. Health care services would benefit from moving away the biomedical model and towards a new model of health that encompasses not only the physical and mental needs of the service user, but also the social needs.
Promoting Wellbeing by Focusing on the Environment
When discussing the impact of the environment on people living with
chronic conditions specifically, contact with nature and environmental
modifications are key areas. The biophilia hypothesis provides a
theoretical background for the importance of being immersed in the
natural environment, with our innate need for contact with nature and
life (Wilson, 1984). We have previously discussed the impact of nature
on general health and wellbeing, and whilst these benefits are useful
for the general population, a greater focus needs to be placed on
contact with nature for those with chronic conditions as they face
health issues on a daily basis, and have additional barriers in their
life which may prevent them from easily accessing opportunities such as
green spaces \citep*{Meek_2018}. These potential barriers include a
lack of time due to physician visits and/or hospitalisations, and
accessibility due to a physical disability. Along with this, research
has highlighted an association between contact with nature and
prevalence of disease. For example, a systematic review analysed the
evidence linking green spaces with mortality, in which 12 studies were
included with study populations ranging from the thousands to the
millions (Gascon et al., 2016). Results found a negative correlation
between cardiovascular disease mortality and residential greenness in
the majority of studies, the pathways through which this relationship
occurs can be explained by Kuo (2015). A review on 17 studies based in
Japan concluded there is a positive impact of natural environments on
brain activity, the cardiovascular system, endocrine system and immune
function \citep*{Haluza2014}. However, when going in
to more detail the results are mixed. For example, the review concluded
beneficial impacts of nature on cardiovascular functions, however, when
concerning blood pressure, only two out of nine studies reported clear
positive effects (a decrease), with six reporting mixed effects and
three reporting no significant effects. A similar pattern arises with
heart rate, with four studies reporting positive effects (a decrease),
three reporting mixed results and two reporting no significant effects.
When focusing on heart rate variability, two studies reported a positive
effect (an increase) with four studies reporting mixed effects. Similar
patterns arise with data linking nature with the endocrine system and
immune function. Despite these mixed results, the review concluded an
overall health benefit of contact with nature, with a clear potential to
target at-risk people or those living with cardiovascular problems.
Introducing green spaces into communities and care homes is one route
through which those with chronic illness and/or disabilities can easily
access contact with nature when living in an urban environment. Research
on 126 care facilities for the elderly across 17 European cities found
green spaces within the facility grounds had a significant impact on the
quality of life for the residents, along with benefits for the staff and
visitors (Artmann et al., 2017). The green spaces facilitated physical
activities, recreation and social engagement, which provide subsequent
health benefits associated with such factors. It is important to
consider contact with nature when designing care packages for service
users with chronic conditions as they are more vulnerable to losing
contact with nature as day-to-day living is more difficult. Care homes
would benefit from designing a timetable which guarantees all residents
access to nature for a certain period every day or by including green
spaces on their property.
Traditionally, care homes were designed for the health and safety of
residents, neglecting what is important to the people that live there
and what could potentially improve their health and wellbeing, but this
is beginning to change (Ausserhofer et al., 2016). Modifying the
environment for residents or patients in care facilities should be a
focal point, taking into account their condition and which modifications
will facilitate health and wellbeing improvements. Simple additions,
such as indoor plants, have reportedly reduced stress for patients in
hospital \citep*{Dijkstra2008}. A review of 30 studies
found positive effects for sunlight, windows, odour and seating
arrangements \citep*{Dijkstra2006}. Whilst evidence for
sound, nature, spatial layout, television and stimuli interventions was
inconsistent. The impact of the modifications was dependent on patient
population characteristics and the context, highlighting the need for a
person-centred approach when designing the building and rooms for
service users. This is highlighted in a qualitative study which reported
both positive and negative outcomes from home modifications; the
researchers concluded that the negative impact to be attributable to a
lack of understanding about the individual client \citep*{Aplin2015}. It would be useful for health facilities to modify
their design to accommodate the service users, particularly care homes
where residents live for the remainder of their lives. For example,
individuals with dementia would benefit from modifications that
normalise their circadian rhythms, including lighting and ambient
temperature, along with modifying walkways and exits to make it clearer
and safer (Luxenberg, 1997). A review of 57 articles focusing on
environmental design or changes for people with dementia concluded that
there is sufficient evidence for the effectiveness of varying ambience,
size and shape of spaces in a home, unobtrusive safety measures and
controlling levels of stimulation \citep*{Fleming2010}.
- Include research linking design and colour schemes
Overall, the evidence linking nature and health continues to grow, but
with mixed results. Reasons for such could be attributed to a lack of
concrete recommendations concerning what level of exposure to nature
would be sufficient to elicit health changes and what type of nature
environment has a greater benefit. Shanahan and colleagues (2015) have
propose using dose-response modelling when providing nature-based
interventions to identify a cost-effective level of urban nature. They
argue that manipulating the type and amount of nature exposure will
subsequently impact differently on health outcomes. By applying this
method in future research, it will allow researchers to better identify
what types of nature-based interventions are effective and at what dose.
With sufficient research, recommendations can then be made for future
generations to utilise nature, and particularly green spaces for urban
environments, to build health and wellbeing among all populations. The
introduction of green spaces should be a focal point for urban areas,
which will moderate the climate change impact, help prevent disease over
a life course model, improve health and wellbeing and subsequently
lessen the burden on the health care services. Feasibility research has
been carried out to investigate the impact of urban green spaces on
health \citep*{Pearce2016} and further development
in this area may provide substantial health-related data associated with
green spaces across a life course model.
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Facilitating
Behavioural Change
FOR INTEGRATION:
INTRO TO BEHAVIOUR CHANGE:
Changing one's behaviour and adopting recommended, 'healthy' behaviours based upon educational information is not simply an easy choice an individual makes (Kelly & Barker, 2016); else undesirable health behaviours would surely be amiss for many. Providing individuals with information does not necessarily equate to behaviour change. Rather, behaviour change must be understood through comprehensive models and facilitated through guiding framework's and appropriate change-inducing strategies.