Yeunsook Lee PDF

SHB2012 - 6th International Symposium on Sustainable Healthy Buildings, Seoul, Korea 27 February 2012
Identifying Space Planning Guidelines for Elderly Care Environments from the Holistic Health Perspective
Yeunsook Lee1, Jihye Hwang1, Soohyun Lim1, Hyunsoo Lee1, Jeong Tai Kim2
2 1
Department of Housing & Interior Design, Yonsei University, Korea Department of Architectural Engineering, Kyung Hee University, Yongin 446-701, Korea
Abstract The elderly care environment is a special interactive architectural environment. For successful development of an elderly environment, there needs be a clear understanding of the service and utilization of the related service plans, appropriate planning principles and architectural elements. The purpose of this paper is to identify space planning guidelines for elderly care facilities from the holistic health perspective. The outcome of this research it was expected to promote better understanding of elderly care environments as a resource for health. The major method used in this paper was a content analysis technique where the criteria were physical, psychological and social health. Data for analysis were collected through an in-depth interview with care facility administrators using a checklist of 114 items related to spatial planning that were developed through analyzing design guidelines from Japan, the UK, Germany, and the USA. As a supplemental method, a literature review of the current status of Korean healthcare facilities and recent trends in design theories for elderly care facilities was utilized. As results, a matrix was developed where each guideline item was matched to each of three health dimensions, thereby delineating the relationship between them. The elderly care environment is a vital resource to provide and support holistic health. Therefore, it is important to understand how they are related to and utilized by each other, in order to increase the congruence between them. The resulting matrix is expected to be a base to provide better planning services and that could be further developed as an "elderly welfare facility design guideline for holistic health ". Keywords: Elderly Welfare Facility, Nursing Home, Holistic Health, Evaluation System, Design Guidelines
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1. Introduction 1.1 Background and Purpose The necessity of welfare facilities for the elderly has been emphasized continuously with the aging of society and a deficiency of awareness of the need to support elderly. With this background, a long term care insurance system for elderly was implemented in 2008 and 1,513 elderly welfare facilities were established by 2008 and the number increasing continuously since [1]. However, these facilities were design to accommodate specific stage of health and are not equipped to handle the range of age-related health deterioration. In addition, the architectural standards of these facilities stipulate the space and facility usage only according to the number of residents without providing suitable environments for thoes elderly who suffer from deteriorating physical functions due to aging, changes in overall sense and sensibility functions and socio-psychological changes. Facilities for the elderly serve an important function in preventing the elderly, who are the typical socially underprivileged from being socially excluded and helping them live well as normal members of society. Therefore, the facilities not only provide physical residential space but also have decisive affects on the physical and psychological health and welfare of the elderly. Concluding from the numerous opinions of diverse scholars, elderly homes provide safe space and diverse services for the elderly whose physical, psychological and social functions decrease so that they may live as autonomously as possible [2]. From the perspective that elderly welfare facilities should not serve solely as simple residential spaces, but as comprehensive living spaces that guarantee a system of physical, psychological and social comfort and convenience for the elderly, it is urgently necessary develop an integarated model based on the needs of the users [3]. Therefore, it is necessary to study practical evaluation systems for integrated elderly welfare environments by satisfying the two conditions of precise understanding of quality services for special architectural environments for the eldelry, and plannings principles and utilization of factors for suitable physical architecture environments. Accordingly, from the holistic health perspective, this study aims to analyze methods of establishing guidelines for elderly welfare facilities previously developed in recent precedent studies. Most guidelines have health factors latently, but as they do not reveal them outwardly people are not likely to recognize them. Therefore, in order to improve the recognition that guidelines with health factors are necessary, it is required to anlyze respective guidelines to identify their varied aspects and characteristics. And by sharing the study results a new direction for better guidelines with more considerations for holistic health can be suggested. Through this process, this study intends to contribute to setting up practical indicators in planning welfare and nursing environments for more healthy environment in future.
1.2 Methodology Content analysis and a small group workshop were used as a methodology. First of all, by using a content analysis method, a content analysis was made with a focus on literature analyzes evaluation tools for elderly welfare facilities in advanced countries overseas that deal with environmental theories and design guidelines for elderly people. Through analyzing
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literature regarding the behavior of a number of evaluation tools developed by a variey of research onstitutes in different countries, a metric (planning factors) was identified. Also used in this paper as a basic tool for analysis was as evaluation system which resulted from the verification of a survey that a precedent study conducted upon 120 respondents, including experts related with elderly welfare facilities and currently employed care givers in professional elderly welfare facilities in Korea. This paper aims to identify an evaluation system for elderly welfare facilities in order to organizationally collate the planning of elderly welfare environments for holistic health and the necessary information to design the environment. Therefore, for this purpose, in order to practically prove the importance of each item of the evaluation system that was developed in the precedent study, the evaluation system was reanalyzed and verified through small group workshops with experts of elderly welfare facilities from the viewpoint of the holistic health of residents, that comprised of physical, psychological and social perspectives, with a view to positively connect with the aging society. 2. Literature Review 2.1. Theoretical review on holistic health and health architecture Holistic health comprises physical/physiological health, psychological/emotional/mental health, and socio-psychological/social health and means a comprehensive health defined by the WHO (World Health Organization). WHO defines health as: Health is the state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. As WHOs definition of health is accepted widely in the world, if there is any problem in regards to any of the three dimensions of physical, mental and social health, health condition is perceived negatively. In addition to physical health, mental and social healths have been perceived to be important. Recently, people are paying more attention to socio-psychological health and social health. As such a well-designed architectural environment activates healthy behavior patterns. Architectural environments design with socio-psychological support lead especially the mental and social health of the users. Dailani said that the basic function of design with socio-psychological support leads to positive psychological changes that minimize or eliminate the anxieties of human-beings[4]. Because a healthy home supports the purpose of environmental design and create physical environment to carry sustainable value through ecological dynamism, a home that supports the health of a family is a healthy home with living energy. In order to support health at such multiple levels, Yeonsook Lee (2006) analyzed the characteristics of homes in relation with health levels as shown in the following table 1. The table explains how a healthy house affects the health of human-beings extensively from planning facilities and spatial factors such as location, moving lines and positions, environmental design of sounds, heat and lighting, and overall factor plans of illumination, wiring, materials, indoor landscape, coloring, furniture and equipment. The whole house in large scale and small scale of bedrooms, living rooms, bathroom/toilets, kitchens, family rooms and study rooms affects the health of a family (Figure 1)[5].
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Figure 1. Architectural design concept of health Table 1. Examples of home support characteristics by health aspects Health aspects Home support characteristics Prevention of physical factors that cause falls and exhaustion Physical Health / Elimination of harmful factors such as noise, air pollution, poor light and Pysiological illuminations Health Endowment of stimulus for physical growth and biological satisfactions Elimination of tensions in mental and psychological state Psychological / Endowment of opportunities to enhance emotion and to promote psychological Mental Health security and calmness Elimination of social tensions among family members Social / Socio Maintenance of proper privacy Psychological Endowment of potential opportunities for proper interaction stimulus/guidance Health
*Source: Lee SM, Lee YS: Health Friendly House Planning Elements Demanded by Consumers; J Korea Institute of Ecological Architecture and Environment; 2008;8(6):11-20, Ibid [6].
As holistic health becomes important, studies and experience about health and architecture are exchanged in diverse ways. Recently, the environmental design of work places and the health of worker; the relationship between productivity, quality of life and the consistency of environmental design, music and health; the relationship between architectural environment and satisfaction, nature and health including eco-gardens and healing environments have become major topics of studies, and scientific evidencebased-designs in relation with health have been emphasized [7]. In addition, theory of Lawton [8], Carp&Carp [9], Atchely [10] and Murth&Lee [11] about the relationship with aging and spatial design in architectures have been quoted in many domestic doctoral study papers [12, 13, 14]. Valins [15] explained how to design elderly residents for customers, architectural designers and indoor designers in his work Housing for Elderly People. He proposed design guidelines as a base for activities. Many conceptual frameworks and guidelines are presented and theories and scientific bases have begun to take root, while theories and practical studies have become necessary and will become very active in future [16].
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2.2 Initiative evaluation guidelines for global elderly welfare facilities In the case of advanced foreign countries that have experienced an aging society prior to Korea, various evaluation tools for elderly welfare facilities have been developed. And if we look into the recently developed Comparative Study on Examples of Leading Design Guidelines, on a scientific and empirical basis (Table 2), a comprehensive review was made of the advanced guidelines of the U.K., Germany, the U.S.A. and Japan. Based on this review, the structural system of design guidelines that decide the frameworks of spaces were analyzed and verified by the above research process (Table 3). The care environment is largely divided into two divisions of the human system based on the behavior of the elderly and a special system based on the physical environment of facilities, while the design guidelines of elderly welfare facilities with a focus on management and operation for the two divisions have been referred to as an important factor to be applied from the viewpoint of integration that does not have any bias toward on either divison (Figure2).
Table 2. Case study of analysis objects for environmental theories and design guidelines for the elderly Items
TESS-NH/RC (Therapeutic Environment Screening Scale for Nursing Homes and Residential Care)
Contents
Researcher: Philip D. Sloane et. al. Research institutute (year): University of Carolina, the U.S.A. (2001) Evaluation tools for treatment environments from the perspective of managerial and operational aspects of elderly welfare facilities The tools are utilized in many research activities. Research institutute (year): Health Facilities Scotland, the U.K., Dementia Service Development Centre(2007) Evaluation tools for planning factors of spaces in elderly care facilitities for people with dementia Research institutute (year): Baden-Wrttemberg, Germany, Social welfare planning office of local government (2010) Design guidelines for each sector of architecture of elderly welfare facilities based on physical environments to enhance the quality of life from the aspects of psychological and social life as well as physical health Research institutute (year): Archtectural Institute of Japan(2011) Design guidelines applicable in environments according to the status and behavior of the elderly from the perspective of health and behavioral patterns of the elderly
DDC (Dementia Design Checklist)
MBAB (Matrix Bauliche Anforderungen und Bereiche)
EDC (Environment Dementia Care)
*Source: Lee YS, Lim SH, Hwang JH: Comparative Analysis of Leading Design Guidelines for Environment of Elderly People with Dementia; J Archtectural Institute of Korea 2011; 27(11):92-96 [17].
On the other hand, Yeonsook Lee et al. (2011) tried to practically verify the utility of evalualtion tools through a survey at 120 respondents including experts of elderly welfare facilities and care helpers on site at current elderly welfare facilities in Korea with 114 items of design guidelines (Table 4) by setting up basic evaluation tool frames (Table5) based on this integrated structure.
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Table 3. Guideline identifying process of each system

Space Psychological/social aspect Guidielines Awareness & Orientation Safety & Security Privacy Provision of Privacy Stimulus Functional capacity & Capability maintenance Autonomous decision/ Control Continuity of the Self Social contact Space Guidelines Bedrooms Bathrooms(private-common) Corridor Kitchens Dining rooms and living rooms Mulitipurpose rooms Entrance Outdoor space (Terrace, Garden) Space Guidelines Bedrooms Bathrooms(private-common) Corridor Kitchens Dining rooms and living rooms Mulitipurpose rooms Entrance Outdoor space (Terrace, Garden)
Space System
Individual room Bathroom(private-common) Corridor Kitchen Dining romm and living room Multipurpose space Entrance area Outdoor space (Terrace, Garden) Living behavior patterns Interaction/ Meetings House works Meals/Coffee & tea Sleeping/Getting-up Bath Toilet use Washing Walking/shopping Maintenance Maintenance Cleanness Smell/ordor Safety Illumination Physical surface Direction/clue Privacy Noise Plants
Human System
Managerial System
*Source: Lee YS, Lim SH, Hwang JH: Comparative Analysis of Leading Design Guidelines for Environment of Elderly People with Dementia; J Archtectural Institute of Korea 2011; 27(11): 98, Ibid [17].
Figure 2. Integrated conceptual structure for healthy environment design for elderly people with dementia
*Source: Lee YS, Lim SH, Hwang JH: Comparative Analysis of Leading Design Guidelines for Environment of Elderly People with Dementia; J Archtectural Institute of Korea 2011; 27(11): 97, rearrangement of the contents [17].
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Table 4. Design concept and physical environmental factors of verified evaluation tools
Design Concepts 1. Awareness & Orientation 2. Safety & Security Evaluation Contents Is a regular activity program available for reinforcement of perceptive and congnitive capabilities? Is there enough space for the activity program? Are residents safe in the spaces? Are dangerous materials kept safe? Can residents choose their roommate? Do employees respect the privacy of the residents? Were the floor structures designed to protect the residents privacy? Is the independent behavior of residents supported? Are physical environments helpful for maintenance and enhancement of the residents ADL? Are there any stimuli that give positive effects without any negative stimulus like noise for the elderly and that are provided through environment or a program? Are residents allowed to use their old furniture or private effects that they used to use at their previous residence and are that useful to encourage the pride of the residents and sustain their memories of their past affairs? Can residents live freely? How much do the regulations of the facilities reflect the will of the individuals? Do the space lay-out or furniture positions facilitate social contacts among the residents and employees? Is social contact promoted by programs? NumberofItems 16
19
3. Provision of Privacy
4. Support Functional Abilities 5. Regulation & Quality of Stimulation
22
10
6. Continuity of the Self
13
7. Opportunities for Personal Control 8. Facilitation of Social Contact
12
14
*Source: Lee YS, Hwang JH, Lim YS, Lim CS, Park YW: Care Helpers Evaluation and Requests on Designs of Elderly Welfare Facilities in Korea; J Architectural Institute of Korea 2011; 27(12): 94 [18]. **Through verification of five experts on elderly welfare facilities, the evaluation contents by design concepts were rearranged by choosing total 114 items excluding ambiguous two items out of existing total 116 items.
Table 5. Evaluation contents and items of design concepts of verified evaluation tools
Physical Environment Bedroom Bathroom Design concept 1. Awareness & Orientation 2. Safety & Security 3. Provision of Privacy 4. Support Functional Abilities 5. Regulation & Quality of Stimulation 6. Continuity of the Self 7. Opportunities for Personal Control 8. Facilitation of Social Contact Corridor Kitchen Dining Room &Living Room Multipurp Entrance ose Room Outdoor Spaces
*Source: Lee YS, Hwang JH, Lim YS, Lim CS, Park YW: Care Helpers Evaluation and Requests on Designs of Elderly Welfare Facilities in Korea; J Architectural Institute of Korea 2011; 27(12): 94, Ibid [18].
This presents a fundamental base for the design of elderly welfare facilities that can be
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utilized in Korean situation and has been used for analyzing the evaluation system for elderly welfare facilities from the holistic perspective of this thesis. This is to improve the previously developed basic framework of fundamental evaluation tools from the holistic health perspective for the spaces and environments for the elderly that were designed for the sake of all users of elderly welfare facilities. In addition, this is the basis for developing the systems and manuals for good design of elderly welfare environments in consideration of holistic health.
3. Analysis of Evaluation System 3.1 Objects of Analysis The evaluation guidelines used in this study were utilized to analyze the evaluation system more sophisticatedly from the viewpoint of holistic health on the basis of survey results (Table 6, 7) that were verified through the survey of 120 care helpers who are working in professional elderly welfare facilities in Korea. The importances of design concept from the viewpoint of environmental behavior patterns of the basic evaluation system drawn from the precedent study, and the importance of physical environmental factors, were reviewed. The evaluation system of respective factors was researched in detail from the viewpoints of physical, psychological and social health considering the concept of holistic health.
Table 6. Major design concept for each space of evaluation system analysis objects and their reliabilities
Physical Environment Bedroom Bathroom Design concept 1. Awareness & Orientation 2. Safety & Security 3. Provision of Privacy 4. Support Functional Abilities 5. Regulation & Quality of Stimulation 6. Continuity of the Self 7. Opportunities for Personal Control 8. Facilitation of Social Contact Dining Room &Living Room Multipurp Entrance ose Room Outdoor Spaces
Corridor
Kitchen
*Source: Lee YS, Hwang JH, Lim YS, Lim CS, Park YW: Care Helpers Evaluation and Requests on Designs of Elderly Welfare Facilities in Korea; J Architectural Institute of Korea 2011; 27(12): 97[18]. ** 4 points and over and less than 5 points, 3 points and over and less than 4 points, 2 points and over and less than 3 points.
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Table 7. Reliabilities of questionnaire items

Design Concept Reliability index (Cronbach's alpha) No. of questions Awareness/ Orientation Safety / Security Provision of Privacy Support Regulation/ Opportunities Facilitation Continuity Functional Quality of for Personal of Social of the Self Abilities Stimulation Control Contact
0.604
0.842
0.778
0.888
0.825
0.875
0.739
0.877
15
16
13
27
13
12
12
13
*Source: Lee YS, Hwang JH, Lim YS, Lim CS, Park YW: Care Helpers Evaluation and Requests on Designs of Elderly Welfare Facilities in Korea; J Architectural Institute of Korea 2011; 27(12): 95 [18]. **Cronbach's alpha of reliability analysis indicates the internal consistency and if Cronbach's alpha is 0.60 or more, reliability is positive and all items can be analyzed as proportionate scale.
3.2 A Small Group Workshop A small group workshop was held in January 2012 and the surveyed people were experts on environmental designs for elderly welfare facilities. All the experts had doctoral degrees with a mimimum of two years of work experience in projects related with environments for the elderly, and have written many papers on the elderly and the aging society for international presentations at conferences as well as academic journals. Five experts reviewed the proprieties and handicaps of the evaluation guidelines and analyzed the evaluation system in detail from the perspective of design concepts and holistic health. The details are explained in Table 8.
Table 8. Items of each detail of the design concept and the holistic health persfective
Items Contents 1 Is there space on the walls for paintings and photos? 2 Are there storage closets for private belongings? 3 Is there sufficient space for wheelchairs and moving equipment? In case of emergency, can care givers observe the individual rooms 4 form outside through a window? 5 Is the indoor space designed to observe the elderly from the outside? 6 Do the individual rooms have privacy protection? 7 In case two people share the space, is their privacy protected? In case three people share the space, is their individual privacy 8 protected? 9 Does the individual room have a private toilet? 10 Does the individual room have a bathroom/shower-room? 11 Does the individual room have a washing basin? Can users of individual rooms observe the outside landscape from the 12 individual room? 13 Is it easy to access the toilet from the bedroom? 14 Is it possible to observe the inside of the bathroom from the bedroom? 15 Is the washing basin easy to use in a wheelchair? 16 Does the wash basin have enough space to use while sitting? Is there spacious storage for large items like adult diapers for urinary 17 incontinence patients? 18 Are windows easy to open? 19 Is it possible to utilize and control the visual and acoustic contacts? 20 Are the rooms similar to conventional rooms of existing houses? Design Concept AO SS Hoilstic Health PP SFA RQ CS OPC FSC PP PM SP
B E D R O O M
159
Items 21 22 23 24 25 26
Contents
AO SS
B E D R O O M
Is it possible to use conventional household goods? Is there a window for natural ventilation? Are the windows placed properly to observe the outside? Is there enough space for two sofas ? Do they protect privacy while minimizing the sense of isolation? Are individual rooms near living rooms and shared spaces? Is it easy to identify the spatial characteristics of the near distance as 27 viewed from the door of bedrooms? Is there enough space near the doors of bedrooms for moving patient 28 beds 1 Does the door of bathroom block the entrance if it is open? 2 Are there anti-slipping measures in bathrooms? 3 Are the semi-private or shared bathrooms near individual rooms? 4 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1 2 3 4 Are there spaces of 2x2m or more for wheelchair users and care givers? Are there safety bars to prevent slipping accidents? Are the corridors easy to find ways and navigate? Is it possible to observe diverse spaces and activities in the corridors? Are exits, stairways and emergency doors controllable for patient care? Are thresholds and furniture placed safely to prevent falls? Are there resting spaces for individuals and small groups? Are there various interesting visual and sensory stimuli? Is it easy to find a toilet in the corridors? Is it easy to access corridors? Is there enough space for wheelchairs and moving equipment? Are corridors placed safely for continuous moving? Is there an opening or closing sign at the end of corridors? Is it possible to access corridors from diverse spaces? Are the doors not placed monotonously along the corridors to avoid any image of public welfare facilities? Are there windows for natural ventilation to avoid the sordid atmosphere of public welfare facilities? Are there proper seats for comfortable sitting around places for activities? Are there spaces for natural interactions of care givers and the elderly people Are the kitchen space and the entrance to the kitchen easily visible? Can people smell food and observe and hear the cooking process? Is the work table placed properly in the kitchen so that employees may observe the elderly? Are the storage closets properly placed for easy notice and a familiar atmosphere? Is it possible to control movement when necessary? Are sharp corners and edges around the kitchen eliminated? Do employees work at the kitchen within sight of the elderly? Does the kitchen give visual and olfactory stimuli like ordinary homes? Is the kitchen easy to access by the elderly? Is there a work table in the kitchen that enables the elderly to participate in meal preparation? Is it possible to access beverages freely day and night in the kitchen? Are there kitchen facilities available that help the residents live independently? Is it considered that elderly people may prepare their meals with the employees? Is the kitchen comfortable like home?
Design Concept Hoilstic Health PP SFA RQ CS OPC FSC PP PM SP
B A T H R O O M
C O R R I D O R
K I T C H E N
5 6 7 8 9 10 11 12 13 14
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Items 15 16
D I N N I N G R O O M & L I V I N G R O O M
Contents Is there space in the kitchen for natural interaction among care givers, employees and the elderly? Are the kitchen facilities placed properly to stimulate the interaction between the elderly and employees? Is the kitchen visible from corridors through windows or open style? Is the kitchen spacious for wheelchair users? (about 5 square meters per person) Is the kitchen differentiated with diverse furniture? Is the kitchen easily observable by care givers and employees? Is the kitchen safe without the observance of employees? Is the kitchen set up for serving small groups? Is it possible to place pots for flowers and trees in and around the kitchen? Is the kitchen connected with neighboring spaces for communication and participation of the elderly? Is it possible to see the dining space or any sign for the space? Is the toilet near the dining space? Is dining space similar to conventional homes? Is the kitchen small enough for a familiar feeling? Is the kitchen designed as a group home or unit-care model? Are there observating points? Are there shared spaces for natural interactions? Can employees dine with the elderly side by side? Is furniture placed properly for multipurpose activities? Is there sufficient space for equipment? Is there space for dangerous equipment in multipurpose rooms? Can flowers and trees be placed near multipurpose rooms? Are work and activity spaces easily visible? Is it possible to see activity spaces and any signs for the spaces from the entrance of residents bed rooms? Is the accessibility to the common toilet high from major activity spaces? Are the activity spaces easy to access? Is there a space for laundry temporarily in the activity spaces? Are employee rooms near the multipurpose room to observe the elderly with perception disorders? Are there various activity spaces in consideration of social classes? Are there activity spaces in consideration of gender? Can familiar activities be performed in multipurpose room? Are there spaces for hairstyle service, massage service or aroma theraphy? Is there a space for interaction with other elderly people? Is there a space in the activity rooms for natural interaction with care givers and employees? Is the lay-out of activity rooms proper for comfortable communication among the elderly, care givers and employees? Is the entrance easy to monitor? Does the entrance function to prevent the elderly from going out without permission?
AO SS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 2
M U L T I P U R P O S E R O O M
E N T R A N C E
3 Is the entrance placed at a hidden or invisible spot? 4 Is there space for employee to check the entrance? 5 Is the step height at the entrance 180mm or less? 6 Does the entrance entice the elderly to go out? Does the entrance allow for easy use of wheelchairs and other moving 7 equipment? 8 Does the exit have a control device? 9 Are there locations to observe the entrance?
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Items O U T D O O R 1
Contents
AO SS
Is it possible to access outdoor spaces, gardens and terraces from indoor spaces? 2 Are there steep roads or other obstacles in the outdoor space? Is there a safe fence outside that prevents the elderly from going out 3 while observing the outside? Are the indoor spaces of the facility designed to allow the residents to 4 observe the outside as much as they can? Are there spaces for sun bathing or other considerations to experience S 5 the changes in season? P 6 Is the outdoor space designed to feel the changes of sun and time? A C Are the wheelchairs and moving equipment maintained well for easy 7 E movement to outdoor spaces? *AO = Awareness & Orientation, SS=Safety & Security, PP=Provision of Privacy, SFA= Support Functional Abilities, RQ=Regulation & Quality of Stimulation, CS=Continuity of the Self, OPC=Opportunities for Personal Control, FSC=Facilitation of Social Contact. **PP=Physical/Psychological Health, PS=Psychological/Mental Health, SP=Social/Socio-Psychological Health.
4. Results The combined status of the major design concepts of respective space sectors in analyzing design guidelines and the analysis results from the holistic health viewpoint are presented in Table 9. Looking into the distribution of questions on special design concepts, the item of functional ability Support Functional Abilities has the most extensive distribution out of eight design concepts. Other items have similar distributions. Out of a total of 114 items, 80 or more reflect the aspects of physical/pysiological Health.
Table 9. Design concept of analyzed design guidelines and its integrated distribution from holistic health perspective
Perspective Design Concept Holistic Health
Integrated Distribution
*AO = Awareness & Orientation, SS=Safety & Security, PP=Provision of Privacy, SFA= Support Functional Abilities, RQ=Regulation & Quality of Stimulation, CS=Continuity of the Self, OPC=Opportunities for Personal Control, FSC=Facilitation of Social Contact. **PP=Physical/Psychological Health, PS=Psychological/Mental Health, SP=Social/Socio-Psychological Health. ***Distribution of averages by integrating frequencies of each item.
Looking into the distribution of detailed items of special design concepts and holistic health viewpoints, first, in case of bedrooms, the support functionality abilities of the design concept and the provision of privacy show the highest distribution. This implies that the bedroom is a private space whose privacy must be protected in the shared common facilities where elderly people with similar diseases are living together and it is the result of basic guideline for elderly environment design that support the maintenance of physical functions by provision
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of familiarities in private spaces. From the holistic health perspective, physical health showed the highest distribution, while the social health aspect marked a somewhat higher distribution than psychological health. This is related with the fundamental design principles for the elderly that protect their privacy in the case that a room is shared by two or more people, while preventing their social isolation. Second, in the case of the design concept of bathrooms, Safety/Security and Support Functional Abilities and the Physical/Pysiological health aspect from the holistic health viewpoint were considered as major issue. This is due to the fact that the representative characteristics of the elderly in their life cycle are their physical aging, and the bathroom is the space where they are exposed to accidents most frequently. Proper measures are necessary to prevent risks. Third, in the corridor the design concepts had a similar distribution in general in comparison with other spaces but Support Functional Abilities and Opportunities for Personal Control had a somewhat high distribution. The aspect of physical health marked the highest point from the holistic health viewpoint in the corridor, too. Psychological and social health aspects also recorded a similar distribution. This is because corridor is the space connecting the individual spaces with shared spaces and elderly residents should control themselves while they roam there or when they have social interactions with other elderly residents or employees in the corridors. Fourth, in the case of the kitchen, the Awareness & Orientation factor marked the highest distribution and all the design concepts except for protection of privacy seemed to be reflected in the survey result. From the holistic health viewpoint, the degrees of distribution were similar to the corridor with the order of physical health > social health > psychological health. The kitchen is one of the few spaces that can show the living environment in which the elderly used to live before they came to the welfare facilities. The design of kitchenware and furniture which look like those in ordinary homes simulates the visual sense of the residents, and the acoustic and olfactory stimuli which come from delicious smells while cooking in enhance the cognitive abilities of the elderly. Fifth, dining room and living room, facilitation of social contact marked the highest design concept, in contrast to other spaces. From the holistic health viewpoint, the social health aspect showed a high distribution like the physical health aspect and psychological health revealed somewhat lower distribution than the other two health aspects. This is because the dining room and living room provide spaces for natual social interactions while dining or talking with other elderly people or employees except during the hours of special common activities in the facilities. Sixth, multipurpose rooms marked the highest design cocept, in Continuity of the Self and other concepts except for privacy protection, also marked high distribution in the area. From the holistic health viewpoint, the physical health aspect showed the highest distribution like other common spaces and the social health aspect also marked a high distribution. This is because the elderly can participate in hobbies or other pleasant activities that they enjoyed before they came to the facilty, together with their fellow residents in the multipurpose spaces. Seventh, entrance area showed low distribution rates in overall design concepts except for the Safety/Security aspect. From the holistic health viewpoint, the social health aspect was reflected in the items but most items indicated physical health aspects in general, recording the highest distribution. It is because the entrance area is a space the elderly residents, employees and their family members visit frequently and it is necessary to prevent the elderly residents from facing any risk or danger by leaving the facility without any care or aid.
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Finally, the outdoor space marked the highest distribution in the aspect of regulation and quality of stimulation. Following this, Safety/Security, Support Functional Abilities and facilitation of social contact were marked prominently. From the holistic health viewpoint, the physical health aspect showed a comparatively high distribution and the psychological health aspect marked the highest distribution, uniquely and differently from other aspects. Through contact with diverse plants, a healing effect can be achieved through visual, acoustic, olfactory and tactile stimuli. In addition, transcending the boundary of indoor spaces, outdoor gardens and terraces help the elderly residents maintain their physical functions and health through physical exercise and social interactions with neighbors in the commucity. This reflects the importance of relationships with local community members and social interactions. Table 10 shows the distribution graphs of the above data.
Table 10. Design concept of each space and its distribution from holistic health perspective Space Design Concept Perspective Holistic Health Perspective
Bedroom
Bathroom
Corridor
164
Space
Design Concept Perspective
Holistic Health Perspective
Kitchen
Dinning Room & Living Room
Multipurpose Room
Entrance
165
Space
Design Concept Perspective
Holistic Health Perspective
Outdoor Space
*AO = Awareness & Orientation, SS=Safety & Security, PP=Provision of Privacy, SFA= Support Functional Abilities, RQ=Regulation & Quality of Stimulation, CS=Continuity of the Self, OPC=Opportunities for Personal Control, FSC=Facilitation of Social Contact. **PP=Physical/Psychological Health, PS=Psychological/Mental Health, SP=Social/Socio-Psychological Health. ***Distribution of averages by integrating frequencies of each item.
5. Discussion Generally speaking, the Support Functional Abilities" aspect that maintains and enhances the autonomous behavior and daily activities of the residents took the largest share of distribution among all evaluation aspects in every space. And from the holistic health viewpoint, the Physical/Psychological Health aspect recorded the highest distribution among all the items excluding outdoor environment, reflecting the considerations that protect the elderly residents from physical/biological risks and stimuli in an elderly welfare environment. This implies that the evaluation guidelines of this study deal with considerations to support functional abilities for the daily life of elderly people in a safe material environment without physical/pysiological obstacles as the most important task. Spaces with many social interactions such as the dining room/living rooms, multipurpose rooms, the corridor and outdoor spaces had similar distributions in Facilitation of Social contact, Continuity of the Self, Safety/Security, and Awareness & Orientation. On the other hand, Provision of Privacyshowed overall low distributions in all spaces except for the sleeping room. This results from the fact that protection and safety of elderly residents who have weak physical functions due to aging has top priority in planning the environment for elderly welfare and nursing care facilities. When elderly welfare facilities and models for elderly residences are developed, it is very important to design for the realization of the holistic health of the elderly. At the same time, it is also required to develop guidelines based on a total design concept comprising the details of architectural design, indoor space design and factor design. Therefore, the distribution map of details for design guidelines from the viewpoint of total design was drawn in Figure 3 through analysis and rearrangement. Looking into the distribution map for planning factors of health architecture in design guidelines that are the object of evaluation in this study, design factors are distributed diversely in physical/ psychological/and social environments according to layout plan. Particularly, factor design components (A) of floors, walls and furniture that compose ground plans took a wide distribution comparatively. And the indoor space design factors (B) such as the bedroom, kitchen, living room, bathroom, and multipurpose rooms that classify the characteristics of ground plans also had a wide distribution. However, architectural design factors (C) had comparatively low distribution in general.
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Figure 3. Distribution of evaluation guideline by planning factors for healthy architecrue from behavioral science perspective
The developed scale is the comparative profile of the scale that was based on the empirical research. The results of this study reveal how the scale can be developed in future and how it should be used. When guidelines are developed, health architecture factors for holistic health cannot be always stipulated in detail. However, the factors are required to be considered for more extensive application from design aspects. Therefore, more extensive studies are needed for organizational collation of diverse health architecture factors. 6. Conclusion This study intended to reanalyze exisiting evaluation guidelines based on design concepts by physical sectors, by choosing design guidelines recently verified in precedent studies. This is to confirm the design concepts and holistic health aspects through profiles showing their trends, by transcending the simple ground layout plans for the spaces classified by existing evaluation guidelines and by analyzing the design concepts and holistic health aspects present in welfare and nursing environments in consideration of integrated and diverse health aspects. This research and analysis made it possible to suggest an insight on possibilities and a development direction of design guidelines from a more holistic health perspective by researching with viewpoints and levels different from the existing ones. In addition, this research means analyzing various evaluation guidelines can bring a new momentum for practical use. And in order to design more efficient and healthful elderly welfare facilities, it is necessary to activate the studies not only in analyzing the health factors in guidelines to practically apply them in the architectural plans and designs, but also in utilizing the
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numerous guidelines suggested by various research institutes in matters relating to the elderly. And if fundamental discussions are made about what should be contained for what purpose in the elderly welfare environments, seeking a better holistic health environment and sharing the study results, it will be possible to learn about environmental designs for holistic health reciprocally and develop together.
Acknowledgements This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MEST) (No. 2012-0000609). References
[1] www.mw.go.kr [2] Park SY, Kim JJ, Choi EH: The Problems of Housing for the Elderly in Korea and its Desirable Direction; J The Korea Gerontological Society 1999; 19(2): 129-146 [3] Lee YS, Yoon HG, Yoo HJ, Lim YJ, Hwang JH: Pre-Evaluation of Users on Flexible Elderly Housing Alternative; J Korea Insitute of Interior Design 2012; 21(1): Inedited [4] Dilani: A, Design & Health IV; Future Trends in Healthcare Design, 2005. [5] Lee YS, Lee SM: Healthful House; Yonsei University Press, Seoul, 2006 [6] Lee SM, Lee YS: Health Friendly House Planning Elements Demanded by Cosumers; J Korea Institue of Ecological Architecture and Environment 2008; 8(6): 11-20 [7] Dilani: A, Design & Health III; Health Promotion through Environmental Design, 2003 [8] Lawton, M, Powell, and Nahemow, L.: Ecology and the Aging Process. In C. Eisdorfer and M. Lawton, (eds.) the Psychology of Adult Development and Aging Wash.; D.C. American Psychological Assoociation, 1973 [9] Carp, F. M & Carp, A.: A Corrplementary/Congruence Model of Well-Being or Mental Health for the Community Elderly; In Altman, I. et al. Elderly People and the Environment; Plenum Press, New York, 1984 [10] Atchley, Robert C.: Continuty and Adaptation in Aging: Creating Positive Experiences; The Johns Hopkins University Press, 1999 [11] Lee YS: Elderly Housing Indoor Environment Design Guideline; Kungchunsa Press, Seoul, 1998. [12]Byeon HR: A link between theory and practice of environmental design for people with dementia; PhD Thesis, Yonsei University, 2001 [13] Oh CO: An Elderly Housing Model through Preference of middle-aged; PhD Thesis, Yonsei University, 1992 [14] Lee YH: Housing environment for life quality of Korean family with demented elderly; PhD Thesis, Yonsei University, 2003 [15] Valins, M. Housing for Elderly People: A Guide for Architects, Interior Designers and their Clients; Van Nostrand Reinhold Co., New York, 1988 [16] Lee YS, An SM, Lim SH: Formation of Composite Theory of Planning Built Environment for Holistic Health; J Korea Institue of Ecological Architecture and Environment 2010; 10(1): 97-107 [17] Lee YS, Lim SH, Hwang JH: Comparative Analysis of Leading Design Guidelines for Environment of Elderly People with Dementia: J Archtectural Institute of Korea 2011; 27(11): 9296 [18] Lee YS, Hwang JH, Lim YS, Lim CS, Park YW: Care Helpers Evaluation and Requests on Designs of Elderly Welfare Facilities in Korea; J Architectural Institute of Korea 2011; 27(12): 9198
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SHB2012 - 6th International Symposium on Sustainable Healthy Buildings, Seoul, Korea 27 February 2012

DDC (Dementia Design Checklist)

MBAB (Matrix Bauliche Anforderungen und Bereiche)

EDC (Environment Dementia Care)

Table 3. Guideline identifying process of each system

4. Support Functional Abilities 5. Regulation & Quality of Stimulation

6. Continuity of the Self

7. Opportunities for Personal Control 8. Facilitation of Social Contact

Table 7. Reliabilities of questionnaire items

Design Concept Hoilstic Health PP SFA RQ CS OPC FSC PP PM SP

Design Concept Hoilstic Health PP SFA RQ CS OPC FSC PP PM SP

Design Concept Hoilstic Health PP SFA RQ CS OPC FSC PP PM SP

Design Concept Perspective

Holistic Health Perspective

Dinning Room & Living Room

Design Concept Perspective

Holistic Health Perspective

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