future healthcare building design.

Method:

A scoping review of 4,506 papers, collected from four databases and three scientific journals in 2015, resulted in 14 papers relating health promotion to building design and outpatient healthcare. From the subsequent content analysis, multiple common themes and subthemes emerged.

Results:

The review reveals diverse range of health promotion interpretations, three health promotion perspectives (health behavior, health equity, and sense of coherence), associated design approaches, design objectives, health-related outcomes, building features, and solutions.

Conclusions:

While diverse health promotion perspectives might merely represent variations in focus, these differences become problematic when relating to building design. To support further dialogs on development of health promotion in, and in relation to, the build environment, there is a need to strengthen the health promotion vocabulary. Further research is needed to compare different design approaches and how these can be combined to minimize contradicting implications for building design.

Keywords

building design design approaches health behavior healthcare facilities health equity health promotion outpatient centers salutogenics

Health promotion is receiving increased attention in healthcare services (Wilson, Harris, Hollis, & Mohankumar, 2010). The approach is considered to be a solution for several public health problems (Wilson et al., 2010), including the increase in chronic diseases, higher healthcare costs, and growing health inequality. Health promotion is commonly defined as “the process of enabling people to increase control over and to improve their health” (World Health Organization [WHO], 1986, p. ), in which health is not merely the absence of disease or infirmity but rather includes physical, mental, social, and spiritual dimensions (WHO, 1986).

A growing body of research supports the relevance of the built environment for health promotion (Perdue, Stone, & Gostin, 2003). Previous research has related health promotion to urban design (Barton, Grant, & Guise, 2010) and building design (McGann, Creagh, Tye, Jancey, & Blackford, 2014; Zimring, Joseph, Nicoll, & Tsepas, 2005). As a result, several checklists, certification schemes, and organizations focusing building design have been developed, including active city and building design guidelines (Center for Active Design, 2010), WELL certification (International WELL Building Institute, 2016), and the Green Building Council (World Green Building Council, 2016–2018). While these guidelines provide starting points for discussion, these guidelines, certification schemes, and organizations do not specifically focus on healthcare facilities and have a limited community perspective.

Previous studies of healthcare buildings have been largely internally focused on inpatient healthcare building design and individual health and well-being (Dijkstra, Pieterse, & Pruyn, 2006; Ulrich, Berry, Quan, & Parish, 2010; Ulrich et al., 2008). Other studies have explored the implementation of new healthcare processes and technology in relation to shifting healthcare facility needs (Carthey, Chow, Jung, & Mills, 2011). However, it is unclear how health promotion approaches relate to these built environments (Korp, 2016), and even less is known about the aspects of building design for outpatient facilities (Tzeng & Huang, 2009) or community hospitals (Pati et al., 2013). Therefore, this study reviews the conceptualizations of health promotion in the context of and in relation to outpatient healthcare building design.

Background

Different health promotion definitions have been developed over the last 30 years (Rootman, Goodstadt, Potvin, & Springett, 1997). These definitions represent diverse perspectives rather than fundamentally conflicting meanings (Green, Poland, & Rootman, 1999). Nevertheless, there is no consensus definition (Whitehead, 2004b), and the concept is often confused with other approaches such as disease prevention (Antonovsky, 1996). The difference between prevention and promotion can be explained based on the work of Antonovsky (1987), who argued that most of the attention to increased health has focused on understanding the origins of disease (pathogenic/disease prevention) rather than on understanding the origins of health (salutogenics/health promotion). Additionally, Green, Poland, and Rootman (1999, p. 9), while referring to others (Downie, Fyfe, & Tannahill, 1990; Goodstadt, 1995; WHO, 1986), addressed this issue by listing certain criteria that distinguish health promotion from other health-related approaches:

encouraging public participation by individuals and communities;

taking a social and cultural perspective in understanding and responding to health issues and problems;

emphasizing equity and social justice;

fostering intersectional collaboration;

including physical, mental, social, and spiritual dimensions of health; and

focusing on enhancing health, not just preventing problems.

Green et al. (1999, p. 8) additionally argue that health promotion initiatives in practice are “increasingly complex in their goals, content, approaches and implementation,” therefore multilevel action and multidimensional approaches are needed to sustain impact.

Health Promotion and the Environment

One of the main health promotion objectives is to create supportive environments, since health is being created where people live, work, and play (WHO, 1986, WHO 1991a). These environments, which consist of the built, natural, and social environments, should promote health resources for both individuals and populations as well as opportunities for empowerment (WHO, 1991b). This notion resulted in the successful settings approach, which focuses on adjusting general health promotion strategies to specific environments such as schools, workplaces, or healthcare facilities (Green et al., 1999; WHO, 2017).

Health-Promoting Healthcare Facilities

Healthcare facilities are often considered one of the five major settings for health promotion (Goel & McIsaac, 1999; WHO, 1997), as they are the working environments for a large number of healthcare and support staff, are accessible meeting places for staff and the local population, and can serve as nodes in the community (Green et al., 1999). Nevertheless, some authors have been critical of the healthcare facility setting for health promotion because they are often associated with medicalization, individualization, and institutionalization rather than health empowerment among groups and communities (Hancock, 1993; Johnson, 1999). As noted by some researchers, it therefore remains difficult to implement health promotion initiatives in healthcare settings (Aujoulat, Le Faou, Sandrin-Berthon, Martin, & Deccache, 2001). However, the healthcare setting is associated with illness and health (Green et al., 1999) and thus has a role to play in representing the healthcare system (Milz & Vang, 1988). Additionally, most people will visit a healthcare facility at some point in their lives, and it is a major employer in the community (Johnson, 1999; Milz & Vang, 1988). Moreover, healthcare facilities include or are part of other health-promoting settings such as the workplace and community setting (Hancock, 1999; Whitehead, 2004a). And increasing number of outpatient facilities are adding nonmedical program, such as educational kitchen or spiritual spaces (Miedema, Lindahl, & Elf, 2017). The health-promoting hospital must thus be one part of the process of creating healthier communities (Hancock, 1999).

This approach is recognized by the Health Promotion Hospital Network, a worldwide organization of collaborating healthcare institutions that focus on supporting health promotion actions in hospitals (Groene, Jorgensen, Fugleholm, Møller, & Garcia-Barbero, 2005). This network interprets healthcare facilities as being both internally and externally focused on the health and well-being of the community (Hancock, 1999).

However, there is still limited empirical evidence concerning the relationship between health promotion and healthcare building design. Thus, to enable discussions in the context of outpatient building design, there is a need for a critical review of the current literature addressing health-promoting building design.

Method

A scoping review was conducted based on the framework of Arksey and O’Malley’s (2007) iterative phases: (1) identifying the research question(s), (2) identifying relevant studies, (3) selecting certain studies, (4) extracting the data, and (5) summarizing and reporting the results. The aim of a scoping review is to summarize the relevant fields of study, identify research gaps in the existing literature, and clarify working definitions and/or conceptual boundaries.

Identifying the Research Question(s)

The included papers were scanned to answer the following questions:

Research Question 1: How is health promotion conceptualized in the context of outpatient healthcare building design?

Research Question 2: How is health-promoting building design conceptualized in the context of outpatient building design?

Identifying Relevant Studies

A comprehensive, systematic literature search was conducted in four databases (Web of Science, Scopus, ProQuest, and MedLine), and hand searching was performed in three journals (Health Environments Research & Design Journal, Health & Place, and Health Promotion International). The search was performed in May 2015. The key terms used were health promotion, outpatient facility, and building design, and similar terms were included that describe those concepts (Tables 1 and 2). The search terms were decided in consultation with university librarians and guided by MeSH terms of the accessed databases.

Table 1.

Table Overview of Search Terms.

‘health promotion’ (hp)	‘health care facility*’ (hcf)	‘built environment’ (be)
salutogenics	‘health facilit*’	architecture
‘universal design’	‘ambulatory care facilit*’	‘physical environment’
wellbeing	‘health cent*’	‘facility design’
wellness	‘outpatient facility’	‘building design’

Table 2.

Table of Search Strategies.

Pilot Search
Health promotion AND Architecture AND Healthcare Facility	(‘health promotion’ or salutogenics or ‘universal design’ or wellbeing or wellness) and (architecture or ‘built environment’ or ‘physical environment’ or ‘facility design’ or ‘building design’) and (‘health care facility’ or ‘health facilit’ or ‘ambulatory care facilit’ or ‘community health cent’ or ‘outpatient facility’)
Search String 1
Health promotion AND Architecture	(‘health promotion’ or salutogenics or ‘universal design’ or wellbeing or wellness) and (architecture or ‘built environment’ or ‘physical environment’ or ‘facility design’ or ‘building design’)
Search String 2
Health promotion AND Healthcare Facility	(‘health promotion’ or salutogenics or ‘universal design’ or wellbeing or wellness) and (‘health care facility’ or ‘health facilit’ or ‘ambulatory care facilit’ or ‘community health cent’ or ‘outpatient facility’)
Search String 3
Architecture AND Healthcare Facility	(architecture or ‘built environment’ or ‘physical environment’ or ‘facility design’ or ‘building design’) and (‘health care facility’ or ‘health facilit’ or ‘ambulatory care facilit’ or ‘community health cent’ or ‘outpatient facility’)

The included literature should (1) address building design aspects, (2) address the factors involved in health promotion, (3) be situated in an outpatient healthcare setting, (4) be written in English, and (5) be published between 2005 and 2015 (Table 3). We excluded only newspaper articles and dissertations in order to provide a broad mapping of the topic.

Table 3.

Listing of the Inclusion and Exclusion Criteria for the Scoping.

Inclusion Criteria	Exclusion Criteria
Situated as part of a healthcare facility with outpatient program Refers to health promotion Refers to building design English Between 2005 and 2015 Journal papers and professional articles	Situated in wards in inpatient care Journals from other research domains such as information technology or biology Other sources such as newspaper articles, dissertations, and letter to editor

Selecting the Studies

A total of 4,506 titles were selected for inclusion after duplicates, newspaper articles, dissertations and papers from computer science, biochemistry, genetics, and molecular biology were excluded. The initial title selection was generous, meaning that titles were selected if they mentioned two of the three main key words, that is, health promotion, outpatient healthcare facility, or built environment. This approach was used to avoid hasty exclusion due to vague titles. However, the following selection phases required all three main key words, that is, health promotion, outpatient healthcare facility, and built environment. This resulted in 651 abstracts and 160 full texts assessed by both authors and ultimately resulted in 14 papers to be included in the review (Figure 1). Papers were excluded after full-text evaluation if they did not relate to the built environment, building design, or spatial aspects. Others were excluded because they addressed inpatient facilities rather than outpatient facilities. The selection focused on the building itself and did not actively search for literature addressing the route to the healthcare facility. The final selection addressed all three concepts: health promotion, building design, and outpatient facility. The study selection process was documented to ensure methodological rigor.

Extracting the Data

The details of the publications included in the review are presented in Table 4. The first author extracted data from the included studies using a charting form that included (1) source information (authors, year), (2) topic, (3) method, (4) interpretation of health promotion, and (5) interpretation of health-promoting building design.

Table 4.

Overview of Included Sources With Topic Summary, Method Summary, and Conceptualization of Health Promotion.

Author(s) (year)	Topic	Method	Addressing Health Promotion
Brittin et al. (2015 )	Desirable resources for community-centric hospital integrating healthcare, health promotion, and other community resources	Mixed method; interviews, focus groups, survey, and spatial analysis on settlement patterns	Health promotion: Focus on long-term population health in addition to individual health, with understanding similarities and differences amongst local ethnic groups
Chiou and Chen (2009)	Framework development for age-friendly hospital (and services), Taiwan	Merging “age-friendly principles” with “health-promoting hospitals” and elder-friendly hospital initiative	Health promotion for older people; opportunity and ability to control (determents of) health as essential part of human dignity and integrity throughout life
Davis (2011 )	Evaluating a rooftop garden used primarily for physical therapy	A postoccupancy evaluation: mix of interviews, behavior mapping, survey, and questionnaire	Accessibility of the therapeutic rooftop garden Active use of the garden to healing physically, emotionally, and spiritually for specific patient populations, population needs, and awareness
Dilani and Armstrong (2008 )	Salutogenic approach to designing a health-promoting hospital environment	Conversations and own experience on several projects	Health-promotion and salutogenic approach, not explained Included concepts: Wellness and sense of coherence, social cohesion, personal control, meaningfulness, comprehension, manageability, and access
Dilani (2001 )	Integration of care philosophy in building design	Discussing different models and theories	Health promotion used as the salutogenic approach designing a health-promoting hospital environment Included concepts: Wellness, physical needs, comprehension, quality of care, and psychosocial factors
Foote (2012 )	Core principles of patient-centered to architectural design features	Merge outcomes of working groups, a conference, and a case	Holistic (or whole person) care, including wellness, interdisciplinary care integration, family-centered approaches and evidence-based design, integrity of the clinical encounter, patient empowerment, focus on relief of suffering, and care of whole person, and creating lifelong healing relationships
Foster and Hillsdon (2004 )	Effectiveness environmental interventions to enhance physical activity	Systematic literature review	Mentioned as promoting health-enhancing physical activity in relation to health behavior
Golembiewski (2010 )	Architectural extrapolation of Antonovsky’s salutogenic theory	Theoretical exploration	Salutogenics: As the psychosocial study of what keeps people healthy—sense of coherence, meaningfulness, comprehension, and manageability
Gulwadi, Joseph, and Keller (2009 )	Impact physical environment on patient outcomes in ambulatory care settings	Literature review	Patient-/family-centered initiatives—new models of providing underserved populations access to qualitative health services; integrated iterative, patient-centered approach
Jordan (2004 )	Wellness environments’ in a rural community hospital	Case description of the design intentions	Wellness—meeting current population needs
Mroczek, Mikitarian, Vieira, and Rotarius (2005 )	Staff satisfaction, supportive physical environment, and organizational environment	Exploratory analysis of employee satisfaction data, literature review, and empirical research	Need for hospital to be sensitive to the entire building population and supportive of healing, health, and well-being—connection, privacy, access to social support, and empower
Rousek and Hallbeck (2011)	“Simulated visual impairment” to identify hospital design elements influencing wayfinding difficulties	Observations and questionnaires	Accessibility for people with special needs, specifically the visually impaired—human rights wayfinding experience, patient satisfaction, spatial cognition, patient flow, dignity, and interdependence
Shepley and Song (2014 )	Cultural aspect of health needs for design of healthcare environments	Literature review	Mentioned as salutogenic, (only search term) as cultural population needs, and cultural and religious health belief system of the healthcare setting In combination with patient-centered care, access, empowerment, familiarity, social interaction, comfort, privacy, safety, and proxemics
Siddiqui, Zuccarelli, Durkin, Wu, and Brotman, (2015)	Perceptions of “care” versus “physical environment of care” for patient-centered design	Analysis of patient satisfaction survey data	Mentioned as patient-centered care; positively impact provider, ancillary staff, and overall satisfaction and facility satisfaction Included concepts: Control, access garden, population approach, positive distraction, safety, workflow, efficiency, productivity, and stress (reduction)

Summarizing and Reporting the Results

A critical analysis of the 14 papers was conducted by the first author, followed by an analysis by all authors. Summaries were constructed for each paper, with a particular focus on commonalities and differences across papers. This synthetic approach allowed for the extraction of basic information about the different papers (Table 4), common themes that emerged concerning health promotion (Figure 2), and health-promoting building design (Figure 3).

Results

The results revealed the different views used to address health promotion related to outpatient building design. The majority of the included papers (n = 10) originated from the United States, while the others originated from Europe (Dilani, 2001; Foster & Hillsdon, 2004) or Asia (Chiou & Chen, 2009). The authors of the included papers represented disciplines ranging from building design, nursing, public health, and environmental psychology (Table 4).

Health Promotion Perspectives

Table 4 and Figure 2 show the diversity in addressing health promotion in the context of outpatient building design. Four studies explicitly used the term health promotion as a key concept (Brittin et al., 2015; Chiou & Chen, 2009; Dilani, 2001; Dilani & Armstrong, 2008) and used the concept interchangeably with similar concepts such as psychosocial care, the salutogenic perspective on health, and wellness factors (see Figure 2). The other studies have minimal references to existing definitions or frameworks, although three perspectives on health promotion emerged: salutogenics, healthy behavior, and the health equity perspective.

Salutogenics

The salutogenic perspective was the most explicitly used health promotion perspective in relation to outpatient building design (Dilani, 2001; Dilani & Armstrong, 2008; Golembiewski, 2010; Shepley & Song, 2014). Both Golembiewski (2010) and Dilani and Armstrong (2008) referred to a framework that includes comprehension, manageability, and meaningfulness (sense of coherence). Shepley and Song (2014) merely used salutogenics as a search term in their study on the cultural needs of populations in relation to religious and cultural health belief systems. Within the included papers, salutogenics was combined with other terms such as wellness (Dilani, 2001; Dilani & Armstrong, 2008) and patient centeredness (Shepley & Song, 2014). Golembiewski (2010) added that salutogenics and the sense of coherence framework may provide a basis for focused design decisions where empirical evidence is limited.

Health behavior

From the selected literature, only Foster and Hillsdon (2004) explicitly referred to health behavior in relation to outpatient building design. Foster and Hillsdon (2004) addressed promoting health-enhancing physical activity as part of enhancing health behaviors. They argued for a social ecological approach that considers these behaviors as a result of the mix and interaction of the components of context, setting, and function. The authors also stated that this combination of components can promote or discourage a particular behavior. Several other authors associate to healthy behavior through terms such as lifestyles (Chiou & Chen, 2009; Dilani, 2001; Foster & Hillsdon, 2004; Shepley & Song, 2014), physical activity (Brittin et al., 2015; Chiou & Chen, 2009; Davis, 2011), and healthy nutrition (Chiou & Chen, 2009; Davis, 2011; Foster & Hillsdon, 2004).

Health equity

The term health equity, or equality, was not mentioned in relation to outpatient building design. However, authors addressed terms associated to health equity, such as dignity (Rousek & Hallbeck, 2011), human rights (Chiou & Chen, 2009; Rousek & Hallbeck, 2011), vulnerable populations (Brittin et al., 2015; Chiou & Chen, 2009; Davis, 2011; Golembiewski, 2010; Gulwadi, Joseph, & Keller, 2009; Mroczek, Mikitarian, Vieira, & Rotarius, 2005; Rousek & Hallbeck, 2011), or accessibility (Brittin et al., 2015; Chiou & Chen, 2009; Davis, 2011; Dilani, 2001; Dilani & Armstrong, 2008; Foster & Hillsdon, 2004; Golembiewski, 2010; Gulwadi et al., 2009; Mroczek et al., 2005; Rousek & Hallbeck, 2011; Shepley & Song, 2014; Siddiqui, Zuccarelli, Durkin, Wu, & Brotman, 2015).

Several types of accessibility were mentioned, including distances within the building (Dilani, 2001; Golembiewski, 2010) and to the healthcare facility (Brittin et al., 2015; Foster & Hillsdon, 2004) and spatial barriers (Chiou & Chen, 2009). In addition, some authors mentioned opening hours (Chiou & Chen, 2009; Foster & Hillsdon, 2004) and the availability of healthcare services or support programs (Dilani, 2001; Foster & Hillsdon, 2004). Only Rousek and Hallbeck (2011) and Chiou and Chen (2009) explicitly referred to human rights, while multiple studies addressed the specific needs of vulnerable population groups (Brittin et al., 2015; Chiou & Chen, 2009; Davis, 2011; Golembiewski, 2010; Gulwadi et al., 2009; Mroczek et al., 2005; Rousek & Hallbeck, 2011). Davis (2011, p. 15) added that architects need a better understanding of healthcare and its environment in order to design accessible environments for various patient populations.

These perspectives represent different focal points, although they often use the same terms. For instance, accessibility is used in combination with salutogenics (Dilani, 2001) and in combination with health behavior and lifestyles (Foster & Hillsdon, 2004). Similarly, patient centeredness is combined with salutogenics (Shepley & Song, 2014) and accessibility (Gulwadi et al., 2009; Mroczek et al., 2005; Shepley & Song, 2014; Siddiqui et al., 2015).

Intended outcomes

The selected papers refer to different types of intended outcomes (see Figure 2) including health-related effects and organizational effects. For instance, Foster and Hillsdon (2004) discussed the possible influences of the environment on health-enhancing physical activity, focusing on behavioral changes by observing stair use by building users. Several papers also noted the difficulties of evaluating the effects of health promotion interventions, which are complex and multidimensional (Golembiewski, 2010).

Target populations

The results also showed that the included papers addressed different target population including patients, staff, visitors, and the community. Several papers focus on vulnerable groups, such as the elderly (Chiou & Chen, 2009), children (Brittin et al., 2015; Shepley & Song, 2014), people with low socioeconomic status (Brittin et al., 2015), and visually impaired (Rousek & Hallbeck, 2011) or psychiatric patients (Golembiewski, 2010).

Health-Promoting Building Design

None of the papers refer to the term health-promoting building design, here defined as aspects of building design that support health promotion. However, the literature includes different themes that relate health promotion aspects of building design, including design approaches, design objectives, and design characteristics (Figure 3).

Design approaches

A few design approaches were used multiple times, including universal design (Chiou & Chen, 2009; Rousek & Hallbeck, 2011), age-friendly design (Chiou & Chen, 2009; Jordan, 2004), patient-centered design (Foote, 2012; Jordan, 2004; Siddiqui et al., 2015), and salutogenic design (Dilani, 2001; Golembiewski, 2010).

Design objectives

Several design objectives were found, although not all were explicit (Figure 3). Foster and Hillsdon (2004) referred to a health enhancing physical environment, which they defined as “any aspect of the physical environment (natural and man-made) that consciously or unconsciously relates to individuals and their health enhancing physical activity behavior” (p. 2). Similarly, Rousek and Hallbeck (2011, p. 447) used the term health-promotive environment, which they defined as “architectural principles that meet the needs of visually impaired people, with consideration of their independence, dignity and safety” (p. 447). In contrast, Jordan (2004, p. 10) was less explicit and wrote about environments made-by-wellness (p. 10), without explaining what the term means in the paper. Other authors referred to buildings that are age-friendly environments (Chiou & Chen, 2009) or creating a psychosocial environment (Dilani, 2001; Dilani & Armstrong, 2008). Not all of these objectives also refer to desired outcomes instead of ambitions.

Design Characteristics

Several of the included papers addressed design characteristics of outpatient buildings (Figure 3), such as noise control elements (Dilani & Armstrong, 2008; Foote, 2012; Siddiqui et al., 2015) and the need for good (day) lighting (Chiou & Chen, 2009; Dilani & Armstrong, 2008; Mroczek et al., 2005). Foote (2012) listed several of these architectural features in relation to patient-centered design, including air, noise, and infection control as well as the incorporation of nature, art, and spirituality. Several explicit design solutions are addressed in the selected papers, with a majority of them referring to adding programs (Brittin et al., 2015) such as facilitation wellness facilities (Foote, 2012) and visitor accommodations (Foote, 2012; Siddiqui et al., 2015). Chiou and Chen (2009) linked the age-friendly hospital design to simple and easily legible signage for improved orientation of patients, appropriate bed heights, clear walkways with handrails on both sides, nonslip surfaces, and facilitated transport to and within the hospital.

Discussion

This review paper aimed to map and describe aspects of health promotion in the context of and in relation to outpatient building design. The results confirmed the paucity of studies relating the two topics, even though the initial title search suggested an abundance of research (Figure 1).

A scoping review does not provide an evaluation of the quality of the included papers (Arksey & O’Malley, 2007; Pham et al., 2016). Neither is a scoping intended to prescribe or find solutions. However, this scoping aimed to map and subsequently describe gaps and challenges to enable and support future research on health-promotive care environments, and consequently dialogues on the planning and designing of healthcare buildings. Most importantly, the review disclosed the weak and inconsistent vocabulary used when relating the two concepts.

this scoping aimed to map and subsequently describe gaps and challenges to enable and support future research on health-promotive care environments, and consequently dialogues on the planning and designing of healthcare buildings

There is an abundance of ambiguous terms associated with health promotion that often lack explanation, even though they are central to the selected articles. This, in combination with the use of terms interchangeably with dissimilar terms, make it difficult to understand how these terms relate to each other in a paper. Wellness, a term with multiple definitions, is defined by Dilani (2001) combined with a reference to Ulrich (1992) but is also used without explicit interpretation (Dilani & Armstrong, 2008; Mroczek et al., 2005). We argue that it might be impossible for researchers to agree on one definition, but an interpretation of the central concepts should be proposed, preferably in reference to the existing definitions.

Similarly, there are multiple interpretations of health promotion that are often not defined or are inconsistent. This review revealed that definitions or explanations of the term health promotion were often missing in the papers. In fact, only one paper referred to the WHO’s definition (Chiou & Chen, 2009). Moreover, several papers discussed aspects that related to healthy behavior; however, the terminology referred to everything from lifestyles, health-enhancing behavior, and physical activity to active behavior. By using a term such as “healthy behavior” interchangeably with health promotion, one can easily neglect other essential aspects, such as, for example, a focus on vulnerable populations or the need for empowerment. Other studies leave the interpretation of the multidimensional concept to readers, although multiple definitions (Rootman et al., 1997) and perspectives (Green et al., 1999) are available. Project members in research or practice would benefit from describing their interpretation preferably by referring to others.

Different interpretations of health promotion seem to become problematic in the context of building design. In contrast to Green et al. (1999), this review revealed that a variety of health promotion definitions represent not only variations in focal points but also fundamental differences concerning the implications of the built environment. This review underlines these differences and how they may become problematic in relation to building design. For example, a behavioral perspective focuses on enhancing physical activity, while an equality perspective focuses on accessibility for all people. Both have consequences; one might emphasize the need for visible stairs (which require physical activity) and hiding elevators, while the second emphasizes the need to position elevators in clear sight to avoid stigmatizing vulnerable groups. This limited provision of definitions, weak vocabulary, and lack of references to previous definitions might also create difficulties in finding related research. Thus, working with health promotion includes familiarizing oneself with the different types of strategies and positioning each project in relation to the different strategies.

The different perspectives result in a simplification of the multidimensional concept. This seems to occur when a health promotion perspective develops into a health promotion strategy, resulting in a health promotion activity that then leads to building design requirements. For instance, health promotion includes stimulating healthy behavior, which was easily reduced to the facilitation of physical activity, which was then once again reduced to the visual placement of stairs (Foster & Hillsdon, 2004).

The balance between different health promotion perspectives and their implications for building design are now left to project teams, the members of which might not be familiar with the different definitions and dimensions of health promotion. In other words, by identifying and categorizing the isolated aspects of health-promoting building design, it may be possible to develop small interventions such as adding an additional nonmedical program. Nevertheless, to achieve integration of health promotion processes in the built environment, cooperation among different interventions is needed. It therefore seems important for healthcare building designers to be familiar with the different dimensions of health promotion. This review allowed us to complement the six criteria developed by Green et al. (1999, p. 9) in the introduction with a seventh, as health-promotion building design by Foote (2012) and by Hancock (1999) has also been associated to minimizing the ecological impact of the building:

encouraging public participation by individuals and communities;

taking a social and cultural perspective in understanding and responding to health issues and problems;

emphasizing equity and social justice;

fostering intersectional collaboration;

including physical, mental, social, and spiritual dimensions of health;

focusing on enhancing health, not just preventing problems; and

considering the ecological footprint of the building design and its use.

The scoping review confirms that the evaluations of health promotion building design efforts are complex (Beurden, Kia, Zask, Dietrich, & Rose, 2013). The review reveals different types of intended outcomes related to health promotion building design, including health-related outcomes and organizational outcomes. These intended outcomes can be explicitly related to health promotion and design ambitions, but this should not mean that health promotion can be simplified to a checklist of items that are measurable; rather, as suggested by Trzpuc and Martin (2011), interventions should be evaluated through mixed method approaches. This could be complemented by approaches founded in socioecological approaches or frameworks. For instance, Beurden, Kia, Zask, Dietrich, and Rose (2013) provided a framework that aims to distinguish between these simple (causal), complicated, complex, and chaotic measurable relations.

Surprisingly, the literature shows a range of design approaches, including universal, patient-centered, or age-friendly design, in relation to outpatient building design. Some of these approaches are users-centered approaches, while others are health focused, or address the ecological footprint. None of these approaches seems to include all aspects of health promotion, as listed by Green et al. (1999). Moreover, the similarities and differences between the design approaches are difficult to grasp, as they are used interchangeably, often without explanation or reference to other authors. While patient-centered care and the related architectural principles were clearly set out by Foote (2012), readers are assumed to know what is meant by universal design, green design, and psychosocially supportive design. Future explorations might continue to focus on approaches used in the practice of planning and designing health promotion hospitals, such as the study by Miedema, Lindahl, and Elf (2017). Another possible avenue to explore is the relations and contradictions between universal design and active design approaches. Additionally, the other approaches presented may provide a starting point for a discussion of health-promoting building design and what guides and defines it.

Unfortunately, this review reveals that many solutions are considered in isolation, while opportunities for health promotion are expected be found when combined with each other (Aujoulat et al., 2001). The real challenge is to find those synergies, which are expected to be contextual and related to the local needs and culture.

With the ongoing development in mind, we can only advise to start new planning and design projects by (1) defining health promotion; (2) map local health needs; (3) reflect on synergies in healthcare planning and building design for the overall development of the healthy community, including mapping of possible collaborative partners; and (4) set health-promotive ambitions, preferably in relation to action and expected outcomes; (5) consider the design process for involvement of both patient groups, staff, visitors, and the surrounding community; (6) reflect on the program weather it supports salutogenic activities besides pathogenic activities; and (7) consider the symbolic value of a healthcare facility as a role model for building healthy environment.

Conclusions

This review exposed the paucity of, and inconsistencies in, literature relating health promotion to building design of outpatient healthcare facilities. Several gaps in the literature were identified, including (1) the lack of definitions or explicit descriptions for health promotion and health-promoting building design, (2) the inconsistency in addressing health promotion approaches, and (3) the lack of directives for the design practice. If we seek to design health-promoting buildings without clarification of what this entails, what outcomes are desired and feasible, it becomes difficult to guide design choices, especially when the evaluation of such buildings has already been identified as complex. Additionally, the lack of a robust terminology complicates finding the latest research on the topic because one might not be familiar with all the terms relating to different aspects of health promotion.

Nevertheless, the results indicate that both health promotion and healthcare building design appear in complex and multidisciplinary studies, and these studies recognize the relationships and important connections between the care approach and the built environment. These similarities can form the basis for discussion and collaboration between public health and building design professionals, which can benefit the development of health promotion and healthcare building design. The presented scoping review suggests terminology, perspectives, and design approaches to guide future research.

Implications for Practice

Formulate or choose a health promotion definition within the projects context to guide planning and design decision-making.

Relate this health promotion definition to project’s to intended health, organizational and design outcomes, including how these relate to strategies and evaluation.

Consider both the needs for building users (patient, staff visitors), the community, and the environment in decision-making regardless of their background.

Consider both the design process and the building as means for health promotion processes, including participation, health education, and empowerment.

Consider salutogenic focus on health enhancement, besides the often-dominant pathogenic focus on treatment, prevention, and protection.

Consider how a design affect relates to social, cultural, judicial, equality, and so on issues.

Initiate knowledge development on strategic and project level on health promotion to enable organizations’ and stakeholders to develop an understanding of different interpretations/concepts of health promotion, develop terminology, and develop a design approach encompassing health promotion.

Support thinking beyond immediate effects of building design and consider use and effects related to building design as an active part of the organizational setting.

Footnotes

Authors’ Note

The study is part of an ongoing PhD project at Chalmers Technical University, Department of Architecture and Civil Engineering, Gothenburg, Sweden. The PhD project is part of Architectural Innovation in Dwelling, Ageing and Healthcare (AIDAH).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The AIDAH project is funded by the Swedish research council for Environment, Agricultural Sciences and Spatial Planning (FORMAS).

ORCID iD

Elke Miedema, MSc, LIC, PhD(c)

Marie Elf, RN, PhD

References

Antonovsky

(1987). Unravelling the mystery of health. San Francisco, CA: Jossey-Bass.

Antonovsky

(1996). The salutogenic model as a theory to guide health promotion. Health Promotion International, 11(1), 11–18.

Arksey

O’Malley

(2007). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8, 19–32. doi:10.1080/1364557032000119616

Aujoulat

Le Faou

Sandrin-Berthon

Martin

Deccache

(2001). Implementing health promotion in health care settings: Conceptual coherence and policy support. Patient Education and Counseling, 45, 245–254. doi:10.1016/S0738-3991(01)00188-4

Barton

Grant

Guise

(2010). Perspectives in public health—Shaping neighbourhoods for local health and global sustainability. The Journal of the Royal Society for the Promotion of Health, 126, 252–253. doi:10.1177/1466424006070466

Beurden

E. K. V.

Kia

A. M.

Zask

Dietrich

Rose

(2013). Making sense in a complex landscape: How the Cynefin framework from complex adaptive systems theory can inform health promotion practice. Health Promotion International, 28, 73–83. doi:10.1093/heapro/dar089

Brittin

Elijah-Barnwell

Nam

Araz

Friedow

Jameton

… Huang

T. T.

(2015). Community-engaged public health research to inform hospital campus planning in a low socioeconomic status urban neighborhood. Health Environments Research & Design Journal, 8, 12–24. doi:10.1177/1937586715575908

Carthey

Chow

Jung

Y.-M.

Mills

(2011). Flexibility: Beyond the buzzword-practical findings from a systematic literature review. Health Environments Research & Design Journal, 4, 89–108.

Center for Active Design (Producer). (2010). Checklist building design [Electronic pdf checklist]. Retrieved March 27, 2018, from https://centerforactivedesign.org/guidelines/

10.

Chiou

S. T.

Chen

L. K.

(2009). Towards age-friendly hospitals and health services. Archives of Gerontology and Geriatrics, 49, S3–S6. doi:10.1016/S0167-4943(09)70004-4

11.

Davis

B. E.

(2011). Rooftop hospital gardens for physical therapy: A post-occupancy evaluation. Health Environments Research & Design Journal, 4, 14–43.

12.

Dijkstra

Pieterse

Pruyn

(2006). Physical environmental stimuli that turn healthcare facilities into healing environments through psychologically mediated effects: Systematic review. Journal of Advanced Nursing, 56, 166–181. doi:10.1111/j.1365-2648.2006.03990.x

13.

Dilani

(2001). Psychosocially supportive design—Scandinavian health care design. World Hospitals and Health Services: The Official Journal of the International Hospital Federation, 37, 20–24.

14.

Dilani

Armstrong

(2008). The “salutogenic” approach—Designing a health-promoting hospital environment. World Hospitals and Health Services: The Official Journal of the International Hospital Federation, 44, 32–35.

15.

Downie

R. S.

Fyfe

Tannahill

(1990). Health promotion: Models and values. New York, NY: Oxford University Press.

16.

Foote

F. M. C. U. S. N.

(2012). The Epidaurus project: Holism in department of defense health facilities. Military Medicine, 177, 8–10.

17.

Foster

Hillsdon

(2004). Changing the environment to promote health-enhancing physical activity. Journal of Sports Sciences, 22, 755–769. doi:10.1080/02640410410001712458

18.

Goel

McIsaac

(1999). Health promotion in clinical practice. In Poland

Green

L. W.

Rootman

(Eds.), Settings for health promotion—Linking theory and practice. Thousand Oaks, CA: Sage.

19.

Golembiewski

J. A.

(2010). Start making sense: Applying a salutogenic model to architectural design for psychiatric care. Facilities, 28, 100–117. doi:10.1108/02632771011023096

20.

Goodstadt

M. S.

(1995). Health promotion and the bottom line: What works? Paper presented at the Seventh National Health Promotion Conference, Brisbane, Australia.

21.

Green

L. W.

Poland

Rootman

(1999). The settings approach to health promotion. In Poland

Green

L. W.

Rootman

(Eds.), Settings for health promotion—Linking theory and practice (pp. 1–43). Thousand Oaks, CA: Sage.

22.

Groene

Jorgensen

S. J.

Fugleholm

A. M.

Møller

Garcia-Barbero

(2005). Standards for health promotion in hospitals: Development and pilot test in nine European countries. International Journal of Health Care Quality Assurance Incorporating Leadership in Health Services, 18, 300–307.

23.

Gulwadi

G. B.

Joseph

Keller

A. B.

(2009). Exploring the impact of the physical environment on patient outcomes in ambulatory care settings. Health Environments Research & Design Journal, 2, 21–41.

24.

Hancock

(1993). Healthy communities: The role of the academic health centre. In Promoting the health of the community (pp. 116–138). Washington, DC: Association of Academic Health Centres.

25.

Hancock

(1999). Creating health and health promoting hospitals: A worthy challenge for the twenty-first century. International Journal of Health Care Quality Assurance Incorporating Leadership in Health Services, 12, 8–19.

26.

International WELL building institute. (2016). WELL v1. In WELL Building Standard (Vol. 1, pp. 246). New York, NY: Delos Living LLC.

27.

Johnson

J. L.

(1999). The healthcare institution as a setting for health promotion. In Green

L. W.

Poland

Rootman

(Eds.), The settings approach to health promotion (pp. 175–198). Thousand Oaks, CA: Sage.

28.

Jordan

(2004). Facility profile. Hospital brings “wellness” to rural setting. Health Facilities Management, 17, 10–11.

29.

Korp

(2016). Vad är hälsopromotion? (1. uppl. ed.). Lund, Sweden: Studentlitteratur.

30.

McGann

Creagh

Tye

Jancey

Blackford

(2014). Stationary in the office: Emerging themes for active buildings. Architectural Science Review, 57, 260–270. doi:10.1080/00038628.2014.958127

31.

Miedema

Lindahl

Elf

(2017, 26-27 April 2017). Health-promotive ambitions related to building design—The case of Angered Nearby Hospital. Paper presented at the ARCH17—Third International Conference on Architecture, Research, Care and Health, Copenhagen, Denmark.

32.

Milz

Vang

J. O.

(1988). Consultation on the role of health promotion in hospitals. Health Promotion International, 3, 425–427. doi:10.1093/heapro/3.4.425

33.

Mroczek

Mikitarian

Vieira

E. K.

Rotarius

(2005). Hospital design and staff perceptions: An exploratory analysis. The Health Care Manager, 24, 233–244.

34.

Pati

Pietrzak

M. P.

Harvey

T. E.

Armstrong

W. B.

Clarke

Weissman

N. J.

… Collins

J. M. G.

(2013). Advancing translational research through facility design in non-AMC hospitals. Health Environments Research & Design Journal, 6, 126–137.

35.

Perdue

W. C.

Stone

L. A.

Gostin

L. O.

(2003). The built environment and its relationship to the public’s health: The legal framework. American Journal of Public Health, 93, 1390–1394.

36.

Pham

M. T.

Rajić

Greig

J. D.

Sargeant

J. M.

Papadopoulos

McEwen

S. A.

(2016). A scoping review of scoping reviews: Advancing the approach and enhancing the consistency. Research Synthesis Methods, 5, 371–385. doi:10.1002/jrsm.1123

37.

Rootman

Goodstadt

Potvin

Springett

(1997). Toward a framework for health promotion evaluation. Copenhagen, Denmark: World Health Organization Regional Office for Europe.

38.

Rousek

J. B.

Hallbeck

M. S.

(2011). The use of simulated visual impairment to identify hospital design elements that contribute to wayfinding difficulties. International Journal of Industrial Ergonomics, 41, 447–458.

39.

Shepley

M. M.

Song

(2014). Design research and the globalization of healthcare environments. Health Environments Research & Design Journal, 8, 158–198. doi:10.1177/193758671400800112

40.

Siddiqui

Z. K.

Zuccarelli

Durkin

A. W.

Brotman

D. J.

(2015). Changes in patient satisfaction related to hospital renovation: Experience with a new clinical building. Journal of Hospital Medicine, 10, 165–171. doi:10.1002/jhm.2297

41.

Trzpuc

S. J.

Martin

C. S.

(2011). Application of space syntax theory in the study of medical-surgical nursing units in urban hospitals. Health Environments Research & Design Journal, 4, 34–55.

42.

Tzeng

S.-Y.

Huang

J.-S.

(2009). Spatial forms and signage in wayfinding decision points for hospital outpatient services. Journal of Asian Architecture and Building Engineering, 8, 453–460. doi:10.3130/jaabe.8.453

43.

Ulrich

R. S.

(1992, 9/10). How design impacts wellness. Healthcare Forum Journal, 35, 20–25.

44.

Ulrich

R. S.

Berry

L. L.

Quan

Parish

J. T.

(2010). A conceptual framework for the domain of evidence-based design. Health Environments Research & Design Journal, 4, 95–114.

45.

Ulrich

R. S.

Zimring

Zhu

DuBose

Seo

H. B.

Choi

Y. S.

… Joseph

(2008). A review of the research literature on evidence-based healthcare design. Health Environments Research & Design Journal, 1, 61–125.

46.

Verderber

(2010). Innovations in hospital architecture. New York, NY: Routledge.

47.

Whitehead

(2004a). The European Health Promoting Hospitals (HPH) project. How far on? Health Promotion International, 19, 259–267. doi:10.1093/heapro/dah213

48.

Whitehead

(2004b). Health promotion and health education: Advancing the concepts. Journal of Advanced Nursing, 47, 311–320.

49.

World Health Organization. (1986). Ottawa Charter for Health Promotion. Paper presented at the International Conference on Health Promotion, the move towards a new public health, Ottawa, Canada.

50.

World Health Organization. (1991a). The Budapest Declaration of Health Promoting Hospitals. Copenhagen, Denmark: Regional office Europe.

51.

World Health Organization. (1991b, 6 9–15). Sundsvall statement on supportive environments for health. Paper presented at the Third International Conference on Health Promotion, Sundsvall, Sweden.

52.

World Health Organization. (1997). The Vienna recommendations on health promotion hospitals. Copenhagen, Denmark. Retrieved from http://www.euro.who.int/document//IHB/hphviennarecom.pdf

53.

World Health Organization. (2017). Introduction to healthy settings. Healthy Settings. Retrieved from http://www.who.int/healthy_settings/about/en/

54.

Wilson

D. M.

Harris

Hollis

Mohankumar

(2010). Upstream thinking and health promotion planning for older adults at risk of social isolation. International Journal of Older People Nursing, 6, 282–288. doi:10.1111/j.1748-3743.2010.00259.x

55.

World Green Building Council. (2016–2018). World Green Building Council. Retrieved from http://www.worldgbc.org/

56.

Zimring

Joseph

Nicoll

G. L.

Tsepas

(2005). Influences of building design and site design on physical activity: Research and intervention opportunities. American Journal of Preventive Medicine, 28, 186–193. doi:10.1016/j.amepre.2004.10.025