Literature Review

Health Environments Research

& Design Journal
1-18
Conceptualizing Health ª The Author(s) 2018
Article reuse guidelines:
Promotion in Relation to sagepub.com/journals-permissions
DOI: 10.1177/1937586718796651

Outpatient Healthcare Building journals.sagepub.com/home/her

Design: A Scoping Review

Elke Miedema, MSc, LIC, PhD(c)1 , Göran Lindahl, PhD1,

and Marie Elf, RN, PhD1,2

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 pro-
motion perspectives (health behavior, health equity, and sense of coherence), associated design
approaches, design objectives, health-related outcomes, building features, and solutions. Conclu-
sions: 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

1
Division of Building Design, Department of Architecture and Civil Engineering, Chalmers University of Technology,
Gothenburg, Sweden
2
School of Education, Health and Social Studies, Dalarna University, Falun, Sweden

Corresponding Author:
Elke Miedema, The School of Architecture, Chalmers University of Technology, Sven Hultins gata 6, Gothenburg 412 96, Sweden.
Email: miedema@chalmers.se
2 Health Environments Research & Design Journal XX(X)
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. 5), 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 rele-
vance of the built environment for health promo-
tion (Perdue, Stone, & Gostin, 2003). Previous
research has related health promotion to urban
design (Barton, Grant, & Guise, 2010) and build-
ing design (McGann, Creagh, Tye, Jancey, &
Blackford, 2014; Zimring, Joseph, Nicoll, & Tse-
pas, 2005). As a result, several checklists, certi-
fication 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 orga-
nizations 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 promo-
tion 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, Good-
stadt, Potvin, & Springett, 1997). These definitions
represent diverse perspectives rather than funda-
mentally conflicting meanings (Green, Poland, &
Rootman, 1999). Nevertheless, there is no consen-
sus definition (Whitehead, 2004b), and the concept
is often confused with other approaches such as
disease prevention (Antonovsky, 1996). The dif-
ference 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 pre-
vention) 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 cer-
tain criteria that distinguish health promotion
from other health-related approaches:
1. encouraging public participation by indi-
viduals and communities;
2. taking a social and cultural perspective in
understanding and responding to health
issues and problems;
3. emphasizing equity and social justice;
4. fostering intersectional collaboration;
5. including physical, mental, social, and
spiritual dimensions of health; and
6. focusing on enhancing health, not just pre-
venting 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 mul-
tilevel action and multidimensional approaches
are needed to sustain impact.
Miedema et al.
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 environ-
ments 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 associ-
ated with medicalization, individualization, and
institutionalization rather than health empower-
ment 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 health-
care 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 facil-
ities 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
3
as educational kitchen or spiritual spaces (Mie-
dema, Lindahl, & Elf, 2017). The health-
promoting hospital must thus be one part of the
process of creating healthier communities (Han-
cock, 1999).
This approach is recognized by the Health Pro-
motion Hospital Network, a worldwide organiza-
tion 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 evi-
dence 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 ques-
tion(s), (2) identifying relevant studies, (3) select-
ing 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 exist-
ing 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 promo-
tion conceptualized in the context of outpa-
tient healthcare building design?
Research Question 2: How is health-
promoting building design conceptualized
in the context of outpatient building design?
4 Health Environments Research & Design Journal XX(X)

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 (‘health promotion’ or salutogenics or ‘universal design’ or wellbeing
AND Healthcare Facility 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 (‘health promotion’ or salutogenics or ‘universal design’ or wellbeing
Facility 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’)

Identifying Relevant Studies an outpatient healthcare setting, (4) be written in

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 sim-
ilar terms were included that describe those con-
cepts (Tables 1 and 2). The search terms were
decided in consultation with university librarians
and guided by MeSH terms of the accessed
databases.
The included literature should (1) address
building design aspects, (2) address the factors
involved in health promotion, (3) be situated 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.
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 promo-
tion, outpatient healthcare facility, or built envi-
ronment. This approach was used to avoid hasty
exclusion due to vague titles. However, the fol-
lowing selection phases required all three main
Miedema et al. 5

Table 3. Listing of the Inclusion and Exclusion Criteria for the Scoping.

Inclusion Criteria Exclusion Criteria

Situated as part of a healthcare facility with Situated in wards in inpatient care

outpatient program Journals from other research domains such as information
Refers to health promotion technology or biology
Refers to building design Other sources such as newspaper articles, dissertations, and
English letter to editor
Between 2005 and 2015
Journal papers and professional articles

Figure 1. Illustration of flowchart.

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 envi-
ronment, building design, or spatial aspects. Oth-
ers were excluded because they addressed
inpatient facilities rather than outpatient facili-
ties. The selection focused on the building itself
and did not actively search for literature addres-
sing the route to the healthcare facility. The final
selection addressed all three concepts: health
promotion, building design, and outpatient facil-
ity. 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 informa-
tion (authors, year), (2) topic, (3) method, (4)
interpretation of health promotion, and (5)
interpretation of health-promoting building
design.
6 Health Environments Research & Design Journal XX(X)
Table 4. Overview of Included Sources With Topic Summary, Method Summary, and Conceptualization of
Health Promotion.
Author(s)
(year) Topic
Brittin et al. Desirable resources for
(2015) community-centric hospital
integrating healthcare, health
promotion, and other
community resources
Chiou and Chen Framework development for
(2009) age-friendly hospital (and
services), Taiwan
Davis (2011) Evaluating a rooftop garden
used primarily for physical
therapy
Dilani and Salutogenic approach to
Armstrong designing a health-promoting
(2008) hospital environment
Dilani (2001) Integration of care philosophy Discussing different models Health promotion used as the
in building design
Addressing Health
Method Promotion
Mixed method; interviews, Health promotion: Focus on
focus groups, survey, and long-term population health
spatial analysis on in addition to individual
settlement patterns health, with understanding
similarities and differences
amongst local ethnic groups
Merging “age-friendly Health promotion for older
principles” with “health- people; opportunity and
promoting hospitals” and ability to control
elder-friendly hospital (determents of) health as
initiative essential part of human
dignity and integrity
throughout life
A postoccupancy evaluation: Accessibility of the therapeutic
mix of interviews, rooftop garden
behavior mapping, survey, Active use of the garden to
and questionnaire healing physically,
emotionally, and spiritually
for specific patient
populations, population
needs, and awareness
Conversations and own Health-promotion and
experience on several salutogenic approach, not
projects explained
Included concepts: Wellness
and sense of coherence,
social cohesion, personal
control, meaningfulness,
comprehension,
manageability, and access
and theories salutogenic approach
designing a health-promoting
hospital environment
Included concepts: Wellness,
physical needs,
comprehension, quality of
care, and psychosocial
factors
(continued)
Miedema et al. 7

Table 4. (continued)

Author(s) Addressing Health

(year) Topic Method Promotion

Foote (2012) Core principles of patient- Merge outcomes of working Holistic (or whole person)
centered to architectural groups, a conference, and care, including wellness,
design features a case 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 Effectiveness environmental Systematic literature review Mentioned as promoting
Hillsdon interventions to enhance health-enhancing physical
(2004) physical activity activity in relation to health
behavior
Golembiewski Architectural extrapolation of Theoretical exploration Salutogenics: As the
(2010) Antonovsky’s salutogenic psychosocial study of what
theory keeps people healthy—sense
of coherence,
meaningfulness,
comprehension, and
manageability
Gulwadi, Impact physical environment Literature review Patient-/family-centered
Joseph, and on patient outcomes in initiatives—new models of
Keller (2009) ambulatory care settings providing underserved
populations access to
qualitative health services;
integrated iterative, patient-
centered approach
Jordan (2004) Wellness environments’ in a Case description of the Wellness—meeting current
rural community hospital design intentions population needs
Mroczek, Staff satisfaction, supportive Exploratory analysis of Need for hospital to be
Mikitarian, physical environment, and employee satisfaction sensitive to the entire
Vieira, and organizational environment data, literature review, building population and
Rotarius and empirical research supportive of healing, health,
(2005) and well-being—connection,
privacy, access to social
support, and empower
Rousek and “Simulated visual impairment” Observations and Accessibility for people with
Hallbeck to identify hospital design questionnaires special needs, specifically the
(2011) elements influencing visually impaired—human
wayfinding difficulties rights wayfinding experience,
patient satisfaction, spatial
cognition, patient flow,
dignity, and interdependence

(continued)
8 Health Environments Research & Design Journal XX(X)
Table 4. (continued)
Author(s)
(year) Topic Method
Shepley and Cultural aspect of health needs Literature review
Song (2014) for design of healthcare
environments
Siddiqui, Perceptions of “care” versus Analysis of patient
Zuccarelli, “physical environment of satisfaction survey data
Durkin, Wu, care” for patient-centered
and Brotman, design
(2015)
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 ¼ 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
Addressing Health
Promotion
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
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)
design, nursing, public health, and environmental
psychology (Table 4).
Health Promotion Perspectives
Table 4 and Figure 2 show the diversity in addres-
sing 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 psy-
chosocial 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 perspec-
tives 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,
Miedema et al. 9

Figure 2. Overview of health promotion aspects as addressed in selected papers.

2010; Shepley & Song, 2014). Both Golem-
biewski (2010) and Dilani and Armstrong
(2008) referred to a framework that includes com-
prehension, 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 rela-
tion to religious and cultural health belief sys-
tems. Within the included papers, salutogenics
was combined with other terms such as wellness
10 Health Environments Research & Design Journal XX(X)

Figure 3. Overview of health-promoting building design aspects as addressed in selected papers.

(Dilani, 2001; Dilani & Armstrong, 2008) and and the sense of coherence framework may pro-
patient centeredness (Shepley & Song, 2014). vide a basis for focused design decisions where
Golembiewski (2010) added that salutogenics empirical evidence is limited.
Miedema et al.
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 pro-
moting 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 func-
tion. The authors also stated that this combina-
tion of components can promote or discourage a
particular behavior. Several other authors asso-
ciate 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 build-
ing design. However, authors addressed terms
associated to health equity, such as dignity (Rou-
sek & Hallbeck, 2011), human rights (Chiou &
Chen, 2009; Rousek & Hallbeck, 2011), vulner-
able populations (Brittin et al., 2015; Chiou &
Chen, 2009; Davis, 2011; Golembiewski, 2010;
Gulwadi, Joseph, & Keller, 2009; Mroczek, Miki-
tarian, Vieira, & Rotarius, 2005; Rousek & Hall-
beck, 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, Zuccar-
elli, 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 & Hills-
don, 2004). Only Rousek and Hallbeck (2011) and
Chiou and Chen (2009) explicitly referred to
human rights, while multiple studies addressed the
11
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 environ-
ment 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 combina-
tion 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 orga-
nizational effects. For instance, Foster and Hills-
don (2004) discussed the possible influences of the
environment on health-enhancing physical activ-
ity, 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 com-
plex 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 vulnera-
ble groups, such as the elderly (Chiou & Chen,
2009), children (Brittin et al., 2015; Shepley &
Song, 2014), people with low socioeconomic sta-
tus (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 dif-
ferent themes that relate health promotion
12
aspects of building design, including design
approaches, design objectives, and design char-
acteristics (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 environ-
ment (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 environ-
ment, which they defined as “architectural prin-
ciples 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 outpa-
tient 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 fea-
tures in relation to patient-centered design,
including air, noise, and infection control as well
as the incorporation of nature, art, and spiritual-
ity. Several explicit design solutions are
Health Environments Research & Design Journal XX(X)
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 eva-
luation of the quality of the included papers
(Arksey & O’Malley, 2007; Pham et al.,
2016). Neither is a scoping intended to pre-
scribe 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 environ-
ments, and consequently dialogues on the plan-
ning 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
Miedema et al.
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 refer-
ence 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 dis-
cussed 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 interpreta-
tion 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 proble-
matic 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
13
groups. This limited provision of definitions,
weak vocabulary, and lack of references to pre-
vious definitions might also create difficulties in
finding related research. Thus, working with
health promotion includes familiarizing oneself
with the different types of strategies and posi-
tioning each project in relation to the different
strategies.
The different perspectives result in a simplifi-
cation of the multidimensional concept. This
seems to occur when a health promotion perspec-
tive 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 promo-
tion perspectives and their implications for build-
ing 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 dif-
ferent 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 comple-
ment 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:
1. encouraging public participation by indi-
viduals and communities;
2. taking a social and cultural perspective in
understanding and responding to health
issues and problems;
3. emphasizing equity and social justice;
4. fostering intersectional collaboration;
14
5. including physical, mental, social, and
spiritual dimensions of health;
6. focusing on enhancing health, not just pre-
venting problems; and
7. considering the ecological footprint of the
building design and its use.
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.
The scoping review confirms that the evalua-
tions 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 out-
comes 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 measur-
able; rather, as suggested by Trzpuc and Martin
(2011), interventions should be evaluated through
mixed method approaches. This could be comple-
mented by approaches founded in socioecological
approaches or frameworks. For instance, Beur-
den, Kia, Zask, Dietrich, and Rose (2013) pro-
vided a framework that aims to distinguish
between these simple (causal), complicated, com-
plex, and chaotic measurable relations.
Surprisingly, the literature shows a range of
design approaches, including universal, patient-
centered, or age-friendly design, in relation to out-
patient 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 differ-
ences 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
Health Environments Research & Design Journal XX(X)
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 explora-
tions might continue to focus on approaches used
in the practice of planning and designing health
promotion hospitals, such as the study by Mie-
dema, Lindahl, and Elf (2017). Another possible
avenue to explore is the relations and contradic-
tions between universal design and active design
approaches. Additionally, the other approaches
presented may provide a starting point for a dis-
cussion of health-promoting building design and
what guides and defines it.
Unfortunately, this review reveals that many
solutions are considered in isolation, while oppor-
tunities 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 part-
ners; and (4) set health-promotive ambitions, pre-
ferably 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 incon-
sistencies 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
Miedema et al.
design practice. If we seek to design health-
promoting buildings without clarification of what
this entails, what outcomes are desired and feasi-
ble, it becomes difficult to guide design choices,
especially when the evaluation of such buildings
has already been identified as complex. Addition-
ally, the lack of a robust terminology complicates
finding the latest research on the topic because
one might not be familiar with all the terms relat-
ing 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 profes-
sionals, which can benefit the development of
health promotion and healthcare building design.
The presented scoping review suggests terminol-
ogy, 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 regard-
less of their background.
 Consider both the design process and the
building as means for health promotion pro-
cesses, including participation, health edu-
cation, 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.
15
 Initiate knowledge development on strate-
gic and project level on health promotion
to enable organizations’ and stakeholders
to develop an understanding of different
interpretations/concepts of health promo-
tion, 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.
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 Spa-
tial Planning (FORMAS).
ORCID iD
Elke Miedema http://orcid.org/0000-0002-
8440-4859
Marie Elf http://orcid.org/0000-0001-7044-
8896
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