The term ‘salutogenic’ is widely used in healthcare architecture, even though very few healthcare architects have much of a handle on what the term means. Here, we clarify the key concepts of salutogenesis, demonstrate how they work and show how they have been designed into healthcare facilities to yield exemplary results.
The central idea is that there are three resources that combine to provide a Sense of Coherence—a forward thrust that resists the entropic forces of illness and infirmity. The sense of coherence is made up of resources that improve manageability—the capacity to maintain homeostasis and physical function; resources that improve comprehensibility—an ability to negotiate circumstances in order to maximise their benefit; and resources that enrich a sense of meaningfulness—the desires, causes and concerns that give us the need to resist illness in the first place.
Keywords:Aesthetics, Architectural psychology, Architectural theory, Architecture, Behaviour, Comprehensibility, Emotion, Evidence-based design, Exemplars, Health, Healthcare design, Hospitals, Manageability, Meaningfulness, Neuroscience, Patient journey, Recovery, Restorative environments, Salutogenic, Sense of coherence (SOC)
In recent years, the term ‘salutogenic’ has become a buzzword for marketing architecture for health and nursing care. The term was coined to describe a model for socioenvironmental influences on health, but in the designers’ hyperbole it now rarely means more than fuzzy intentions to create restorative environments by providing views that represent nature: whether it be designed parkland, grassy areas, views of the sky or even video representations of these things. The term is thus bleached of meaning. The design industry needs a theory to establish whether or not views of nature are likely to be restorative on a case-by-case basis, and perhaps more importantly, to reach beyond this axiom and locate other ways to design and improve restorative environments. The marketer’s sense that salutogenic theory is a powerful tool for understanding the impacts of the design process on the health and illness continuum is well-placed; as Antonovsky suggested, salutogenesis could be the only comprehensive theory of health promotion (1996), something the industry needs for the design process itself, not just for marketing spin.
Substantial evidence shows aesthetic design changes in healthcare settings can improve health outcomes for patients. A number of theories have been offered to explain these effects—but most of them are limited to the specific stimulus under the microscope of the theorists. Examples include an evolutionary hypothesis to explain the influence of ‘views of nature’ (Ulrich 1991), and the ecological theory of Lawton and Nahemow (1973), which argued that there is a ‘sweet-spot’ to be found in a trade-off between designing for comfort and designing for mental and physical challenges. Others argue that the most important issues for health in design are cleanliness and pathogen control (Dancer 2004). Lighting, soundscape design and things like wall paint colour have also been considered (Hurst 1960; Vaaler, Morken, & Linaker 2005), along with seating layout in psychiatric settings (Bitterman 2013; Sloan Devlin 1992).
While these theories are all important to hospital design, they ignore the elephant in the room—that architecture can be psychologically manipulative, for better or for worse. Architecture does this by providing a narrative context that affects a person’s behaviour, neural and endocrine systems, and through its influence on the brain and the body, architecture can directly influence health (Golembiewski 2016). Antonovsky’s salutogenic theory provides an accessible overarching logic for determining these effects in design (Golembiewski 2012b).
Salutogenic theory is not a perfect model of health (Mittelmark & Bull 2013), but as theory, it does have a scope and perspective that other ways of understanding health lack (Antonovsky 1996). Salutogenesis is a way of understanding the entire spectrum of wellness and illness, regardless of specificity and detail. In other words, it provides an overarching narrative structure that transcends the individual differences between people, and the differentiation between diagnoses, circumstances, environmental variation and so forth. Salutogenic theory is thus useful for ‘broad-stroke’ approaches to grappling the well-being and health/illness spectra, and as such, it is useful for managing indirect, complex, obscure or unknown factors in health conditions (this complexity typifies the health influences of the physical environment). Because Salutogenic theory has this higher-level validity that makes sense beyond the specific findings of particular experiments and design interventions (Strümpfer et al. 1998a; 1998b), it provides a basis for informed decision making in the absence of specific knowledge, or whenever circumstances are too complex to suggest easy solutions. Understanding this, Dilani (2006, 2008) and the International Academy of Design and Health (which he chairs) has actively promoted the theory to industry. The results have been a rapid improvement in the overall quality of new healthcare buildings around the world, and while this is very welcome, industry lacks the nuanced understanding of the theory needed to bespoke and expand the scope of salutogenic interventions.
Following from the above, this chapter discusses how salutogenesis can be, and has been, applied to healthcare architecture.
The sense of Coherence
Salutogenesis proposes that good emotional, psychiatric and somatic health is maintained through a dynamic ability to adapt to life’s changing circumstances. The opposite is also true—forces that prevent the ability to adapt exert an aetiological influence on illness. One ‘succumbs to illness’, when demands exceed one’s capacity to cope with them. So a germ on its own is insufficient to cause a disease—it needs to be cultured in an environment that has deficient capacity for resistance (Antonovsky 1972). Models that accept ‘multiple causation’ typically describe the forces that cause maladaptivity as ‘stressors’, a grab bag of influences that includes everything from joyous events to life’s tragedies and banal concerns (Antonovsky 1987). In effect, everything can be considered a stressor, making stress a useless concept. The forces at work to improve adaptability, on the other hand, are specific enough to allow practical, buildable and highly bespoke solutions. These forces have been labelled a ‘sense of coherence’, also known as SOC (Antonovsky 1979).
The sense of coherence is the sum of all generalised resistance resources (or GRRs—hereafter ‘resources’) minus all generalised resistance deficits (Antonovsky 1987). Resources fall into three basic (but interrelated) domains—those that enhance comprehensibility, those that enhance manageability, and those that enhance meaningfulness. Resistance deficits (GRDs), on the other hand, are the ubiquitous challenges to these resources. Resistance deficits are entropic, meaning that without a positive sense of coherence thrust, resistance deficits exert a continuous disintegrative force, allowing illness to overcome a person (Antonovsky 1996). With the total failure of manageability, death ensues, unless the most basic support for manageability is delegated to intensive care systems.
When one is unable to adapt to circumstances and experiences, physical or mental health will ‘breakdown’ (Antonovsky 1972, p. 64). But by focusing on the sense of coherence and on resources, a scaffold emerges that can be readily applied to health facility design. Sense of coherence-supportive design can help liberate the resources that enable resistance to illness and reduce the disintegrative forces that cause maladaptation in the first instance.
Springer, Cham (CH)
Golembiewski JA. Salutogenic Architecture in Healthcare Settings. 2016 Sep 3. In: Mittelmark MB, Sagy S, Eriksson M, et al., editors. The Handbook of Salutogenesis [Internet]. Cham (CH): Springer; 2017. Chapter 26. doi: 10.1007/978-3-319-04600-6_26