Therapeutic Landscape as a Healthcare Facility in Egypt : Design and Evaluation Process

Outdoor natural environments are well proven to have psychological, physical, and social benefits, particularly those attached to healthcare facilities. Despite that, the Egyptian Codes devoid of data related to the design of such gardens, which hinders the design process and the inclusion of these spaces within health care facilities. Thus, this paper seeks to reach a set of considerations for the design of different types of therapeutic gardens by summarizing the findings and recommendations of some evidence-based design (EBD) research and post-occupancy evaluations (POEs). Post-occupancy evaluations lack to determining the percentage of achieving the design principles in the garden. Therefore, in addition to the behavioral and visual observations to evaluate Children's Cancer Hospital garden in Egypt (CCHE), an audit tool was integrated to combine the advantages of audit tools and POEs. With this merging, we can reach a steady form of post-occupancy evaluations of pediatric cancer hospital’s gardens to be a guide for future researches and landscape architects.


Introduction
Man has believed in the healing benefits of nature for those suffering from psychological and physical problems for thousands of years. The beginning of this belief was from the ancient Egyptian civilization through the early Asian, Greek, and Romanian, and then to the monastic monasteries in the middle Ages. This interest continued to the beginning of the twentieth century, and then it began to diminish as a result of the preference for functional efficiency and priority of financial gain. Now it being re-discovered in the form of healing landscapes and therapeutic gardens [1]- [5]. When access to nature became well-documented as an element of healing by growing evidence [6]- [11], the research concentrated on studying the design and evaluation process of therapeutic gardens. The American Horticultural Therapy Association (AHTA) has divided the natural environments that aid in the healing process into several different types, according to user groups and garden design programs. In Egypt, some of the therapeutic garden designs, when investigating, you hardly discover whether it serves frail elderly, psychiatric, Alzheimer's, or cancer patients. Therefore, it mostly does not meet all (psychological, physical, and social) needs of all users (patients, visitors, or staff).
Due to the varied types of therapeutic gardens and the different needs of users, it was necessary to identify design criteria that are in line with this difference to increase the effectiveness of these gardens. The various design guidelines were summarized from the results of experimental researches and surveys for gardens attached to different types of hospitals and health care facilities. These results defined decisions for designers to access the highest possible health outcomes and to obtain a base of design guidelines that assist in the evaluation processes.

A. Theoretical Study
Although the terms (healing gardens, therapeutic gardens, and horticultural therapy gardens) intended to improve health outcomes through spending time in, the American Horticultural Therapy Association developed definitions that explain the difference between them Table 1 [12]. Table 1 Definitions of some different types of gardens according to AHTA

Gardens Types Definitions according to (AHTA)
Healing gardens "Healing gardens are natural environments associated with public hospitals and have positive effects on all users, regardless of the type of disability. It can also be classified into subcategories as horticultural or therapeutic gardens." Therapeutic gardens (field of study) "Therapeutic gardens serve specific users (patients with Alzheimer, cancer patients, frail elderly, etc.) and meet their needs. These gardens can be considered as a part of the healing gardens or an indoor rehabilitation area extension." Horticultural therapy gardens "Horticultural therapy gardens also are a subcategory of therapeutic gardens with unique characteristics, it designed specifically for the use of patients in the care and cultivation of plants as part of a treatment program, the thing that stimulates patients to move and strengthen their muscles."

B. Analytical Study
Whereas the therapeutic gardens are healing gardens but more specialized and interest in a certain category of patients, the design considerations were divided into general and specific.

1) General design considerations
According to Cooper Marcos [2], the general design guidelines are organized in three sections Table 2:  Planning process considerations: Considerations relating to the site and buildings in addition to the outdoor spaces, and it should be taken into account from the planning process of the project before the beginning of the outer space design.
 Comprehensive design considerations: Applicable to all components of outdoor spaces in all facilities (whether health care facilities or others) for example, safety, security, and privacy.
 Considerations of the physical elements of all healing gardens: These considerations apply to physical components within all outdoor spaces attached to health care facilities as paths, seating, planting, and the like.

C. Applied Study
Post-occupancy evaluations (POEs) have proven to be very effective in assessing outdoor spaces, regardless if these gardens were therapeutic or not [33]. POEs also gives an overview of the shortcomings and successes in the garden, show who uses it and why, the number of garden visits, different activities, barriers to the visit, and user satisfaction with the garden. However, it lacks a list of elements and qualities that should ideally be incorporated into a therapeutic garden to assess the quality of design considerations implementation from the user perspective and whether it meets Table 2 General design considerations Planning process considerations [2] Comprehensive considerations [10], [2], [13], [14] [15], [16], [17] Considerations for the physical elements of all healing gardens [2], [18], [19], [20], [21], [13], [14], [15], [16]

Gateways and entrances.
 Include the garden with more than one well visible entry.  The entries have to be broad for the movement of wheelchair users Parking areas.
 Provide a sufficient number of parking spaces. Staff must be provided with parking at the rear of the hospital, while parking must be as near to entrance for patients, especially those with disabilities. Paths.
 Paths need to be arranged within a simple hierarchical distribution in hospitals.  The width of one-way roads must be not less than 15 meters, while the width of two-way is not less than 21 meters, and the slope of the crossed slopes must not exceed 2%.  Provide frequent resting spots, distance markers, and raised edges along the pathway.  Control joints on paving units are no wider than 1/8 inch and to prevent wheels of IV poles from slipping. Art.
 The message should be simple and positive for sculpture, artworks and other design components. Furniture in the site.  Seats should be movable, comfortable, and accessible where users want to use. It should be in front of a fascinating view. The material used should not keep heat or cold and rustproofing.  Signage and lighting should be present for all parts of the garden. Planting design:  Maximize the use of low-maintenance planting.  It blends harmonious textures, shapes, colors, and multi-high rising.
Water.  Combine the seats close to the water feature.  Avoid placing sprinklers next to the paths to prevent slipping.  Sensory stimulation with the features of water must be by two sense at least (sight, touch, and sound). minimum standards (audit tool). Therefore, we developed the POE for (CCHE) garden to include questionnaires in the form of an audit tool to be a combination of the advantages of POEs and audit tools. The European Landscape Convention described the landscape as "an area, perceived by people, whose character is the result of the action and interaction of natural and human factors" [34]. Thus, the research method is based on four main criteria (site, users, operations, and evaluation of the garden). This research was based on (visual analysis, behavioral observation, and questionnaires) as tools for data collection, evaluation, and auditing Fig.1. Accessibility Emphasize on variation of access from buildings to the garden (cognitive and physical access).      Emphasize visual access from rooms to allow people who have no access outside (because of their weak immune or mental disorder as violence) to contact with nature.

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Keep the garden without obstacles to seeing the entrances clearly and keeping the shortest distance to the building from any point in the garden because it gives the patients a sense of safety.

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The play areas are preferred to be connected by access to the garden through the playroom.  

Orientation and safety
Design the paths as a returning path system called a loop, e.g. a figure of 8.  Make the garden safe by fences, which should not describe as a wall (masked by planting or decorative wall).
    Monitoring the garden from inside for patients using the garden without physician or escort.
    Provide tracks with handrails (for those who find it difficult to walk), make it bright, and easy to identify.   Protect against obvious dangers as overhanging branches, irregular steps, and fallen leaves that cause slippage.

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Avoid objects that patients can use in any form of damage, either for themselves or others (e.g. Light chairs that they can use to attack each other).

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The layout of the garden preferably to be an open-plan, allowing children to freely choose their play areas and equipment without a regular sequence of the play system.

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Design paths in a manner that is impressive and includes attractive and fun elements.  

Socialization
Emphasize providing plenty of places to sit through the paths and be at regular intervals and repeated every 15 feet.

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The seating design is pleasantly attractive and has a small scale.   It is preferable to fixing chairs and furniture in the ground.    Various activities programs should be integrated and provide wide areas for walking to release aggressive behavior.

General
Avoid sudden changes in paving materials (consider as steps) or reflective substances (consider as water).
  Avoid frequent light reflections or dark (pergola structures), which cause deep shadows. Avoid dark inspection rooms that may be considered by the patient as ground holes.

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Small-scale design changes are important for people who walk slowly to feel visual diversity.   Maintenance that creates dust and pollen should be at times other than when the patients in the garden. 1) Evaluation criteria  Site: The site was examined through (geographical and physical analysis). The geographical analysis was conducted by visual analysis to studying the location, climate orientation, visibility and accessibility, the ratio of street width or open space to the building height, and entrances to the garden. The physical examination includes all hard elements in the garden as plants and structures that make up the garden and its various distinct areas Fig.2.
 User and participants: Random samples participated in the research, whether from patients (inpatient, outpatient, surgical, or intensive care) or staff (doctors, nurses, physicians, and administrators).
 Operations (uses and activities): The user's interaction with the garden happens through a group of activities (walking, eating, and passing through) that we monitored in the behavior matrix table 4. The uses of the garden were determined by observation and drawing behavioral maps that used to track the circulations of user groups while using the garden.
 Evaluation of the garden: The evaluation was at three points (1) Achieving general design considerations. (2) Achieving specific design considerations. (3) The degree of user satisfaction.

2) Evaluation tools:
 Visual analysis: It provides an understanding of the physical, geographical conditions, and spatial proportions of the environment. It was conducted during the period from November 2018 until August 2019.
 Behavioral observation: In the behavior observation data collected through on-site observation by the researcher for a week to know the user groups in the garden and drawing behavior mapping through which we can determine general use distribution and most distinct places in the garden for patients, visitors, and staff. The questionnaire was divided into four sets of questions. In the first group, the respondents were asked about number of visits, duration of visitation, reasons for visiting the garden, and obstacles that prevent them from the visit. In the second and third set, respondents were asked about the garden's achievement of general and specific design considerations. The degree of satisfaction was calculated by a scale of ten degrees, to assess the user satisfaction with the garden features.

A. Site Analysis
The hospital is located in the area of Qasr Al-Aini, Cairo. The site has a quiet location as it has no sources of noise. The site is easy to access as it can be reached through four main streets and linked to three points of road intersection (nodes) make it easier to access. Furthermore, the hospital has a distinctive design form that makes it visible from nearby and surrounding places. The ratio of outdoor building heights to the street width is approximately 1:2, which consider as an appropriate ratio to create an opportunity for privacy within the garden. Table 4 shows the data of behavior observations in the form of a matrix to illustrate the information collected within a typical week period by watching the garden every day for ten minutes (from 11 to 11:10 AM), where 643 occupancy instances were monitored during the research period (families, visitors, children, staff and patients with therapist) Fig. 3.

2) Time that user spent in the garden
There are many observations about the time of using the garden, whether the frequency of the garden, the length of visitation, or the time of the day users prefer to visit the garden. This information was collected through the questionnaires, which included 51 responses 16 of the staff and 35 were nonstaff (visitors and patients) Fig. 4, Fig. 5, and Fig. 6.

C. Operations 1) Activities
From the behavior matrix, it is possible to determine what users do in the garden from a group of activities were counted within a week of field observation Table 4; Fig. 9.

2) Uses
 Use distribution: Fig. 10, Fig. 11, and Fig. 12 illustrate graphics usage patterns that explain the shape of the garden use. The garden is monitored from a point in its middle so as to allow the observer to detect all the garden and monitor the users from the beginning of their entry to the garden until they exit. By comparing the motion path for both visitors and patients, both are almost identical where patients or visitors leave the hospital International Journal of Research in Engineering, Science and Management Volume-3, Issue-11, November-2020 https://www.ijresm.com | ISSN (Online): 2581-5792 116 heading to the play area or sitting area near it. This tour may interrupt by heading to the cafeteria and then returning to the play or sitting area again. The path of the staff is different where the workers using the garden either to pass through or to reach the cafeteria.     Table 5 A questionnaire of the planning process considerations. This questionnaire is for the designers participating in the design of the garden understudy Planning process considerations Yes No Is the garden designed based on the evidence-based design approach? 0 4 The design respects all garden users (patients, visitors, and staff). 2 2 The organizational structure of the institution, the cultures, and the policies used were considered in the design. 3 1 All stakeholders were involved in the design process. 1 3 Functional, physical, and programmatic requirements formed the basis for how to garden was designed.
4 0 There is a major source of funding, from the design process to periodic maintenance. 4 0 The garden was designed by an interdisciplinary design team (IDT) including landscape designers. 4 0 If the garden was planned by a team of landscape designers, were they trained to design therapeutic gardens? 3 1 As a garden for a pediatric cancer hospital, does the design team include the appropriate professionals to design this type of garden as (occupational, physical, other professional therapists)? 0 4 Components of the overall environment of care EOC (concepts, people, systems, layout, operations, and implementation) are generally considered a healthy environment.
3 1   Respondents rated the garden's features by a 10-degrees scale. Fig. 13. represents the percentage of satisfaction and discontent for each feature separately in the garden.

Conclusion
The research aims to study the design of the different types of therapeutic gardens in Egypt and propose, (1) developing the Egyptian code to include the designing of outdoor environments as health care facilities. (2) The designer must take these gardens into account from the first stages of planning the project to reach the best possible results. (3) The necessity to differentiate between the types of these gardens. And raise the efficiency of the design elements depending on the needs of the user groups. (4) Incorporate the evaluation of these gardens into design approaches to increase design recommendations, thus assist in future research. (5) Developing the assessment to include general and specific design considerations in the form of an audit tool to combine how the garden is used and the extent to which design considerations are met. (6) Attempting to arrive at a consistent form for a comprehensive evaluation to be a reference for later designers. Finally, the evaluation can be used later as a starting point in the issuance of licensing certificates for such kind of gardens in Egypt to stop launching the concept of therapeutic gardens in any green area.