Bereket A Lemberh An Final 2019

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Therapeutic Landscape Design In The Hospital Environment Of Ethiopia
Thesis · July 2019
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EIT-M School of Architecture and Urban Planning THERAPEUTIC LANDSCAPE
MEKELLE UNIVERSITY (EIT-M)

SCHOOL OF
ARCHITECTURE AND URBAN PLANNING
DEPARTMENT OF
ARCHITECTURE
THERAPEUTIC LANDSCAPE
Introducing Therapeutic Landscape Design In The Hospital

Environment Of Mekelle In The Case Of Ayder, Mekelle And
Quiha Hospitals
Author: Bereket Alemberhan Besha
Advisor: Jemal Mohammedbrehan (MSc )
A thesis submitted in partial fulfillment of the requirements For BSc In Architecture, at

Mekelle university, School of Architecture and Urban Planning Department of Architecture.
JULY 2019
DECLARATION
I Bereket Alemberhan Besha declare that this thesis project entitled “Introducing Therapeutic
Landscape Design In The Hospital Environment Of Mekelle In The Case Of Ayder, Mekelle And Quiha
Hospitals” describes work undertaken as part of Bachelor Degree fulfillment at Ethiopian Institute of
Technology Mekelle University, SchoolDofDArchitectureDandDUrbanDPlanning department of
Architecture, is my original work and has not been presented in anydother universitydor platform.
Alldviewsdanddopinionsdexpresseddtheredindremaindthedsole responsibility of the author. I
alsoddeclare that all sources I have used ordquoted have been cited, indicated, and acknowledged
bydmeans of complete Bibliography or references.
Signature Date…………July 2019
Confirmation
The thesis can be submitted for examination with my approval as an institute’s advisor.
Jemal Mohammedbrehan ________________ ________________
Signature Date
CERTIFICATION
This thesis project entitled “ Introducing Therapeutic Landscape Design In The Hospital Environment
Of Mekelle In The Case Of Ayder, Mekelle And Quiha Hospitals “, by AUTHOR: BEREKET ALEMBERHAN
BESHA submitted to the Department of Architecture; School of Architecture and urban planning;
Ethiopian Institute of Technology – Mekelle (EIT-M); Mekelle University in partial fulfillment of the
requirements for the Bachelor degree in Architecture.
Date: July 2019
Approved by Board of Examiners:
_______________ _______________ ________________
Advisor Signature Date
_______________ _______________ ________________
Examiner 1 Signature Date
_______________ _______________ ________________
_______________ _______________ ________________
Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 I

ACKNOWLEDGEMENT
First and foremost, Glory to the Most High for helping me through the ups and down from
the beginning.
Secondly, I would like to show my gratitude to my School Advisor Jemal Mohammedbrehan

for helping me through the whole research in guiding me and providing the most help in
finalizing and finishing this thesis. And, I would also like to thank all of the Department faculty
members for their help and support. And also, I would like to thank the volunteers for the
questionnaire and Interview participation and I would like to thank staffs of the hospitals for
giving me the relevant information and guidance.
Finally, I wish to express my sincere thanks to my dear family and friends, for their support
throughout the years, I am very grateful for the unconditional love and encouragement.
Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 II

CONTENTS
DECLARATION -------------------------------------------------------------------------------------------------------------------
CERTIFICATION ---------------------------------------------------------------------------------------------------------------- I
ACKNOWLEDGEMENT ----------------------------------------------------------------------------------------------------- II
TABLE OF FIGURES --------------------------------------------------------------------------------------------------------- VI
LIST OF ACRONYMS AND ABBREVIATIONS ------------------------------------------------------------------- VIII
ABSTRACT ---------------------------------------------------------------------------------------------------------------------- IX
CHAPTER ONE ----------------------------------------------------------------------------------------------------------------- 1
1.1 INTRODUCTION -------------------------------------------------------------------------------------------------------------- 1
1.1.1 Background of the study ---------------------------------------------------------------------------------------------------------------------------2
1.2 PROBLEM STATEMENT AND JUSTIFICATION -------------------------------------------------------------------------------- 3
1.2.1 Problem statement -----------------------------------------------------------------------------------------------------------------------------------3
1.2.2 Justification of the research -----------------------------------------------------------------------------------------------------------------------3
1.3 OBJECTIVE OF THE STUDY--------------------------------------------------------------------------------------------------- 3
1.3.1 General Objective -------------------------------------------------------------------------------------------------------------------------------------3
1.3.2 Specific objectives -------------------------------------------------------------------------------------------------------------------------------------3
1.3.3 Research Questions ----------------------------------------------------------------------------------------------------------------------------------4
1.4 RESEARCH METHODOLOGY ------------------------------------------------------------------------------------------------- 4
1.4.1 Literature Review -------------------------------------------------------------------------------------------------------------------------------------4
1.4.2 Case study -----------------------------------------------------------------------------------------------------------------------------------------------4
1.4.3 Research Design---------------------------------------------------------------------------------------------------------------------------------------5
1.5 SCOPE OF THE STUDY -------------------------------------------------------------------------------------------------------- 4
1.6 SIGNIFICANCE OF THE RESEARCH ------------------------------------------------------------------------------------------- 4
CHAPTER TWO LITERATURE REVIEW ----------------------------------------------------------------------------- 6
2.1 DEFINITIONS OF TERMS ----------------------------------------------------------------------------------------------------- 6
2.2 THERAPEUTIC LANDSCAPES ------------------------------------------------------------------------------------------------- 6
2.3 HISTORY OF THERAPEUTIC LANDSCAPE----------------------------------------------------------------------------------- 7
2.3.1 Asclepieia Of Ancient Greece ------------------------------------------------------------------------------------- 7
2.3.2 Monastic Infirmaries Of The Middle Ages ----------------------------------------------------------------------- 7
2.3.3 The Pavilion Styledhospital ----------------------------------------------------------------------------------------- 8
2.3.4 Planetree Hospitals--------------------------------------------------------------------------------------------------- 8
2.4 TYPES OF THERAPEUTIC GARDENS----------------------------------------------------------------------------------------- 8
2.5 THE ROLE OF LANDSCAPE IN THERAPY ----------------------------------------------------------------------------------- 9
2.6 THERAPEUTIC LANDSCAPE FEATURES -------------------------------------------------------------------------------------- 9
2.6.1 Patient-Oriented Landscape Features ---------------------------------------------------------------------------- 9
1.1.1 Feeling Of Security -------------------------------------------------------------------------------------------------- 10
2.7 DESIGN PRINCIPLES OF A THERAPEUTIC GARDEN ---------------------------------------------------------------------- 10
2.7.1 Understanding User Groups And Their Needs ---------------------------------------------------------------- 10
2.7.2 Offering Different Types Of Activities -------------------------------------------------------------------------- 11
2.7.3 Different Rooms ----------------------------------------------------------------------------------------------------- 11
2.7.4 Privacy And Social Interaction ------------------------------------------------------------------------------------ 11
Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 III
2.7.5 Surrounding And Views -------------------------------------------------------------------------------------------- 11

2.8 CHARACTERISTICS OF THERAPEUTIC LANDSCAPE----------------------------------------------------------------------- 12
2.9 PHILOSOPHY OF THE HEALING AND THERAPEUTIC LANDSCAPE DESIGN -------------------------------------------- 13
2.9.1 Design And Construction Guidelines Of Therapeutic Landscape For Medical Centers --------------- 15
2.10 SUMMARY OF LITERATURE REVIEW---------------------------------------------------------------------------------------- 15
CHAPTER THREE RESEARCH DESIGN AND METHODS ----------------------------------------------------- 16
3.1 RESEARCH METHODOLOGY ------------------------------------------------------------------------------------------------ 16
3.2 DATA SOURCES -------------------------------------------------------------------------------------------------------------- 16
3.2.1 Primary data source ------------------------------------------------------------------------------------------------------------------------------ 16
3.2.2 Secondary data source--------------------------------------------------------------------------------------------------------------------------- 16
3.3 PRIMARY DATA COLLECTION METHODS ---------------------------------------------------------------------------------- 17
3.3.1 Observation ------------------------------------------------------------------------------------------------------------------------------------------ 17
3.3.2 Interview ----------------------------------------------------------------------------------------------------------------------------------------------- 17
3.3.3 Questionnaire---------------------------------------------------------------------------------------------------------------------------------------- 17
3.4 HOSPITAL SELECTION CRITERIA ------------------------------------------------------------------------------------------- 17
3.5 THE STUDY SITE DESCRIPTION --------------------------------------------------------------------------------------------- 17
CHAPTER FOUR DATA ANALYSIS AND PRESENTATION ------------------------------------------------- 20
4.1 INTRODUCTION ------------------------------------------------------------------------------------------------------------- 20
4.2 CONTEXT OF THE STUDY AREA ------------------------------------------------------------------------------------------- 20
4.3 BACKGROUND OF THE STUDY SITES--------------------------------------------------------------------------------------- 21
4.3.1 Case One Ayder Referral Hospital ---------------------------------------------------------------------------------------------------------- 21
4.3.2 Case Two Mekelle General Hospital------------------------------------------------------------------------------------------------------- 21
4.3.3 Case three Quiha General Hospital -------------------------------------------------------------------------------------------------------- 22
4.4 OBSERVATION ANALYSIS OF THE HOSPITALS----------------------------------------------------------------------------- 22
4.5 SUMMARY OF THE OBSERVATION ANALYSIS ------------------------------------------------------------------------------ 29
4.6 IDENTIFIED ELEMENTS OF THERAPEUTIC LANDSCAPE FEATURES OF THE HOSPITALS --------------------------------- 30
4.7 QUESTIONNAIRE SURVEY RESULTS ----------------------------------------------------------------------------------------- 31
4.8 TRIANGULATION ANALYSIS ------------------------------------------------------------------------------------------------ 37
4.9 KEY FINDINGS AND SUMMARY --------------------------------------------------------------------------------------------- 42
4.9.1 Key Findings ------------------------------------------------------------------------------------------------------------------------------------------ 42
4.9.2 Summary Of Data analysis and Presentation ------------------------------------------------------------------------------------------ 43
CHAPTER FIVE GUIDELINES FOR DESIGNING THERAPEUTIC GARDENS --------------------------- 44
5.1 INTRODUCTION ------------------------------------------------------------------------------------------------------------- 44
5.2 PLANNING -------------------------------------------------------------------------------------------------------------------- 45
5.3 SITE SELECTION -------------------------------------------------------------------------------------------------------------- 45
5.4 LAYOUT ---------------------------------------------------------------------------------------------------------------------- 46
5.5 GARDEN STRUCTURES ------------------------------------------------------------------------------------------------------- 47
5.6 AMENITIES -------------------------------------------------------------------------------------------------------------------- 48
5.7 VISUAL COMMUNICATION AND SIGNAGE --------------------------------------------------------------------------------- 52
5.8 DIRECTIONAL MARKER ------------------------------------------------------------------------------------------------------ 53
5.9 INTERPRETIVE SIGN ---------------------------------------------------------------------------------------------------------- 54
5.10 OTHER CONSIDERATIONS -------------------------------------------------------------------------------------------------- 55
5.11 PLANTING & COMPOSITION ------------------------------------------------------------------------------------------------ 55
5.12 EXAMPLES OF PLANTS FOR USE IN THERAPEUTIC GARDENS -------------------------------------------------------------- 57
Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 IV

CHAPTER SIX CONCLUSION AND RECOMMENDATION -------------------------------------------------- 59

6.1 CONCLUSION --------------------------------------------------------------------------------------------------------------- 59
6.2 RECOMMENDATIONS ------------------------------------------------------------------------------------------------------- 60
CHAPTER SEVEN PROPOSAL DESIGN ------------------------------------------------------------------------------ 62
7 ----------------------------------------------------------------------------------------------------------------------------------- 63
7.1 INTRODUCTION TO PROTOTYPE DESIGNS -------------------------------------------------------------------- 63
7.2 PROTOTYPE ONE: DEMENTIA THERAPEUTIC GARDEN ------------------------------------------------------------------ 64
7.3 PROTOTYPE TWO: CATASTROPHIC THERAPEUTIC GARDEN --------------------------------------------- 67
7.4 PROTOTYPE GARDEN THREE: PSYCHIATRIC THERAPEUTIC GARDEN ---------------------------------- 69
REFERENCES ------------------------------------------------------------------------------------------------------------------- 73
APPENDIXES ------------------------------------------------------------------------------------------------------------------ 76
INTERVIEW/QUESTIONNAIRES PAPER ------------------------------------------------------------------------------------- 76
Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 V

LIST OF FIGURES
Figure 1 Research Design .................................................................. Error! Bookmark not defined.
Figure 2 The Wilheit-Keys Peace Garden (Northeast Georgia Medical Center, In Gainesville) ...9
Figure 3 Ayder Referral Hospital Pictures ............................................................................................... 18
Figure 4 Mekelle General Hospital pictures ............................................................................................ 18
Figure 5 Quiha General Hospital pictures ............................................................................................... 19
Figure 6 research Flow ................................................................................................................................. 19
Figure 7 Location map of mekelle .............................................................................................................. 20
Figure 8 Location map of the hospitals ..................................................................................................... 21
Figure 9 Ayider Hospital Map ..................................................................................................................... 21
Figure 10 Mekelle Hospital Map ................................................................................................................. 21
Figure 11 Quiha Hospital Gate ................................................................................................................... 22
Figure 12 Stakeholders of therapeutic gardens....................................................................................... 45
Figure 13 Shade and shadow considerations ........................................................................................... 47
Figure 14 Recommended height for wheelchair accessible planter ................................................... 48
Figure 15 Recommended height for planter ............................................................................................ 49
Figure 16 Pavement widths.......................................................................................................................... 49
Figure 17 Types of paving to be used and avoided ................................................................................ 50
Figure 18 Distance of setback between seating and paving ................................................................. 50
Figure 19 Benches type recommendation ................................................................................................ 51
Figure 20 Recommended shelter dimension for 10 to 12 people ...................................................... 51
Figure 21 Recommended height for hand rails ....................................................................................... 51
Figure 22 Types of users figure .................................................................................................................. 52
Figure 23 Sign types in the garden ............................................................................................................. 52
Figure 24 Directional marker should be placed at decision-making points or junctions for clearer
orientation of the space around ................................................................................................................. 53
Figure 25 It should be visible from far and remains unobstructed .................................................... 53
Figure 26 An example of a directional marker with suggested clearance ...................................... 54
Figure 27 An example of an interpretive sign with an uncluttered layout and clear foreground
elements ........................................................................................................................................................... 54
Figure 28 showing what to Avoid using all capital letters for body text........................................... 54
Figure 29 An example of an interpretive sign with suggested heights ............................................... 55
Figure 30 Examples of common and Recognizable pictograms/icons ................................................ 55
Figure 31 Key Symbols ................................................................................................................................. 57
Figure 32 Base map for prototype ............................................................................................................. 63
Figure 33 Prototype Catastrophic Therapeutic Garden ....................................................................... 67
Figure 34 Prototype Psychiatric Therapeutic Garden ........................................................................... 69
Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 VI

List of Tables
Table 1 Ayder Hospital Observation Analysis ........................................................................................ 22
Table 2 Quiha Hospital Observation Analysis ........................................................................................ 27
Table 3 Summary Of The Observation Analysis .................................................................................... 29
Table 4 Identified Elements Of Therapeutic Landscape Features Of The Hospitals ...................... 30
Table 5 Triangulation Analysis Of Ayder Hospital ................................................................................. 37
Table 6 Triangulation Analysis Of Mekelle Hospital .............................................................................. 38
Table 7 Triangulation Analysis Of Quiha Hospital ................................................................................. 40
Table 8 Summarized Triangulation Analysis ............................................................................................ 41
Table 9 Kaplan’s, Ulrich’s, And Others Factors In Dementia Therapeutic Garden ....................... 65
Table 10 Kaplan’s, Ulrich’s, And Others Factors In Dementia Therapeutic Garden ..................... 68
Table 11 Kaplan’s, Ulrich’s, And Others Factors In Dementia Therapeutic Garden ..................... 71
Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 VII
LIST OF ACRONYMS AND ABBREVIATIONS

CHD……………………………..The Center for Health Design
WHO………………………………………World Health Organization
UD…………………………………………Universal Design
HT…………………………………………Horticulture Therapy
Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 VIII
ABSTRACT
The connection between humans and green vegetation has existed since ancient time, and the
number of studies focusing on the issue has increased recently. The presence of green vegetation
promotes recovery by inducing positive changes, such as the improvement of blood pressure,
cardiac activity, muscle activity and electrical activity in the brain.
This thesis has been set within a historical and contextual framework to gain a more complete
understanding of the role of the gardens of Ayider, Mekelle and Quiha Hospitals. The data analysis
has led the author to emphasize that the key components (garden essences) of healthcare gardens
are embodied within the principle of therapeutic garden. This new definition helps refine the
character of an effective therapeutic healthcare garden and is useful when considering the design of
a Healthcare Centre, both inside and out. The on-site observation, questionnaires and interviews
were able to highlight stories and layers of experiences of the case study gardens. The findings
present not only relevance of therapeutic landscape but also evidence of where the case studies do
not function effectively as therapeutic garden.
This thesis summarizes that both therapeutic landscape researchers (Landscape Architects) and
healthcare professionals should re-examine not only the value of a garden but also what counts as
evidence. As discussed in the previous sections, garden researchers need to look at the range of
principles that a therapeutic garden holds, embracing both a phenomenological and an ecological
perspective. Such an approach suggests that perception and action are intertwined and that there
is a mutual relationship between perceiving and the environment. A healthcare garden cannot be
discussed in the way that perhaps other aspects of material culture can; its capacities can never be
measured in the way that an object, service, or drug can.
Key Terms: Therapeutic Garden, Horticulture Therapy, Health, Healing, Hospital, Nature
Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 IX

CHAPTER ONE
1.1 INTRODUCTION
Healthcare facility design by tradition has emphasized it is concerns on such as functional efficiency,
costs, and providing effective platform for medical treatments, technology, and medical equipment. A
consequence of this perception has been that mental and social needs of patients have been largely
ignored in the design of healthcare facilities – and often disregarded in creating visitor and staff spaces.
Despite stressful hospital experiences and major strain from illness, slight priority has been given
towards creating environments that calm patients, or help to strengthen coping resources and healthy
processes. Rather, the practical emphasis often produced surroundings now considered frankly
institutional, stressful, and unfavorable to care quality (Ulrich & Parsons, 1992).
According to European Agency for Health (2011), Stress is one of the major health and safety
challenges in Europe and “it is the second most stated work-related health problem, affecting 22% of
workers from EU 27 (in 2005)”. Many studies concentrating on stress and human health recommend
that in order to release the undesirable effects of stress on human health, it should be restored and
recovered. Researches in environmental psychology has indicated that there is a direct connection
between human health and access to nature. They also recommend that a natural environment can be
one of the answers which may be considerably helpful to restoration and recovery from mentioned
issues ( (Kaplan & Kaplan, 1989); (Kaplan, 1995); (Ulrich, et al., 1991); (Van & Wagenaar, 2007).
This thesis, as the title indicates, looks at healthcare gardens/Therapeutic Landscape. It takes as its
focus on hospital environment of Mekelle. It looks at three of the hospital in Mekelle namely Ayider
Referral Hospital, Mekelle General Hospital, and Quiha General Hospital gardens as case studies,
presenting new knowledge of the experiences of these gardens by the people who use them. With
this new knowledge this thesis explores the idea of healthcare gardens operating as “therapeutic
places” and it questions and investigates the ways in which hospital environment of Mekelle’s gardens
may or may not be such places.
This research about therapeutic landscape is set within the aims and objectives of creating hospital
environments more therapeutic for patients and more appealing for visitors and less stressful for the
staffs. This research has been set within a historical and contextual framework to gain a more complete
understanding of the role of the gardens of Ayider, Mekelle and Quiha Hospitals. The data analysis has
led the author to emphasize that the key potentials (garden essences) of healthcare gardens are
embodied within the principle of therapeutic garden. This new definition helps refine the character of
an effective therapeutic healthcare garden and is useful when considering the design of a Healthcare
Centre, both inside and out. The on-site observation, questionnaires and interviews were able to
highlight stories and layers of experiences of the case study gardens. The findings present not only
relevance of therapeutic landscape but also evidence of where the case studies do not function
effectively as therapeutic garden.
Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 1

1.1.1 BACKGROUND OF THE STUDY

Nature has the capability to accelerate the recovery process a lot as provided by researches and policy
level. The effect of the landscape directly involves Horticultural Therapy. Horticultural therapy (HT) is a
process, in which vegetations are used to improve the body, mind, and soul, through horticultural activities
and to increase the consciousness of the naturaldworld. HT is universal, adaptable, and confirmed by
research (Adevi, 2012).
The first recorded data of the incidence of ‘horticultural therapy’ was around 1600 AD. This occurred
when poor people who could not pay their hospital bills so they were made to work in the gardens to pay
it off. Due to their working in the garden, it was observed that the patients who were working in the garden,
as well as those who had a view of the gardens, recovered way fasterdthan other patientsdwho had no
interaction with the gardens (Ananth, 2008). Landscape therapy offers a widedrange of activities that can be
done by a person of any age. Activities depend upon what a person can do and what skills would like to be
gained or improved. Gardening boxes and surfaces can be created on all the levels for those patients who
are unable to move on theirdown and for those who are on wheelchairs (Parson, R; Harting, T; J.T,
Cacioppo; L, G Tassinary; G, G Bernt-son; Eds, 2000) (Van den & Koole, 2003) (Harting , T; Mang, M; Evans,
GW, 2008).
Architecture has the distinctive ability of being able to have a direct effect on the way people feel within
a space, so this research tries to break down the principle of therapeutic landscape and suggest that natures
integration can have a big effect on healing environment and sets out to show that Architecture can play a
vital role in the healingdprocess. While the evidencedfor the importance of accessdto nature is there—
and growing—the actualdprovision ofdappropriatedoutdoor space in healthcaredfacilitiesdis often less
than adequate, with limited “green nature,” unmetdneeds fordprivacy and “getting away,” even poor
provisiondof thedmost basic needs, such as easedof access, comfortabledseating, safe walking surfaces,
protectiondfrom thedsun, and so on.
In this paper, a review of Literatures and other ‘theories of therapeutic landscapes’ will be assessed together
with a case studies research to enable an analysis of how the value of specific applications of therapeutic
landscapes design can be applied. The research was done mostly by observation and Interviewing the
Hospital users and staffs to provide quantitative evidence to indicate the effect and size of the landscape
features that engage visits; and, furthermore, rank the choices of landscape features specific to diverse user
groups based on the result of the engagement of visits (Marcus & Naomi, 2014).

1.2 PROBLEM STATEMENT AND JUSTIFICATION

1.2.1 PROBLEM STATEMENT
The numberdof healthdcare facilities especially hospitals are rapidly increasing in Ethiopia today but the
big question is are they serving their mere purpose which is healing? As more researches are showing that
the immediate environment of the patient can have a big impact on the healingdprocess and accelerate
the recovery time. However, many health care facilities in Tigray specifically in Mekelle have not taken
advantage of this. Most of the hospitals in Mekelle does not have outdoor spaces or they are large expanses
of unorganized spaces (which is the case in most general/Specialized hospitals) most of the hospital
landscapes are poorly designed without variety of garden schemes to enhance the quality of the hospital
environment, which should have been a pleasing experience for patients, visitors, and staffs.
1.2.2 JUSTIFICATION OF THE RESEARCH
The WorldHealth Organization defines health as ‘‘a state of complete physical, mental and social
welfare and not just the lack or absence of disease or infirmity’’ (WHO, 2013).
While several individual and organizational reasons are associated with patient safety outcomes, one
critical factor that is not usually discussed is the physical environment. The physical or built
environment and the immediate space surrounding us like the landscape affects how we feel mentally,
physically, socially, and spiritually.
1.3 OBJECTIVE OF THE STUDY
1.3.1 GENERAL OBJECTIVE
The Objective of this study is to research and explore the concept dof therapeutic
landscapedArchitecture and to assess the role of the existing green spaces inside the Hospitals of Mekelle,
in order to understand the effect and consideration by the users and give recommendation and
intervention guidelines to improve their physical characteristics, according to a therapeutic approach.
1.3.2 SPECIFIC OBJECTIVES

❖ To identify the components of the existing landscapes feature in the hospitals facilities that make
it therapeutic
❖ To assess the hospitals in Mekelle the performance of the landscape according to the therapeutic
landscape design principles
❖ To prepare a recommendation and give intervention guidelines for the hospital environments to
make the hospitals more therapeutic for patients and more appealing for visitors and staffs.

1.3.3 RESEARCH QUESTIONS

✓ What are the components that exist in the hospitals that make it therapeutic?
✓ What is the current roledof the landscape in the hospital environment of Mekelle?
✓ How can I achieve the optimal therapeutic landscape environment in the hospital environment of
Mekelle?
1.4 RESEARCH METHODOLOGY

The study will be conducted in three of Hospitals in Mekelle, the study will be conducted through
observation, questionnaires, and interviews. This research will also involve Literature Reviews and Case
Studies.
1.4.1 LITERATURE REVIEW

A review of the therapeutic landscape in Architecture magazines, journals and publications, unpublished
thesis, and internet-based researches of the research area to have a better knowledge base on the topic.
1.4.2 CASE STUDY

The case study method is basically qualitative.
This involves mostly analysis of similar facilities internationally and locally with a view to understanding the
factors and or principles behind their design and composition.
The case studies are: -
i. Three local Case studies
1.5 SCOPE OF THE STUDY

The scope of this thesis is limited to hospital environment in Mekelle. This thesis will include detailed
review of researches and case studies on the therapeutic landscape for the knowledge base to study the
existing environment of hospitals in Mekelle and upgrade the existing one by applying the knowledge that
is gained in the research and case studies. The research will focus on nonclinical spaces in a healthdcare
environment that is mainly and frequently used by patients, visitors, and the staff of the hospital. Clinical
spaces like Operation Rooms and Examination Rooms are excluded.
General areas are analyzed like outdoor landscape area, ward area, and Circulations. The spaces
will be assessed under the circumstances of Ethiopian Context and international quality standards.
1.6 SIGNIFICANCE OF THE RESEARCH

Considering the current hospital physical environment in our country there is a need to explore
possibilities that can improve the whole hospital physical environment and the experiences of it in the
patients, visitors, and staffs.
This research will help understand a new viewdin the healthdcaredsystem (Hospital Architecture) to help
improve the existing environment and can be a reference to explore the therapeutic environments. It can
set the base for other researchers to continue the research in the same topic or related areas.
1.7 RESEARCH DESIGN
Research
Idea
Case Study
Litrature
Analysis
Identify Analyse Principles Standards
Physical Questionaires Universal

Assessment Interviews
Guidelines Standards
Recommendat
ion Conclusion
Proposal
FIGURE 1 RESEARCH DESIGN

CHAPTER TWO
LITERATURE REVIEW
2.1 DEFINITIONS OF TERMS
Therapeutic: relating to the healing of disease. having a good effect on the body or mind.
Therapeutic treatmentdis designed to treatdan illness or to improveda person's health,
ratherdthan to preventdan illness.
Therapeutic Landscapes is greendspaces in healthcaredfacilities which have a therapeutic

effect on physical and mental health.
Horticulture is the art or practicedof garden cultivationdanddmanagement.
Horticultural therapy (HT) is a process, in which vegetations are used to improve the body,
mind, and soul, through horticultural activities and to increase the consciousness of the natural world.
2.2 THERAPEUTIC LANDSCAPES

Therapeutic landscape is a term often used in medical geography or environmental psychology
to denote to landscapes that help achieve physical, mental, and spiritual healing or well-being. The
essential idea is that the value of the design of physical surroundings can impact patient’s medical
results and care quality, and often includes purposeful landscaping of fundamentals of nature into
the built environment.
Green spaces such as gardens, pathways lined with trees and green walls infuse a sense of
vitality into the hospital. Furthermore, treesdand plants releasedoxygen and humidifydand cool
thedatmosphere. A steadydsupply of freshdair allows for theddetoxification of airbornedtoxins in
the body, and can meaningfully lighten one’s mood.
Blue spaces are also an important aspect that may promotedhealthdand wellbeing.
Therapeuticdlandscapes may encompassdfeatures such asdfountains anddstreams. These water
elements are related with helpful mood effects, where the buzzes of water are often thought
calming and uplifting.
The therapeutic aspect of nature can also be achieved from one’s bed in the ward. A paperdby
RogerdUlrich, environmentaldpsychologist and director of the Centredfor HealthdSystems and
Design, emphasizes the aids of a window viewdof nature. In critical caredunits, windowdviews
aredlinked to lower rates of anxietydand depressiondin comparisondto windowless units. Patient
rooms that allow natural sunlight to infiltrate also foster more favorable medical outcomes.
Ulrich uses the term ‘positiveddistraction’ to denote to these conditions that haveda capacity to
redirect an individual’s attention from negative focuses of illness to the restorative features of
nature. Merely viewing nature for five minutes or less can decrease stress and encourage
physiological aids such as the dropping of blood pressure and reduced heart rate. (Lui, 2017).

2.3 HISTORY OF THERAPEUTIC LANDSCAPE

The idea of a therapeutic/healing environment is deep-rooted in long-standing backgrounds of
complementary medicine and complete healing. Unlike modern Western medicine, which
emphases on the causes of illness (pathogenesis) with curing as the goal, complementary medicine
looks at the causes of health (salutogenesis) with healing as its fundamental mission. Within the
later tradition, a healing environment has been defined as an environment that inspires healing
processes by strengthening an individual's internal powers (Jonas, et al., 2003).
2.3.1 ASCLEPIEIA OF ANCIENT GREECE

The Asclepieiadof ancient Greecedis commonly considered to be the first hospitals (or better
said, healthcare centers) of Europe (Risse, 1999). Asclepieia were erected as temples devoted to
Asclepius, the god of health and healing. Starting in about 300 BC, the cult of Asclepius grew to
be very widespread. Pilgrims congregated to this healing temples to be healed. At the Asclepieion,
they received an exclusively spiritual treatment.
The architectural design of Asclepieia approves the spiritual character of the health care
provided in these temples (Chatzicocoli-Syrakou, 1997). First, indline with the ancientdGreek
acceptance in the celestial powers of nature, Asclepieia were generally created in valleys at
favorable wooded locations close to hot or cold springs. While the water had significant symbolic
cleansing ideals in ancient Greece, it was also chosen because people believed that springs
possessed oracular or prophetic powers (Risse, 1999). Thus, the existence of nature, mainly the
presence of water, was a crucial feature of the Asclepieion.
2.3.2 MONASTIC INFIRMARIES OF THE MIDDLE AGES

In the Middle Ages, medical care was meticulously related with the religious institutions of the
time. Christian charitable organizations such as the order of St. Benedict, which succeeded amid
the 6th and 10th centuries, made it their mission to heal their sick comrades in flesh and spirit.
In these days, little was known about physical illness, and ‘healing of the flesh’ was based mostly
on ideas of classical humorism and folk healing backgrounds (Risse, 1999).
The design of monastic infirmaries had many features to encourage the spiritual healing process.
An important feature of the layout of the monastery was the garden. Infirmaries in monastic
cloisters were consciously located next to a central courtyard or garden so that patients could
expect the scenery and make a connection with God. This courtyard was generally designed to
represent the Garden of Eden referred to in Genesis of the Bible. Gardens were also used to
grow medicinal herbs, which were applied in the treatment of patients. In the monastic infirmary,
peace and quiet were highly valued, and patients were encouraged to eat their meals in silence.

2.3.3 THE PAVILION STYLEDHOSPITAL

The pavilion styledhospital was developed in France in the 18th century after a major fire almost
destroyed the oldest hospital in Paris, the Hôtel-Dieu (Mens & Tijhuis, 1999). Instead of a single
massive structure, the pavilion-style hospital consisted of many small, connected buildings or
pavilions. It became the standard for hospital design in thedmid-19th century in many Western
countries (Cook & Henry , 2002).
The pavilion styledhospital was explicitly designed to make of use the natural environment as a
therapeutic instrument. The natural environment was assumed to exert its positive influence on
health through three characteristics: fresh air, sunlight, and peaceful, green surroundings. In
particular, the principle of fresh air can be considered quite revolutionary. Until the advance of
the pavilion-style hospital, it had received little consideration in the design of healing
environments.
2.3.4 PLANETREE HOSPITALS

In the late 1970s, more and more people, specifically patients and nurses, became unhappy
with the sterile and user-unfriendly design and organization of the hospitals of that period
(Frampton, S B; Gilpin, L; Charmel, P, 2003). One patient, named Angelica Theriot, went through
such a traumatic hospitals experience that she took the initiative to found Planetree, a nonprofit
organization that attempts for the change of healthcare settings into healing environments.
The Planetree model provides guiding principle for the design and organization of healthcare
facilities. With respect to facility design, the model orders that buildings should include effective
layouts that provisions the user’s requirements and create home-like spaces. The design should
also stand-in a connection with nature. Healing gardens, fountains, fish tanks and waterfalls are
provided to connect patients, families, and staff with the calming, stimulating, healing, and
meditative aspects of nature. Hearing needs are attended to, understanding that gentle sounds
rather than blaring noises may help people to remain calm and re-claim control.
2.4 TYPES OF THERAPEUTIC GARDENS

The Center for Health Design (CHD) presents the following types of therapeutic gardens
(Westphal, 2000; Smith, 2007):
I. HEALING GARDEN (physical, psychological, and mental healing effect, induction of

overall feeling of well-being);
II. ENABLING GARDEN (based on psychological effects, aiding physical recovery,
improving physical condition based on possible activities, mental growth based on
meaningful activities);
III. MEDITATIVE GARDEN (supports the inner thought process);
IV. REHABILITATIVE GARDEN (primarily based on rehabilitation in the environment);
and
V. RESTORATIVE GARDEN (regeneration after stressful situations).

2.5 THE ROLE OF LANDSCAPE IN THERAPY

The practice of viewing nature as a ‘healer’ can be
drawn from way back in history. In Europe, during
the Middle Ages, monastic hospitals delivered
with fenced vegetation gardens with the purpose
of attaining the spiritual transformation of
patients. The role of nature in bodily restoration
increased a stronger foothold in the 17th and
18th centuries, where the arrival of scientific
medicine advised that infections were spread ‘by
toxic vapors’ in the air.
This encouraged architectural designs that gave

attention to fresh air and cross-ventilation.
FIGURE 2 THE WILHEIT-KEYS PEACE GARDEN (NORTHEAST
Florence Nightingale, in Notes on Nursing (1860), GEORGIA MEDICAL CENTER, IN GAINESVILLE)
wrote on the importance of fresh air, direct
sunlight, and visual contacts to nature in
encouraging recovery of the body. Functions of healing gardens include:
prospects for physical movement and
exercise, prospects to make choices, seek privacy and experience a sense of control, settings
which encourage people to gather together and experience social support and access to nature
and other positive distractions, and relieve pain and stress for patients who suffer incurable or
chronic disease (Ulrich, 1999).
2.6 THERAPEUTIC LANDSCAPE FEATURES

2.6.1 PATIENT-ORIENTED LANDSCAPE FEATURES
The notion of ‘therapeutic landscapes’ denotes to landscapes that help attain physical, mental and
spiritual healing. As such, together with natural features in the physical setting of hospitals can
help to encourage healing and enable rehabilitation.
These gardens have definite therapeutic functions to aid in the recovery and rehabilitation of
patients. These may work together with medical treatments and encourage complete wellness.
2.6.1.1 P HYSICAL THERAPY

Whereas a fitness center or gym might be every so often used by physical therapists, the use of
apparatus may be intimidating to some. Therapy gardens, however, may donate to treatments by
providing outdoor space for activities such as low-impact walking or stretching. Physical
movement and light training are particularly useful for elderly patient and combats mobility
decline that may emerge from spending long hours on the bed. Also, regular physical activity in
the outdoors helps develop muscle strength, aerobic capacity, balance, and flexibility.

2.6.1.2 R ECREATIONAL THERAPY
Horticulture is a common element of recreational therapy, where gardening may be included as

part of treatment programs. Prominent psychiatric psychotherapist and author Sue Stuart-Smith
points out that working in a fenced garden gives a sense of protection to individuals distressed
with trauma or a mental breakdown.
Gardening is also useful for patients looking to recover their motor skills. As a hands-on activity,
it encourages eye-hand coordination, variety of motion and endurance. For the disabled,
apparatus and garden structures should be designed to increase convenience and accommodate
variable needs. This may include ergonomic apparatuses, elevated garden beds, and wheelchair
friendly pathways.
2.6.1.3 H ORTICULTURAL T HERAPY

The idea of horticultural therapy can be applied to both therapeutic landscapes and healing
gardens. The American Horticulture Therapy Association defines horticulture therapy as "a
process utilizing plants and horticultural activities to improve social, educational, psychological
and physical adjustment of persons thus improving their body, mind and spirit."
2.7 DESIGN PRINCIPLES OF A THERAPEUTIC GARDEN

Before starting the design process, it is significant to know the user groups. In designing a
healing garden, the attention should be on the people who are going to use the garden, on the
extra hand, the theories should be considered as a guide. Conditional on user groups there
should be a balance amid the physical activities and just being and go through the garden
passively (Stigsdotter & Grahn, 2003). It is vital to know who are the group of people is going
to use the garden. Who are they? What do they do? (Stigsdotter & Grahn, 2003).
1.1.1 FEELING OF SECURITY

Since, not all gardens have healing effects (Stigsdotter & Grahn, 2002), they should have distinct
characteristics to be called a therapeutic garden. therapeutic gardens should deliver a feeling of
security and safety. By being enclosed off and safe, they could bargain psychological peace and
space for relaxation (Tenngart, 2011). Garden, by showing life with lively components such as
trees, flowers, bushes may give the feeling of security and hope to the visitors (Stigsdotter &
Grahn, 2002). The architecture of the building should give a feeling of security since user groups
are in a more vulnerable situation, they tend to perceive depressive or threatening message
from their surroundings. In order to promote the healing process in therapeutic environments
the surroundings must be unambiguously positive, this means that the process of healing should
be supported by the place (Cooper & Barnes, 1999).
2.7.1 UNDERSTANDING USER GROUPS AND THEIR NEEDS

Healing gardens should be restorative and helpful to participants for improving their wellbeing. In
designing healing gardens, it is extremely critical to understand the user groups and purpose of

the garden. The next step is what the garden can offer to that specific user group (Stigsdotter &
Grahn, 2003). According to Cooper Marcus and Barnes understanding how people see their
surroundings and how they react to it, is one of the most crucial factors of therapeutic design, in
another word what individuals observe and how they interpret it (Cooper & Barnes,
1999).“Sound, sight, and smell in the environment are external stimuli that are directly identified
by the conscious mind” (Cooper & Barnes, 1999).
2.7.2 OFFERING DIFFERENT TYPES OF ACTIVITIES

In healing gardens, giving attention to the need for diverse types of communication is crucial. One
type can relate to a demanding environment. For instance, ponds or water can be the least
demanding part or cultivation in the garden can be considered as the most demanding. And
between these, there are different parts according to the mental capacity of the visitor; one of
them suits her/him (Stigsdotter & Grahn, 2002). According to Ottsson the experiences from
nature depends on ones’ life situation. So, the garden should offer different degrees of demand
for the participants (Ottosson, 2007).
2.7.3 DIFFERENT ROOMS

It is important that the garden has different rooms with different characters. Research shows
that gardens or parks should have some specific characters to be visited by the users. “Healing
garden must be able to interconnect with the visitors on many levels over sight, smell, hearing,
etc.” (Stigsdotter & Grahn, 2003). Senses stimulation is one of the important factors in both the
healing Garden School and the Restorative or Cognitive School. Designers ought to offer different
thing to stimulate the participant’s senses. They can be diverse as listening to running water,
touching stones, tasting berries, or smelling flowers (Stigsdotter & Grahn, 2003).
2.7.4 PRIVACY AND SOCIAL INTERACTION

Exercise reduces stress plus physical exercise improves psychological well-being. It also reduces
depression (Cooper & Barnes, 1999). There should be a steadiness between the gardening actions
and just being passive by experiencing the garden (Stigsdotter & Grahn, 2003). Research shows
that people who are supported socially are usually less stressed and they have improved health
status than people who are more socially isolated. Researches also show that patients and staffs
prefer natural, spatially enclosed settings for active socializing but on the contrary, they prefer
natural, spatially open settings for more passive activities such as seating and viewing the scenery
or watching the other people. Settings with vegetation are more preferred over built
environment for different types of activities (Cooper & Barnes, 1999). Designers should be
conscious of the balance between the social aspect and privacy.
2.7.5 SURROUNDING AND VIEWS

The geographical setting of the garden has an impact on the garden and the practice of the garden.
It is significant to know what surrounds the garden. The history of the place is also important to
know because it shows how the place transformed into the present appurtenance (Stigsdotter &
Grahn, 2003).

2.8 CHARACTERISTICS OF THERAPEUTIC LANDSCAPE

These are the important characteristic that are associated with the notion of therapeutic
landscape. When the budget allows, there are several ways hospitals and other health care
facilities can incorporate therapeutic landscape design:
I. Vegetation
The hardscape walkways and courtyards are part of a good hospital landscaping plan, vegetation
is sovereign. It should be luxurious, with covered landscapes with shade trees, flowers, and
shrubs at several heights. Plant life that offers shade, privacy, and beauty all significant to a
therapeutic atmosphere.
II. Wildlife Presence
Domestic plants — plants unique to the context country should be vastly popular now. They
are resistant and less vulnerable to pests and diseases. They grow fine and need little care. They
also attract flora and fauna, another enhancement to healing. Birds, butterflies, and
hummingbirds will start fluttering around, take pleasure for the patients and hospital workers
who stood outside for some relief.
III. Engaging the Senses
The best therapeutic landscaping should not be just an appealing for the eyes. It must Suggest
gardens that can be touched, smelled, and heard, too. Decorative grasses swoosh mildly in the
breeze. Vague lamb’s ear plants are nice alternatives for pets. Lavender’s odor is well-known
for relaxation and calm. One note that should be Avoided sturdily fragrant flowers or other
odors. Chemotherapy patients are subtle to many smells.
IV. Walkways Accessibility and Safety
Pathways should be inclusive enough to house wheelchairs and pedestrians walking in pairs.
They should be even, so they do not obstruct wheelchair wheels or hitch wheeled IV poles.
V. Healing Plants
Some plants have been related with healing for centuries and are great add-ons to therapeutic
landscaping. They include lavender, rosemary, roses, catnip, sage, and sweet marjoram.
VI. Water Features
The sound of stirring water relaxes us, pacifies our nerves, and makes a hospital visit a bit less
stressful. Waterfalls and fountains are both great choices to include in the courtyard or
communal areas or as a feature in a healing garden.

2.9 PHILOSOPHY OF THE HEALING AND THERAPEUTIC LANDSCAPE

DESIGN
The connection between humans and green vegetation has existed since time immemorial, and
the number of studies focusing on the issue has increased recently. The presence of green
vegetation promotes recovery by inducing positive changes, such as the improvement of blood
pressure, cardiac activity, muscle activity and electrical action in the brain. These findings are
important not only for hospital complexes, which were primarily addressed in this work but in
general (Ulrich, R S; C. Cooper, Marcus; M., Barnes, 1999). Improvement in behavior, a better
pulse, blood pressure, and weight values were demonstrated in patients with various disease
thanks to the garden, but the nature of medicinal use has not changed (Westphal, 2000).
A summary of recommendations for the making of healing gardens, accompanied with more
recent discoveries is provided for the best effect conceivable. Green vegetation is supposed as a
significant means for making medical facilities individuals visit because of their current
psychological or physical problem,
while patients and staff are exposed to a stressful environment (Cooper Marcus, 2007; Shackell
& Walter, 2012; Ulrich, 2002). Based on the research, it is stated that a person goes through the
following three or four stages in terms of psychology, when the person decides to visit green
spaces (e.g. gardens or park areas) or to a natural environment to feel good (Cooper Marcus,
1997):
• a journey - a change of place or flight from the place where stress has occurred,
the healing garden serves as a sanctuary;
• sensory awaking - the awakening of the senses, sensory experience based on
new phenomena, sounds, scents, etc.;
• personal centering - concentration on internal processes, finding inner strength,
changing the view of problems; and
• deeper perception of a human’s connection to the environment, perception of
the whole, relief.
Ulrich’s theory of the so-called restorative design is based on the theory and research of
behavioral science and science in areas related to health. It suggests that green vegetation in
medical facilities is an important comforting means for both patients and staff because it provides
the following in humans (Ulrich, R S; C. Cooper, Marcus; M., Barnes, 1999):
• sociality;
• sense of control (person loses control in a hospital, led by the conditions and
staff of medical facility);
• physical movement;
• access and bond to nature; and
• general, various positive distractions.

The term therapeutic garden can refer to a garden that produces a certain effect and a measurable
outcome in the disease process, related to the particular feature of a disease or healing process
(Mitrione & Larson, 2007). It is less focused on mental health and related more to allopathic
medical systems defined by treatment based on the biological action of the medicine, using
medicine that induces a state opposite or incompatible with the course of a disease (garden
elements and activities in the case of a garden). (Marcus & Barnes, 1999) described therapeutic
gardens as gardens to improve overall patient and employee moods that can induce stress relief
and alleviate physical symptoms. The Centre for Health Design (CHD) presents the following
types of therapeutic gardens (Westphal, 2000); (Smith, 2007):
• healing garden (physical, psychological, and mental healing effect, induction of

overall feeling of well-being);
• enabling garden (based on psychological effects, aiding physical recovery, improving
physical condition based on possible activities, mental growth based on meaningful
activities);
• meditative garden (supports the inner thought process);
• rehabilitative garden (primarily based on rehabilitation in the environment); and
• restorative garden (regeneration after stressful situations).
The principles of creating healing and therapeutic gardens as well as their positive effect on the
human psyche, perception, and health are an important part of designing healing and therapeutic
gardens. When designing the outer hospital space, we can follow several groups of principles.
(Ulrich, 2002) outlined the possibilities for physical movement, selection options, socialization-
supporting elements as well as access to nature and positive distractions as four main aspects of
a medical facility garden.
(Kaplan & Kaplan, 1989)) distinguished four principles that a garden can include as a natural
environment: cohesiveness/coherence, readability - as factors of understanding; and
mystery, complexity - as factors of discovery.
(Cooper, 2007)defined a successful garden using the following principles: variation of spaces,
the abundance, and predominance of green vegetation, movement support, positive
distractions, minimizing interference, minimizing ambiguous elements that can have
different meanings for healthy and ill people.
(McDowell & McDowell, 1998) recommended 7 elements of the healing garden design: a
special entrance that welcomes and takes hold of a visitor to the garden; a water feature for
their physical, psychological and mental effects; the creative use of colors and light that
induces emotions and comfort; an emphasis on natural elements; the integration of art;
elements that attract animals to create animal diversity.
(Kellert, 2005) presented 9 basic environmental values on which the attraction of a person
to nature depends: aesthetics, dominance, humanity, morality, naturality, negativism,
science and scientific knowledge, symbolism, and utility.

2.9.1 DESIGN AND CONSTRUCTION GUIDELINES OF THERAPEUTIC LANDSCAPE FOR

MEDICAL CENTERS
from Cooper Marcus point of view (Cooper, 2007)
➢ Considering the whole site as a therapeutic/healing environment

➢ Landscape architecture as a part of the Main design at the beginning of the design
process
➢ Design in order to serve different patients
➢ Providing at least one distinct outdoor space for the staff
➢ Legible details from the entrance
➢ Garden in a silent place
➢ The proper proportion of the height of adjacent buildings to the width of open space
➢ Curved paths
➢ Minimizing the intense darkness and light areas on the ground
➢ Sufficient space for wheelchairs movement from
2.10 SUMMARY OF LITERATURE REVIEW

The environment can have a positive influence on the recovery of patients and quality of life for
those with medical conditions. Evidence can be applied in the design or upgrading of care facilities
to provide small garden areas. Therapy and leisure activities in the garden should be considered
as a part of care. Common flowers or shrubs in an inexpensive planter can enhance the view
from a window and indoor plants improve the experience of care. Simple gardens with space for
the social and therapeutic activity should be a standard consideration for care facilities as these
can host multiple therapies and provide contact with nature. Post-occupation assessment of
gardens and indoor plantings are necessary to highlight benefits.
Most of the academics in the field of therapeutic gardens highlight on the impact of gardens and
landscapes as a part of treatment and commend general theories for understanding the mental
environment of patients, considering the patient's constraints, getting a intellect of pleasure from
the environment, the positive outcome of landscape on general health, the use of doctors and
specialists' views in general guidelines, and designing according to need. Cooper Marcus has gone
a step further by bringing together theories and history of the subject and by presenting
collaborative design theory to find valuable guidelines for the entire design team including
investors, shareholders, doctors, employees, and patients, and with an evidence-based approach,
Evidence-based design has delivered a scientific justification for a deep-rooted idea on the
significance of the physical environment for health and healing. In recent years, a considerable
knowledge base has become available that can be used by healthcare providers and designers to
make optimal decisions on hospital design. This knowledge base encompasses some suggestion
for the health effects of traditional essentials of healing environments, such as nature, daylight,
fresh air and quiet.

CHAPTER THREE
RESEARCH DESIGN AND METHODS
3.1 RESEARCH METHODOLOGY
The main purpose of this study is to Introduce therapeutic landscape design to hospitals of
Mekelle and to assess how the presence of the existing landscape features perform in the
recovery intent of patients and users in different roles in a hospital setting. The research will be
done mostly by observation and Interviewing the Hospital users and staffs to provide quantitative
evidence to indicate the effect and size of the landscape features that engage visits; and,
furthermore, rank the choices of landscape features specific to diverse user groups based on the
result on the engagement of visits.
This study will involve the relevant presence and priorities of landscape features for the diverse
user groups on hospital property. The study evaluates the connection between indoor and
outdoor spaces, in terms of visual and spatial understanding according to the therapeutic
landscapes’ characteristics.
By applying the evidence-based Design principles, the outside spaces are qualitatively observed
for and quantitatively compared to regulate the effectiveness of the planning and assume any
improvements for the correct and successful use of the gardens.
3.2 DATA SOURCES

The course of the data analysis is amid to study diverse information’s from various sources to
support the hypothetical part of the research. the data collection method Consists, both,
primary and secondary data sources are used.
3.2.1 PRIMARY DATA SOURCE

Primary data sources are received from first-hand sources. The following are data sources for
primary data,
3.2.1.1 O N - SITE OBSERVATION

• Site analysis
• Observing the workflow, structure, and activities patients throughout the Hospitals
• Observing existing situations of the landscape
3.2.1.2 Q UESTIONNAIRES \ I NTERVIEWS

- For Patients, Visitors, caregivers, and staffs for the research
3.2.2 SECONDARY DATA SOURCE

Secondary data are received from secondary sources such as printed material and published
materials and documented files.

3.3 PRIMARY DATA COLLECTION METHODS

3.3.1 OBSERVATION
Observation is a method of primary data gathering in which an investigator collects data based
on their individual observation. The observations help to investigate and comprehend the existing
space conditions and, variable and invariable characteristics for the problem raised in the study.
3.3.2 INTERVIEW
In-depth interviewing is a qualitative investigation procedure that involved conducting thorough
individual interviews with a small number of respondents to discover their viewpoints on a
particular idea. Contributors get asked about the issues of the research and a program about
their involvements and expectations related to the program, the thoughts they have concerning
program operations, processes, and outcomes, and about any information they observe about
the program. This interview is prepared to explore the insights of the respondents and to see
the point of their view. The interview was also prepared to grasp some ideas of the respondents
from their experience in the issue and the most relevant and key questions that could benefit to
the research were asked.
3.3.3 QUESTIONNAIRE
The questionnaire included 13 structured questions to get the preference of the users.
Demographic information such as age and gender were excluded. The questionnaires helped to
gather data about the current personal perceptions of the respondents on the view of the
landscape and it is used. And also, recommendations of the respondents are collected through
the prepared questionnaires.
3.4 Hospital Selection Criteria

The hospitals were carefully chosen purposively and the standards included being general or
referral hospital with active practical departments that can practically manage complications in
the regional capital and outside the capital that have provided comprehensive emergency care in
the past two years prior to the study.
3.5 THE STUDY SITE DESCRIPTION

The study sites are the Ayder Referral Hospital, and Quiha General Hospital Mekelle, Tigray.
Ayder Referral Hospital which is in a central area of the city with a landscape surrounding the
hospital main building. It is categorized as a referral district hospital providing comprehensive
clinical amenities plus regular treatment, emergency treatment, dhospitalization, and long-term
care in eight maindmedical categories including theddepartment of medicine, surgery,
stomatology, obstetrics anddgynecology, dpediatrics, traditionaldmedicine, anddcancer
department. Currently, the hospital has a large ratio of landscape area covered by greens.

Quiha General Hospital is located in entry road to Mekelle with a void pace and a landscape
surrounding the hospital buildings. It is a General Hospital offering basic treatments including
regular treatments, emergency treatment, hospitalization, and Eyecare treatments.
Mekelle Hospital is a General hospital Located in kebele 07 which provides general health care,
offering general clinical services together with regular treatment, emergency treatment,
hospitalization, and long-term cares.
Figure 3 AYDER REFERRAL HOSPITAL PICTURES
FIGURE 4 MEKELLE GENERAL HOSPITAL PICTURES

FIGURE 5 QUIHA GENERAL HOSPITAL PICTURES
Litrature Review
Specific Question 1
Objective 1 Observation Analysis
General Objective
Specific
Objective Research Questions
Objective 2 Question 2 Data Analysis
Specific
Objective 3 Recommendations &
Question 3
proposal
FIGURE 6 RESEARCH FLOW

CHAPTER FOUR
DATA ANALYSIS AND PRESENTATION
4.1 INTRODUCTION
In this chapter detail discussion and study is made on current use of the landscape in the hospitals
of Mekelle which are Ayder Comprehensive Referral Hospital, Mekelle General Hospital and
Quiha General Hospital and other related issues by using different data collecting and analyzing
methods the first part is about the general contextual background on the region where the study
took place which includes detail locations and specific information’s about the location and the
second part in these chapter emphases on detail data analysis of the response from the
questionnaire and on the gathered information’s by observation.
4.2 CONTEXT OF THE STUDY AREA
Mekelle, the regional capital city of

Tigray Region, is located in the
northern highlands of Ethiopia at 777
km drive north of the national capital
city, Addis Ababa.
Geographically it is located between
13924’30” E to 13036’52” N Latitude

and
39025’30” to 39038’33” Longitude
It has an average altitude of 2200

meters
With a mean minimum, mean

maximum and mean average monthly
temperature of 8.7, 26.8 and 17.6 ‘C,
respectively.
Area Total 24.44 km2 (9.44 sq. mi)
Time zone EAT (UTC+03:00)
FIGURE 7 LOCATION MAP OF MEKELLE

4.3 BACKGROUND OF THE STUDY SITES
FIGURE 8 LOCATION MAP OF THE HOSPITALS
4.3.1 CASE ONE AYDER REFERRAL HOSPITAL

Ayder Referral Hospital which is located in a
central area of the city with a landscape
surrounding the hospital main building. It is
classified as a referral regional hospital
present comprehensive clinical amenity
including regular treatment, emergency
treatment, hospitalization, and long-term
care in eight main medical categories
including the department of medicine,
surgery, stomatology, obstetrics and
gynecology, pediatrics, traditional medicine, FIGURE 9 AYIDER HOSPITAL MAP
and cancer department. Currently, the
hospital has a large ratio of landscape area
covered by greens.
4.3.2 CASE TWO MEKELLE GENERAL

HOSPITAL
Mekelle Hospital is a General hospital
Located in kebele 07 which provides general
health care, offering general clinical services
including regular treatment, emergency
treatment, hospitalization, and long-term
FIGURE 10 MEKELLE HOSPITAL MAP
cares.

4.3.3 CASE THREE QUIHA GENERAL

HOSPITAL
Quiha General Hospital is in entry road to Mekelle
with a void space and a landscape surrounding the
hospital buildings. It is a General Hospital offering
basic treatments including regular treatments,
emergency treatment, hospitalization, and Eyecare
treatments.
FIGURE 11 QUIHA HOSPITAL GATE
4.4 OBSERVATION ANALYSIS OF THE HOSPITALS

According to on-site observation and checklist analysis Ayder Referral Hospital and Mekelle
General Hospital are somewhat fulfill the therapeutic landscape principles they can be
transformed in to therapeutic garden with less intervention, and the landscape planning is
adaptable to changes like these, on the contrary, Quiha General Hospital is less fulfills the
therapeutic landscape principles it lacks most of the criteria to be considered as therapeutic
landscape.
TABLE 1 AYDER HOSPITAL OBSERVATION ANALYSIS
Elements Description Pictures
The entrance The Entrance is clear

area in front of with a maintained lawn in
the complex front of the entrance and
part of the parking lot
and inviting place but
lacks seating space for
visitors.
Entrance garden The entrance garden is in

good condition with
formed conifers and a
smaller flowerbed with a
fenced landscape not
accessible it just there for
visual only.

The access part The access part of the

of the area hospital is not shaded
with just greenery at the
side with the lawn and
conifers
Park type of The park type gardens

hospital garden are present in the
premises but because it is
not designed and has no
seating space nobody
uses it the character of
the park type garden is
with free grass areas and
shady areas, groups of
trees creating a forest
park;
Atriums The atrium of the site is

just free space and they
are unused area,
currently just grass and
shrubs, stone edges and
with a lawn.
Vistas/Views there is a vista in the

area that is quite
maintained, a short part
is designed. Problems
with wild vegetation.

Space without any Most of the space in the

function complex is used but a large
area in the western and
eastern part of the complex
located on the side of the
building, connected through
the long corridor and it is not
used. The area is crossed by
pavement proposed as a
walking route but it is not
used.
Different rooms The landscape is not

categorized for users as
their preference or physical
needs. There are no
different spaces for
different activities and user
groups.
Seating spaces There is no seating space

dedicated for users to use
in the garden and no rest
space in between for
waiting in the waiting area
Summary of Ayider Hospital
To summarize Ayider hospital has most of the therapeutic landscape design principles adapts and
the Entrance of the complex is clear with maintained lawn and flowering plants with no access.
The access part of the hospital is not shaded with just greenery at the side with the lawn and
conifers, the park type gardens are present in the premises and the character of the park type
garden is with free lawn areas and shady areas, groups of trees forming a forest park. The atrium
of the site is just free space and they are unused area, currently just grass and shrubs, stone edges
and with a lawn, there is a vista in the area that is quite maintained, a short part is designed but
Problems with wild vegetation. Most of the space in the complex is used but a large area in the
western and eastern part of the complex located on the side of the building.

TABLE 2 MEKELLE HOSPITAL OBSERVATION ANALYSIS
The entrance The entrance is a clear

area in front of and paved path that
the complex emphasizes a fountain
and an open area
emphasizing the
emergency and triage
department
Entrance garden The entrance garden is

planted with flowering
plants and shrubs
Covered by trees on the
sides

of the area complex is covered with
long trees with the lawn
and conifers that shades
the road from sun
Park type of The park type garden

hospital garden exists but it is not
accessible it consists of
free lawn areas and shady
areas, groups of trees
forming a forest park;

Atriums The atrium is just

courtyard gardens as
road separator it is
unused area, just for
vistas only currently just
grass and shrubs,
Vistas/Views The entry fountain is one

of the vistas of the
complex and also there is
a vista in the area that is
quite maintained, a short
part is designed.
Problems with wild
vegetation.
Space without any A large area of the left

function side of the entrance is
unused or left for
expansion, and mostly
the landscapes are not
accessible they are just
fenced garden
Different rooms There are no different

spaces for different
activities and user groups to
interact with


of each department.
Summary of Mekelle Hospitals
The entrance is a clear and paved path that emphasizes a fountain and an open area emphasizing
the emergency and triage department, the entrance garden is planted with flowering plants and
shrubs Covered by trees on the sides. The access part of the complex is covered with long trees
with the lawn and conifers that shades the road from the sun, Large area of the left side of the
entrance is unused or left for expansion, and mostly the landscapes are not accessible they are
just fenced garden. There are no different spaces for different activities and user groups to interact with
no seatings space.
TABLE 2 QUIHA HOSPITAL OBSERVATION ANALYSIS
The entrance The Entrance is Just an

area in front of open unpaved gravel entry
the complex area which is not
welcoming.

of the area hospital is not shaded by
trees it is just a passage
with no hardscape or soft
scape

Park type of The park type gardens

hospital garden are present Mostly little
shady areas, more open
Atriums The atrium of the site is

just free space and they
are unused area,
currently just grass and
shrubs with a lawn.
Space without any Most of the space in the

function complex is unused with a
large area intended for
expansion or just
undeveloped left-over
spaces

Summary of Quiha Hospital
The Entrance is Just an open unpaved gravel entry area which is not welcoming, the access part
of the hospital is not shaded by trees it is just a passage with no hardscape or soft scape and the
park type gardens are present Mostly little shady areas, more open. Most of the space in the
complex is unused with a large area intended for expansion or just undeveloped left-over spaces.
There is no seating space dedicated for users to use in the garden and no rest space in between
for waiting in the waiting area.

4.5 TABLE 3 SUMMARY OF THE OBSERVATION ANALYSIS

Observation Analysis of the three Hospitals
The Components Ayder Referral Hospital Mekelle Hospital Quiha Hospital
The entrance area in a maintained lawn in front of an open area emphasizing the Just an open unpaved
front of the complex – the entrance emergency and triage gravel entry area
and part of the parking lot;
Entrance garden – formed conifers and a smaller Covered by trees on the No entrance garden
flowerbed with a fenced sides
landscape;
The access part of the the lawn and conifers the lawn and conifers No covers just walk lines
area –
Park type of hospital free lawn areas and shady free lawn areas and shady Mostly little shady areas,
garden – areas, groups of trees areas, groups of trees more open
forming a forest park; forming a forest park;
Atriums – unused area, currently just Unused area, just for vistas No atrium almost, there is
grass and shrubs, stone edges only currently just grass and atrium at the eye care center
and a lawn; shrubs, separated from the main
complex
Space without any a large area in the western and A large area of the right side Most of the spaces are
function – eastern part of the complex of the entrance is unused or unused or unplanned
located left for expansion, and mostly
on the side of the building, the landscapes are not
connected through the long accessible they are just fenced
corridor and it is not used. garden
Vistas/Views – there is a vista in the area that formed conifers and a smaller There is good view in
is quite maintained, a short part flowerbed with a fountain some places most of the
is designed. Problems with wild with the fenced landscape; vistas are uncontrolled and
vegetation. open
Indoor vegetation – only located in some places in the only located in some places in No indoor plants the
hospital buildings, in halls, the hospital buildings, buildings are
respectively in corridors some old
flower pots with simple indoor
plants.
walking garden- It is located in the middle of The complex is separated No walking garden just
the complex and side area but and somehow have a walking small plantation in front of
unused/inaccessible garden. the buildings
Different rooms- There are no different spaces There are no different spaces There are no different
for different activities for different activities spaces for different
activities

4.6 TABLE 4 IDENTIFIED ELEMENTS OF THERAPEUTIC LANDSCAPE FEATURES OF THE

HOSPITALS
Therapeutic Landscape Principles Ayder Referral Mekelle Quiha
Hospital Hospital Hospital
✓ ✓ x
Vegetation- greenery should be sovereign.
luxurious, layered landscapes with shade trees,
flowers, and shrubs at various heights.
x
Wildlife Attraction- the attractiveness of
wildlife, another boost to healing. Presence of
Birds, butterflies, and hummingbirds.
x x x
Attraction and Sensory- Offers gardens that
can be touched, smelled, and heard, too.
Decorative grasses swoosh gently in the breeze.
Fuzzy lamb’s ear plants are nice substitutes for
pets.
✓
Walkways Accessibility and Safety- Paths that
are inclusive enough to house wheelchairs and
pedestrians walking in pairs. They should be plane
smooth, so they do not obstruct wheelchair
wheels or snag wheeled IV poles.
x x x
Healing Plants-Presence of healing plants like
lavender, rosemary, roses, catnip, sage, and sweet
marjoram.
x
Water Features- Availability of Waterfalls and
fountains which are both great choices to include x
in the court or common areas or as a main feature
in a healing garden.
x x x
Culture: A historical place which offers
fascination with the course of time. Privacy and
social interaction
x x
Festive: a meeting place for social activities and
festivity. x
x x x
The common: the openness of the green field
that invites you to stay and provides vistas and
views.
✓ x
Rich in species: the abundance of a variety of
species in the environment, you can experience a
variety of different species, both plant, and animals.

4.7 Questionnaire survey results

The questionnaire took place in two hospitals Ayder referral Hospital and Mekelle General
Hospital. 35 persons took part in the questionnaire survey out of which 7 persons were hospital
employees, 15 were patients staying at the hospital, 3 was a patient completing a one-time medical
control and 10 were visitors. They responded to the questionnaire points as follows:
Types of respondents
Most of the respondents are patients who were Hospitalized in the hospitals for a while and the
other are visitors and staff members
I am: (mark one option)
Visitor
Inpatient
Other
Outpatie
nt
Employee
Employee Visitor Inpatient Outpatient
Preference of the respondents from the complex
Majority of the respondents preferred the natural character of the complex the other few
preferred the open grass area of the hospital and a small number of people preferred the walking
route, pavements, and the building. Fewer people preferred the seating space despite the
availability of it. One person preferred outdoor activities and sculptures.
What do you like the most in the complex?
Trees, shrubs, plants, natural

16
character of the area
Open grass area 7
Walking route, pavements 5
Building 3
Seating areas 2
Art and sculptures 1
Outdoor activities 1
Responses 0 2 4 6 8 10 12 14 16 18

Response to time spent in the garden
The majority the respondents do not spend time in the garden especially in Mekelle and Quiha
Hospitals because the gardens were fenced and not accessible. The respondents who barely spent
time in the garden are patients from Ayder hospital they also did not spend time inside the garden
they just around it because it was not intended to be accessed. The few people who spent time
in the gardens are visitors who spent the time waiting for results.
Do you spend time in the garden?
No, not at all 23
Barely sometimes 8
Yes, very much 4
Responses 0 5 10 15 20 25
The respondent’s reason for not spending time in the garden
The majority do not because they are not aware or consider the usefulness and a lot of them
also do not spend time because of the privacy and security of themselves. Few of them responded
that spending time in the garden does not help them feel good.
Why don’t you spend time in the Gardens? if not
I don’t consider it 13
I feel unsafe 7
It doesn’t help me feel good 3
Responses 0 2 4 6 8 10 12 14

Activities Performed in the garden
Most of the respondents use the garden as a passage only a few of them spend time waiting for
medical results and few they use the garden as eating place take away food and some of them
use the garden to relax and talk. Few of the respondents visit it purposefully and walk by the
gardens.
What activities do you do in the Gardens?

pass by 15
wait 5
eat 5
Relax 4
talk 3
visit 2
walk 1
play 0
therapy 0
meeting 0
Responses 0 2 4 6 8 10 12 14 16
Perception of the natural environment
Most of the respondents perceive the natural environment as peaceful, and other won’t
distinguish their feeling and few of them perceive as an active place for interaction and physical
activity and few of them perceive the natural environment as motivation, courage, on person
felt nervous of the natural environment.
How do you perceive the natural environment of the area?

peace 13
other 8
activity 5
motivation 4
courage 3
nervousness 1
anxiety 0
anger 0
Responses 0 2 4 6 8 10 12 14

Response to Whether they are distracted when they visit the garden
Most of the respondents responded that they do not know what they feel when they visit the
garden because they are not aware of the effect, some of them responded that they think about
something else when they are at the gardens and few of them responded that they spend time at
the garden very much, they are destructed from their pain and stress.
Do you feel destructed from your pain when you visit the garden?
(For Patients)
No, I don't know 9
Yes, I think about something else 5
Yes, Very much 4
No. of… 0 1 2 3 4 5 6 7 8 9 10
Response to the feeling after spending time in the gardens
The response to after visiting time in the garden is that most of the staffs and visitors felt no
change of mood after visiting time in the garden, some of the respondents felt better and more
positive after spending time in the gardens few of them felt more relaxed, calmer, refreshed and
stronger.
How do you feel after spending time in the garden?

(For Staff and Visitor)
no change of mood 7
feel better, more positive 4
more relaxed, calmer 3
refreshed,stronger 3
able to think,cope 0
religious or spritual connection 0
Responses 0 1 2 3 4 5 6 7 8

Recommendation of the area from users
Most of the respondents recommended improving the trees, shrubs, and plants. Most of the users
recommended designing seating space in the gardens because currently there is no seating space
in the gardens the three hospitals. Some of them also recommended to have open lawn areas
and to include art and sculpture and improve the walking route and the pavements, few of them
recommended to have barrier-free elements for wheelchairs and hospital beds and Ivy pole less
of the preferred to improve the façade and signs and information table.
What would you recommend improving in the area?

Trees, shrubs, plants 8
Design of the sitting areas 7
Open lawn areas 6
Art, sculptures 5
Walking route, pavements 4
Barrier-free elements 3
Facades of the buildings 1
Signs, information tables 1
Responses 0 2 4 6 8 10
Response to if they would like to small areas to be set apart for planting herbs, fruits,
and Vegetables
Majority of the responded yes and to have small areas set apart for planting herbs, fruits, and
vegetables few of them responded no to the questionnaire and some of them responded that
they do not know if they need it.
Would you like to have small areas set apart for planting herbs,
fruits and vegetables?
Yes 15
rather Yes 9
I don't know 5
No 3
No. of Responses 0 2 4 6 8 10 12 14 16

Response from Doctors if the think whether visiting the garden influences the
recovery of the patients
Two of the doctors responded that spending time in the garden will have a positive effect on the
recovery of the patients and relieves stress from staff and visitors who are waiting for the result
of their relatives, one of the Doctors responded yes partially for the effect to be fully effective
proof is needed but we are not there.
Do you think visiting the Garden has any effect on the patient?
(For Dr)
Yes 2
Yes Partially 1
Not at all 0
No proof yet 0
No. of Responses 0 0.5 1 1.5 2 2.5
Recommendation to Landscape Architects from Doctors viewpoint
Do you have any recommendations for Landscape Architects to Consider in the design process?
(Dr)
Three of the Doctors recommended that Architects while designing Hospital landscapes they
must consider the whole landscape as the main design part of the hospital and to make it realistic
and workable in our context budget level.
In summary, they recommended that in healthcare, where the goal is to promote and restore
human health, “healing” or “therapeutic”, gardens would be landscapes that sustain both people
and the environment, numbers of designers and healthcare organizations should work to bridge
and marry the two intentions.

4.8 TRIANGULATION ANALYSIS

In these section triangulation analyses has been used to triangulate the data’s that were found in
the physical observation and user response from their perspective and commenting on the results
to cross connect the results that are obtained in the research. it was appropriate to see for these
hospitals buildings with several different characters to check on the strength of connection with
the users‟ perceptions. The triangulation analyses in connecting studies between the physical
observations and the users‟ perceptions which are determined in qualitative analyses. As this is
to view the outcome of respondents‟ perceptions towards the use of outdoor spaces or
landscape and connection of spaces with treatment process. Additional information’s was
explained in the analyses to strongly support the connection outcomes as well as to justify the
probabilities of the perceptions. The information’s were obtained while having conversation with
the staffs and on-site observation and photo eclectic analysis.
TABLE 5 TRIANGULATION ANALYSIS OF AYDER HOSPITAL
Discussion point Result from Physical Observation Discussion/Analysis

Questionnaires and
Interviews
Entrance garden The entrance garden is a The entrance garden is in The entrance garden is the
bit interesting but there good condition with formed first thing patients perceive
is a need to implement conifers and a smaller when entering the complex
seating space on the flowerbed with a fenced there should careful use of
garden landscape not accessible it garden that is inclusive and
just there for visual only inviting.
The access part The access part is The access part of the The access parts are not well
of the area uncomfortable and with hospitals is not shaded with thought and they are not
a lot of ups and down just trees and greenery at inclusive for different kinds of
not suitable for the side with the lawn and patients with physical ailments
wheelchair and stretcher conifers and do not provide shade
beds from the sun
Seating spaces There is no siting space There is no seating space The availability of seating
in the garden to spend dedicated for users to use in space very crucial for the
time and wait for the garden and no rest complex to be user friendly it
diagnosis results space in between for waiting should have appropriate
in the waiting area amount of seating space in
every waiting and positive
distraction areas to relieve
stress
Vistas/Views There is a bit of vista there is a vista in the area The existing vistas are not
but no siting spaces for that is quite maintained, a intentional if implemented
access and it is not short part is designed. carefully and purposefully it could
maintained to use every Problems with wild be a good distraction for the
hospital users.
time. vegetation.

Park type of The gardens are good The park type garden exists The park type garden is not
hospital garden but never considered but it is not accessible it accessible and is very good
using because it is not consists of free lawn areas place for privacy if well
inviting and well and shady areas, groups of maintained and designed.
maintained. trees forming a forest park.
walking garden The walking garden The complex is separated The walking garden are is
never used it to sit or and somehow and it is located in the middle and sides
spend time just passing located in the middle of the of the complexes and they are
by the garden. complex and side area but it not used because there is no
is unused and inaccessible. info or sign that directs users.
No walking garden just
small plantation in front of
the buildings.
Different rooms No idea it exists about The landscape is not No different room for users
the different rooms for categorized for users as there is just open space
different categories. their preference or physical without any specific
needs. There are no categorization needs.
different spaces for different
activities and user groups.
MEKELLE HOSPITAL
TABLE 6 TRIANGULATION ANALYSIS OF MEKELLE HOSPITAL

Questionnaires and
Interviews
Entrance No entrance garden just The greenery formed The entrance garden is the
garden open pavement road in conifers and a smaller first thing patients perceive
to the facility with side flowerbed with a fenced when entering the complex
greenery landscape not accessible it there should careful use of
just there for visual only garden that is inclusive and
inviting.
The access part The access part of the The access part of the The access parts are not well
of the area complex is covered hospitals is shaded with just thought and they are not
with long trees with trees and greenery at the inclusive for different kinds of
the lawn and conifers side with the lawn and patients with physical ailments
conifers and do not provide shade
that shades the road
from the sun
from sun

stress
Vistas/Views There is a bit of vista The entry fountain is one The existing vistas are not
but no seating spaces of the vistas of the intentional if implemented
for access and it is not complex and there is a carefully and purposefully it
maintained to use every vista in the area that is not could be a good positive
time. distraction for the hospital
quite maintained,
users.
Problems with wild
vegetation.
Park type of The park type gardens The park type garden exists The park type garden is not
hospital garden are good but never but it is not accessible it accessible and is very good
considered using consists of free lawn areas place for privacy if well
because it is not inviting and shady areas, groups of maintained and designed.
and well maintained. trees forming a forest park.
walking garden No walking garden to The complex is separated There is no walking garden in
gaze through the garden and No walking garden just the complexes and there need
for positive distraction. small plantation in front of to be walking garden to gaze
the buildings. around to relieve stress,

QUIHA HOSPITAL
TABLE 7 TRIANGULATION ANALYSIS OF QUIHA HOSPITAL

Questionnaires and
Interviews
Entrance garden No entrance garden just The entrance just straight The entrance garden is the
open not paved road to path to the facility first thing patients perceive
the facility with no when entering the complex
greenery. there should careful use of
garden that is inclusive and
inviting.
The access part of The access part is The access part of the The access parts are not well
the area uncomfortable and with hospitals is not shaded with thought and they are not
wheelchair and stretcher conifers and do not provide shade
beds from the sun
time and wait for the garden and no rest complex to be user friendly.
diagnosis results space in between for waiting
in the waiting area
Vistas/Views There is no vista but no there is a vista in the area The existing vistas are not
siting spaces for access that is quite maintained, a intentional if implemented
and it is not maintained. short part is designed. carefully and purposefully it
Problems with wild could be a good distraction
vegetation. for the hospital users.

Summary of Triangulation analysis

Table 8 Summarized Triangulation analysis

Questionnaires and
Interviews
Entrance garden The entrance garden is The entrance garden is in The entrance garden is the
interesting but there is a good condition with formed first thing patients perceive
need to implement conifers and a smaller when entering the complex
seating space on the flowerbed with a fenced there should careful use of
garden landscape not accessible it garden that is inclusive and
just there for visual only inviting.
The access part of The access part is The access part of the The access parts are not well
the area uncomfortable and with hospitals is not shaded with thought and they are not
wheelchair and beds conifers and shade from the sun
stress
Vistas/Views There is a bit of vista there is a vista in the area The existing vistas are not
but no siting spaces for that is quite maintained, a intentional if implemented
access and it is not short part is designed. carefully and purposefully it could
maintained to use every Problems with wild be a good distraction for the
hospital users.
time. vegetation.
Park type of The gardens are good The park type garden exists The park type garden is not
hospital garden but never considered but it is not accessible it accessible and is very good
using because it is not consists of free lawn areas place for privacy if well
inviting and well and shady areas, groups of maintained and designed.
maintained. trees forming a forest park.

walking garden The walking garden The complex is separated The walking garden are is
never used it to sit or and somehow and it is located in the middle and sides
spend time just passing located in the middle of the of the complexes and they are
by the garden. complex and side area but it not used because there is no
is unused and inaccessible. info or sign that directs users.
No walking garden just
small plantation in front of
the buildings.
Different rooms No idea it exists about the The landscape is not No different room for users
different rooms for categorized for users as there is just open space without
different categories. their preference or physical any specific categorization needs.
needs. There are no
4.9 KEY FINDINGS AND SUMMARY

4.9.1 KEY FINDINGS
➢ Majority users preferred the natural character of the complex the other few preferred
the open grass area of the hospital.
➢ The majority users do not spend time in the garden especially in Mekelle and Quiha
Hospitals because the gardens were fenced and not accessible
➢ The majority do not spend time in the garden because they are not aware or consider
the usefulness and a lot of them also do not spend time because of the privacy and security
of themselves
➢ Most of the users recommended improving the trees, shrubs, and plants. Most of the
users recommended designing seating space in the gardens because currently there is no
seating space in the gardens in the three hospitals.
➢ Most of the users use the garden as a passage only a few of them spend time waiting for
medical results and few use the garden as eating place take away food and some of them
use the garden to relax and talk.
➢ The characters of the hospitals are mostly pavilion-like and are supported by green
vegetation with aspects of forest park, spacious lawns, and aesthetically developed trees.
➢ The green vegetation in the area is not specially designed for therapeutic gardens, but it
creates a naturally pleasant and cool environment for the hospital.
➢ The one Mekelle General Hospital natural surface area is large in comparison to the
reinforced surfaces.
➢ There are many tree species present in the Complexes that are indigenous and useful for
the purpose of therapy.
➢ The gardens that exist were compact, simple and flexible for revitalization the design.

➢ The majority had lawns, soil level and raised beds, trees for shade. This model may
facilitate therapy if designed purposefully; encourage socialization and activity as well as
restoration and relaxation.
➢ The gardens were not cluttered with built features.
➢ If employed gardening can be used to promote physical movement, present cognitive
challenges, and provide opportunities for social participation including staff.
➢ From the questionnaire and physical observation, the Hospital environment is in very in
need of implementing the concept of therapeutic landscape design.
➢ According to the assessment, the Ethiopian Healthcare system lacks the design guidelines
for therapeutic landscape design.
4.9.2 SUMMARY OF DATA ANALYSIS AND PRESENTATION

The connection between humans and green vegetation has existed since ancient time, and the
number of studies focusing on the issue has increased recently. The presence of green vegetation
promotes recovery by inducing positive changes, such as the improvement of blood pressure,
cardiac activity, muscle activity and electrical activity in the brain.
The principles of creating healing and therapeutic gardens as well as their positive effect on the
human psyche, perception, and health are an important part of designing healing and therapeutic
gardens. When designing the outer hospital space, we can follow several groups of principles that
are provided in Chapter two.
From the observation analysis and Questionnaire survey results we can understand one thing
that is the importance of therapeutic landscape on the overall hospital experience and the
Hospitals need therapeutic landscapes design for the patients to fasten their recovery , for visitor
to make their stay more pleasant, for staff members less stressful and for caregivers to cope up
and give the best care by being relaxed in the garden and focused.
Creating a Comfortable health care environment, associated with green space is beneficial for
patient care, improving the management quality of healthcare facilities, reducing the time of
hospitalization, and saving healthcare costs.

CHAPTER FIVE
GUIDELINES FOR DESIGNING THERAPEUTIC GARDENS
5.1 INTRODUCTION
The role of gardens and the need for encouraging siting to maximize health should be
reintroduced to healthcare. More attention could be paid to the overall site and the relationship
between built and green environment.
However, it disseminates the commonly held view that gardens are an ‘add on’, a luxury or even
an extravagance. This raises a significant point suggesting that Hospital Architecture should place
a stronger focus on site planning; integrating landscape and architecture to speak as one voice,
not as separate elements. They should also re-examine their design process and place greater
emphasis on a collaborative stance. One way to ensure this happens would be to re-balance their
architectural brief.
By re-balancing the brief, the garden and its thresholds lead the design. This rebalancing brings
about, a stronger fusion between ecology and technology in ensuring that the built environment
emerges out of and with a care for nature. It puts more emphasis on the design process and the
idea that site, garden, building, program, and community are all fundamentally connected. That
place, space and the process of dwelling are always closely connected
This is not to suggest that gardens take precedent over buildings, but why not start with the
garden and allow the building to evolve out of it, rather than the other way around? This would
ensure that interior spaces “naturally” lead outdoors. It would also ensure that the gardens are
fully integrated with the centers; offering not only different types of spaces but also further
opportunities for green sensory detail.
While designing healthcare garden below are the brief that are to be followed
✓ Planning;
✓ Site selection;
✓ Layout;
✓ Garden structures;
✓ Amenities;
✓ Visual communication and signage;
✓ Planting and composition and;
✓ Examples of plants for use in therapeutic gardens

5.2 PLANNING
A) Involve all stakeholders in the planning and design process, including users, caregivers, and
healthcare staff, to ensure their needs and concerns are considered. Multiple perspectives help
to maximize the value of the garden1
B) Identify users’ cultural backgrounds, age groups, and extent of their illnesses (e.g. stage of
dementia disease) to better design for their needs
C) Consider programming in tandem with the planning, design, and development of the garden
Landscape
architects/
designers
Healthcare Garden
professionals Stakeholders operation
staff
Users
FIGURE 12 STAKEHOLDERS OF THERAPEUTIC GARDENS
5.3 SITE SELECTION

A. Accessibility
i. It is recommended that vehicular drop-off access be as close to the site as possible to
avoid making elderly users walk long distances
ii. It is recommended that, in the case of rooftop gardens, Universal Design (UD) elements
such as lifts are included to ensure accessibility for all users
B. Locality
It is recommended that the site be located near amenities like toilets, wash areas, or drinking
fountains to ensure users have easy access
C. Terrain
It is recommended that the site be relatively fly at to facilitate ease of movement for users
D. Noise
It is recommended that the site be situated away from roads and amenities such as basketball
courts and playgrounds to minimize disturbance to the users

E. Shade
Adequate shade is recommended on the site to provide respite for users from the sun
F. Borrowed landscape
Choose a site with existing landscape or scenic views to enhance the landscape experience in the
garden
G. Good ventilation
The site should have good airflow and be located away from the exhaust flow of building air vents
5.4 LAYOUT
A) Simple, clear layout
i. It is recommended that the circulation path be easily navigable and identifiable from the
entrance
ii. The general circulation path should be a simple looped pattern or a figure-of-8 pattern,
without dead ends.
B) Zoning
i. Active zone – includes space for group activities such as horticultural therapy, as well as
exercise equipment
ii. Passive zone – includes space for strolling and seating
C) Boundaries
Provide a boundary with shrubs to soften the sight of fences or walls and create a secure space
without having a sense of being enclosed
D) Visibility
i. It is recommended that caregivers be given a clear view of all parts of the garden from all
vantage points
ii. The garden should not have any blind spots which might hide users from their caregivers

5.5 GARDEN STRUCTURES

A) Garden entrance
i. Engage the senses Include design features that engage a user’s senses (hearing, touch, sight,
smell and taste)
ii. Provide contrast Create a distinct color contrast between the circulation path and plants,
furniture, and other garden structures for easy wayfinding.
iii. Evoke memories Provide features to evoke the memory of users, such as plants with
familiar smells.
iv. Incorporate views Allow for views out to a wider landscape for a sense of belonging to a
broader community.
B) Wheelchair accessibility
All areas and appropriate structures within the garden should be accessible by wheelchairs
C) Amenities
Provide an abundance of attractive and well-maintained destination points and facilities:
i. Create pockets of interest throughout the garden

ii. Cluster together interesting elements such as garden ornaments and colorful plants, to
capture users’ attention
iii. Include choices for seating and gathering spaces
iv. Provide for semi-private spaces for 2 to 3 people as well as larger interactive spaces to
accommodate groups of 8 to 10 people.
D) Shade + Shadow
Shadows cast on site by garden structures should be monolithic rather than slatted to avoid
causing agitation for dementia participants. If possible, provide maximum shade using plants.
FIGURE 13 SHADE AND SHADOW CONSIDERATIONS

5.6 AMENITIES
A) Garden entrance
Entrance into the garden should be distinct to make it easy for users to identify the start and end
point
B) Secondary access
i. Provide a secondary entry to enable maintenance staff to enter, or users to leave in an

emergency
ii. Secondary entry needs to be subtly located or designed to be less visually obvious
C) Signage
Install signage for informative and interactive purposes
D) Sculptures
Install features or landmarks in the garden. They can be located near to the entrance as a focal
point
E) Storage area
Provide storage area for tools and materials to support horticultural activities
F) Watering point
Provide a watering source to support horticultural activities
G) Planter
i. Provide raised planters at varying heights for users to interact with plants. They can be used
for horticultural therapy or general ease of viewing
ii. Plants in planters should be within reach of all users
FIGURE 14 RECOMMENDED HEIGHT FOR WHEELCHAIR ACCESSIBLE PLANTER

FIGURE 15 RECOMMENDED HEIGHT FOR PLANTER
H) Paving
i. Minimum width of 1.2m for wheelchair access
FIGURE 16 PAVEMENT WIDTHS
ii. Simple and consistent finishes

iii. Level with good traction to prevent slipping when wet
iv. Glare-free with consistent, light color
v. Avoid gaps in-between paving (except for expansion joints)
vi. Provide edging on either side to support wayfinding and define the edge of the path

FIGURE 17 TYPES OF PAVING TO BE USED AND AVOIDED
I) Seating
i. Armrests with a minimum width of 0.1m should be provided to support movement while
seating down or getting up
ii. Provide a minimum of one bench every 5m along the path. This not only allows users to
rest frequently, but also provides a visual cue to encourage them to walk further
iii. Provide a variety of seating options in spaces that cater to different needs; from benches for
small groups of people in semiprivate spaces to a mix of seating options in public settings
iv. Provide appropriate type of seats in gathering spaces to suit target users’ needs
v. Provide seating at right angles or opposite each other and close together to allow social
interaction
vi. Provide a variety of seating options
vii. Provide a hard surface setback with a minimum width of 0.6m between paving and seat
viii. Provide color contrast between seating and hard surface setback
ix. Do not introduce benches with slumped backs
x. Provide room for a wheelchair next to seats to allow both wheelchair users and non-
wheelchair users to gather
FIGURE 18 DISTANCE OF SETBACK BETWEEN SEATING AND PAVING

FIGURE 19 BENCHES TYPE RECOMMENDATION
J) Shelter
i. Provide a shelter large enough to accommodate groups of 10 to 12 people

ii. Provide a smaller shelter to accommodate smaller groups
iii. Include a minimum of one electrical socket for activity use in each shelter
iv. Provide access for users with wheelchairs
FIGURE 20 RECOMMENDED SHELTER DIMENSION FOR 10 TO 12 PEOPLE
K) Hand rails
i. Hand rails should be provided intermittently along the pathway to support users and help
them to balance themselves while moving through the gardens1
ii. If possible, provide hand rails at various heights
FIGURE 21 RECOMMENDED HEIGHT FOR HAND RAILS

5.7 VISUAL COMMUNICATION AND SIGNAGE

A good visual communication and signage design helps to convey information effectively,
enhancing the users’ visiting experience. This can be achieved with the effective application of
graphic elements, such as images, layout, colors, typography, signage scale and placement, with
specific considerations of the needs for the elderly and/or users suffering from cognitive
conditions such as dementia.
FIGURE 22 TYPES OF USERS FIGURE
Signage can be installed at the entrance, within, or outside the therapeutic garden to provide
direction, educational information, and/or advisory messages for different users:
FIGURE 23 SIGN TYPES IN THE GARDEN

5.8 DIRECTIONAL MARKER

An effective directional marker helps to inform, direct, and identify a space. It leads and informs
users that they have reached their intended destination.
A) Placement and design of sign
i. Be visible from far and remains unobstructed

ii. Use colors that provide differentiation from the immediate surrounding to draw the user’s
attention
iii. Placed at decision-making points or junctions for clearer orientation of the space around
iv. The distance between each sign should be less than 50m (subject to the extent of the line
of sight)
v. Placed perpendicularly to pedestrian flow
vi. Information such as distance and direction should be sequentially linked to surrounding
signs
vii. Information such as ‘exit’, ‘toilet’ and ‘shelter’ are important to users and should be clearly
displayed on the sign
viii. Use bigger font to help older users read easily from afar. The suggested minimum font
height is 20mm
FIGURE 24 DIRECTIONAL MARKER SHOULD BE PLACED AT DECISION-MAKING POINTS OR JUNCTIONS FOR CLEARER
ORIENTATION OF THE SPACE AROUND
Figure 25 It should be visible from far and remains unobstructed

FIGURE 26 AN EXAMPLE OF A DIRECTIONAL MARKER WITH SUGGESTED CLEARANCE
5.9 INTERPRETIVE SIGN

It is more comfortable to tilt the head down to read, especially for older users. For a sign with more content such
as an interpretive sign, it is recommended that information is placed below the natural eye level. In addition, a sturdy
and level pedestal for wheelchair users allows them to get closer to the sign and read the content more easily.
B) Clarity of layout and content
i. Layout should be clear of clutter for the user to read, navigate and digest the content easily
ii. Ensure contrast to distinguish foreground from background elements
iii. Use a light-colored background instead of white to help the user read comfortably
iv. Keep the content simple, short, and easily digested with minimal need to rely on memory
v. Use prominent headers or sub-headers
vi. Use sharp images and ensure copyrights are sought or to seek valid permission before use
vii. Use bigger font to help older users read easily. The suggested minimum font height is 5mm
viii. Avoid using all capital letters (other than for the header)
FIGURE 27 AN EXAMPLE OF AN INTERPRETIVE SIGN WITH AN UNCLUTTERED LAYOUT AND clear foreground
elements
FIGURE 28 SHOWING WHAT TO AVOID USING ALL CAPITAL LETTERS FOR BODY TEXT

FIGURE 29 AN EXAMPLE OF AN INTERPRETIVE SIGN WITH SUGGESTED HEIGHTS
5.10 OTHER CONSIDERATIONS

C) Illumination
i. A well-illuminated sign helps the user read easily in a dim (night) environment
ii. The illumination level on the sign-face should not be significantly higher or lower than the
ambient light around the sign
iii. For a non-illuminated sign, consider placing it next to an existing light source, e.g. park
light, to enhance legibility at night
iv. Distance between light source and sign should be carefully planned to avoid undesirable
highlights and shadows cast on sign-face
v. Finishing Use non-reflective or anti-glare material/finishes on the sign-face as some users
may be sensitive to glare or bright surfaces
vi. Pictogram/Icon Use pictograms or icons that are recognizable and easily understood
FIGURE 30 EXAMPLES OF COMMON AND RECOGNIZABLE PICTOGRAMS/ICONS
5.11 PLANTING & COMPOSITION

A) Mature trees
Existing mature trees provide shade, and a symbolic sense of longevity, continuity, and character
for the overall garden.
B) Sensory attributes
Diverse characteristics and features used in the selection of plants for a therapeutic garden
include:

i. Color
Warm colors like red, yellow, and orange stimulate the mind and excite the senses while cool
colors such as blue and purple create a calming experience.
ii. Texture
Plants with interesting leaf textures can be used to surprise and fascinate visitors through their
sense of touch. These plants should be located within reach of all visitors, including those using
wheelchair.
iii. Smell
The scent of plants may evoke memories by engaging visitors’ sense of smell. Fragrance can be
immediate through the perfume of flowers or released through rubbing/crushing of leaves.
iv. Auditory
The gentle rustling of leaves such as from grasses and trees or a gurgling water feature can create
a serene and peaceful environment.
v. Fauna attracting plants
Opportunities should be created for visitors to observe and
appreciate wildlife like butterflies and birds.
vi. Edibles
Plants that are used for cooking i.e. herbs and spices, fruits and vegetables can also engage users
through a sense of familiarity and the associated comfort that food brings.
vii. Local cultural memory
Plants encountered in childhood or daily life can evoke memories and bring back a sense of
nostalgia to the visitors. These could include culturally significant, edible, or wayside plants.
C) Plants to use with caution
i. Poisonous sap (ingestion)

ii. Irritating hairs/surface oils (contact)
iii. Thorns/spikes/prickles (contact)
iv. Plants with associations with undesirable fauna
D) Contrast in composition

Plant species with contrasting colors, leaf texture, and size can create captivating visual texture
in a garden.
E) Plant labels
Plant identification labels and interactive educational signage will provide interesting information
to visitors.
5.12 EXAMPLES OF PLANTS FOR USE IN THERAPEUTIC GARDENS

The following are some examples of plants that can be featured in therapeutic gardens for their
different characteristics. The list of plants is not exhaustive, and serves only as examples which
can be used. Plants with similar characteristics can also be introduced into the gardens. Plant
selection should be made foremost on-site suitability based primarily on soil, water, and light
conditions. For more information on plant choices, growing conditions, and unique plant
characteristics, source at florafaunaweb.nparks.gov.sg.
Key Symbols:
FIGURE 31 KEY SYMBOLS
EXAMPLES OF PLANTS FOR COLOR

EXAMPLES OF TREES FOR SHADE
EXAMPLES OF FRAGRANT PLANTS
EXAMPLES OF PLANTS FOR ATTRACTING FAUNA

EXAMPLES OF EDIBLE PLANTS
CHAPTER SIX
CONCLUSION AND RECOMMENDATION
6.1 CONCLUSION
Careful analysis of the data revealed the specific networks and affordances presented by the three
case study gardens. This research suggests that healthcare gardens can uniquely embrace certain
qualities, which are defined as the garden essences: thresholds, sensory richness, the density of
time and homeliness.
This research also shows that a garden can provide specific and unique opportunities for care
and this in turn can enhance the therapeutic character of a healthcare environment, thereby
contributing to the wellbeing of its users. The essences offer strength, elasticity and dynamism
that enable a garden to become a therapeutic place and can contribute to the Hospitals user’s
overall wellbeing. The historical background of therapeutic Landscape outlined in the Chapter
Two suggests that at various points in history the role of these garden features has been better
understood. The literature review presented in the previous chapter indicates that there is an
increased understanding, across the disciplines, as to the significance of healthcare therapeutic
gardens. Chapter Four highlighted the need to focus on the user’s experience and to develop
mixed research methods to study a healthcare garden. Chapters Four also presented an in-depth
look at existing gardens of Mekelle Hospitals outdoor environment in the context.

This research has been set within a historical and contextual framework to gain a more complete
understanding of the role of the gardens of Ayider, Mekelle and Quiha Hospitals. The data analysis
has led the author to emphasize that the key potentials (garden essences) of healthcare gardens
are embodied within the principle of therapeutic garden. This new definition helps refine the
character of an effective therapeutic healthcare garden and is useful when considering the design
of a Healthcare Centre, both inside and out. The on-site observation, questionnaires and
interviews were able to highlight stories and layers of experiences of the case study gardens. The
findings present not only relevance of therapeutic landscape but also evidence of where the case
studies do not function effectively as therapeutic garden.
In this conclusion the new perspective presented here, is fully defined and the implications of the
research findings explored. This includes some recommendations for the existing Hospital
environment of Mekelle Hospitals. It also outlines an exploration of further research
opportunities.
This thesis concludes that both therapeutic landscape researchers and healthcare professionals
should re-examine not only the value of a garden but also what counts as evidence. As discussed
in the previous sections, garden researchers need to look at the range of principles that a
therapeutic garden holds, embracing both a phenomenological and an ecological perspective. Such
an approach suggests that perception and action are intertwined and that there is a mutual
relationship between perceiving and the environment.
A healthcare garden cannot be discussed in the way that perhaps other aspects of material culture
can; its capacities can never be measured in the way that an object, service, or drug can.
Understanding its contribution to what (Miller, 2010) calls the ‘aesthetic’ of a place, demands a
mixed method approach to research. Understanding what its contribution to the wellbeing of its
users might be, likewise, demands a further multidimensional deep investigation. Healthcare
professionals need to consider the special needs of a garden, and the opportunities for
consideration. These have more to do with personal experiences and memories more to do with
art than science.
This research has resulted in a series of findings that were supported by the comparative case
studies. It also offered a pioneering research method that presents a new approach within garden
studies (Landscape Architecture) focused on the user experience. While the implications of these
findings for both garden researchers (landscape Architects) and healthcare professionals are
indicated it is also useful to consider them as groundwork for further areas of investigation;
research is now needed to replicate and extend these findings.
6.2 RECOMMENDATIONS
➢ Outdoor spaces, those within healthcare facilities, serve people who may be vulnerable in
one way or another. All aspects of the outdoor space must ensure users’ physical and
emotional safety and security.

➢ Ensuring safe and comfortable use for all people regardless of age or ability is essential.
The design should adhere to universal standards as much as possible.
➢ The overall goal is to create an environment in which people feel cared for and nurtured.
When people are physically and emotionally comfortable, they tend to stay in a garden
longer and benefit more from the experience. The design should provide safe and
comfortable places to walk and sit as well as create opportunities for social connection.
➢ Elements in the garden should, as much as possible, distract users from stress. The
purpose of the garden should be to provide a place of natural beauty to let users get away,
both physically and emotionally, from interior environments that may be alien, stressful,
threatening, or intimidating.
➢ Research has shown that connection to nature, especially in healthcare settings, is one of
the most effective forms of positive distraction. Planting, natural materials and sounds, and
the presence of water are some examples of positive natural distractions.
➢ All therapeutic gardens must be properly maintained to function as safe, useful, and
enjoyable spaces for their target users. Damaged garden elements such as paving or seats
can compromise users’ safety. Also, plants that are not properly maintained may affect
the mood of users and create a negative experience towards the garden.
➢ As much as possible, garden design should be ecologically sustainable by using recycled
materials, tapping on green infrastructure for stormwater management, and choosing
plants that require low maintenance.
The main therapeutic elements that should be added to the outdoor of hospital are:
-
• the possibility of working in the garden in the form of growing plants – horticultural
therapy, and the possibility of growing medicinal herbs and edible plants;
• completing the environment in the spirit of a sensory garden, that is, with elements that
engage touch, smell, sight, taste, hearing;
• adding harmonic colors in the form of plants, water features, flower beds, plants with
interesting textures, nesting boxes;
• singing birds (their introduction to the premises of the hospital in question is currently
planned soon), edible plants; the smells of plants are of great importance;
• wheelchair accessibility, universal design; and
• therapeutic exterior elements according to the character of patient treatment
requirements, elements supporting movement, motor skills, concentration, thinking etc.

The main therapeutic characteristics that are being intuitively meaningful to the
landscape: -
Coherence: Provide a setting that is orderly and organized into clear areas so that people can
easily understand and make sense of a place.
Complexity: Provide a rich setting with many opportunities for sensory engagement. For
example, a garden can have a clear layout but be rich with trees, shrubs, flowers, places to sit,
and paths to wander.
Legibility: Create a distinct setting that has one or more memorable components – something
that helps someone remember the place and allows them to navigate easily through the space.
Mystery: Scenes high in mystery are characterized by continuity; there is a connection

between what is seen and what is anticipated. For example, a view partially obscured by foliage
tempts one to follow the path, “just a little farther”, thus engaging the visitor and drawing him
or her forward.
Positive natural distraction: Provide as many opportunities to engage with nature as
possible. This includes plants, water, and wildlife.
CHAPTER SEVEN
PROPOSAL DESIGN

7.1 INTRODUCTION TO PROTOTYPE DESIGNS

This chapter combines the research and theory discussed in the previous chapter with what
the researcher learned through observations and interviews, to create prototype gardens. The
researcher utilized the footprint of an existing garden space, described below, and designed
three prototype gardens to fit that footprint: one for dementia patients, one for catastrophic
patients, and one for psychiatric patients. In each case, a garden design is displayed first, followed
by a narrative description of the key features of the garden and then by a table that addresses
the garden’s design in terms of the Kaplans’ environmental preference matrix, Ulrich’s
“supportive design theory” and other factors which were revealed through observations and
interviews. Each design considers how each of these patient types move through, use, view, and
benefit from the gardens.
Although the footprint was taken from a dementia garden, the author intended to show that a
space of fixed dimensions could be designed to accommodate different types of patient
populations. The following figure is a base map of the prototype site that shows its dimensions
and courtyard78 location between two buildings. This project would have been very different
had the researcher chosen three separate sites to design.
FIGURE 32 BASE MAP FOR PROTOTYPE

7.2 PROTOTYPE ONE: DEMENTIA THERAPEUTIC GARDEN

Dementia usually comes late in one’s life and has devastating effects on both the patient and the
patient family. The disease slowly destroys an individual memory over time. Everyday tasks
become monumental. The dementia consists of patios, seating space, water feature, fountain,
benches along the side of the garden, positioned plantings for lookout from the window for both
actively and passively experiencing the garden, raised planting beds for horticulture therapy, and
Sculptural pieces.
A shade tree surrounded by the wall seat and a nearby pergola offer shade to patients that
cannot tolerate heat. The tree and pergola provide enough shade, but not so much as to prevent
plants from growing.
On the upper east side of the garden, a wooden bridge crosses a large water feature. The water
feature provides a place for meditation, as well as pleasant sound to drown out extraneous
noise. Fish or turtles can be introduced into the pond as a source of additional interest. It is
important, however, to keep the water shallow, about one inch with a black bottom.

Benches around the water feature offer additional opportunities for relaxation and
conversation.
The smooth paving, utilizing one type of material except where the designer wishes to signal an
exit. The paving should be monochromatic, intended to make the garden less confusing by
helping dementia patients see everything. There are changes in paving pattern at entry and exit
points to alert patients that they are at the garden area boundary.
The sides of the buildings and a wall enclose the garden space. There are secure entry and exit
points. Vertical vegetation on the walls between patient room windows and on the pergola
provides visual intrigue.
Railings around the water feature, around and behind the “C” shaped wall seat, and along both
sides of the bridge are placed to assist patients who have difficulty walking.
TABLE 9 KAPLAN’S, ULRICH’S, AND OTHERS FACTORS IN DEMENTIA THERAPEUTIC

GARDEN


7.3 PROTOTYPE TWO: CATASTROPHIC THERAPEUTIC GARDEN

Patients in catastrophic care facilities usually have experienced a tragic accident, leaving them
paralyzed or with severe motor disabilities. Their injuries affect both their physical and mental
health. The catastrophic healing garden is designed to accommodate and help patients with
these issues.
FIGURE 33 PROTOTYPE CATASTROPHIC THERAPEUTIC GARDEN
The garden includes two fountains, which interviews indicated were particularly important
as distractions for catastrophic patients. The small stones that surround the base of the
fountains are permanently affixed to minimize risk of injury.
The garden also includes three raised planting beds, a potting table, and large planters against
the walls that patients in wheelchairs can easily access. Adaptive tools are available for use in
the planting beds.

The garden includes a wall with semicircular hanging baskets that wheelchair patients can utilize
for planting.
Benches are placed in multiple locations to offer patients an opportunity to move from their
wheelchairs to the benches and to visit with staff, family, or friends.
Shade trees are placed over most seating areas to protect patients and visitors from over
exposure to the sun. Plants placed along the walls and in front of windows provide a sense of
privacy and elements of visual appeal. Sight lines are relatively unobstructed so that patients
can view the garden from one spot.
TABLE 10 KAPLAN’S, ULRICH’S, AND OTHERS FACTORS IN DEMENTIA THERAPEUTIC GARDEN

7.4 PROTOTYPE GARDEN THREE: PSYCHIATRIC THERAPEUTIC GARDEN

The psychiatric garden is geared towards relieving stress and improving the patient’s affect. It
incorporates features that give patients the opportunity to be alone (e.g., benches in niches), as
well as features that encourage the patients to socialize (e.g., herb garden, seat wall along
reflection pool).
FIGURE 34 PROTOTYPE PSYCHIATRIC THERAPEUTIC GARDEN

The garden includes a seating area where patients may visit with staff or family. The seating area
has a seat wall surrounding it. There are also several benches located throughout the garden.
Many of the benches are in front of or beside patients’ room windows.
The designer should pay attention to both the privacy of the garden user and the patient indoors.
It remains important that the patients inside of their room can see out into the garden without
feeling as if people are looking at them. A solution to this is to place vine covered trellises in front
of the windows, perhaps 3-dimensional trellises that provide privacy for the patients but also allow
them a screened or veiled view into the garden while also providing an added measure of privacy
for garden users. The garden users then have the added advantage of being able to garden
vertically.
A number of large trees and the vertical height of the walls that surround the garden offer ample
shade. The trees, however, are deciduous so that sunlight can warm the garden during the cold
months of winter. The design avoids the use of trees with low limbs that patients may climb.
The garden includes a large reflection pool and bubbling fountain, both of which are natural
distractions intended to sooth the patient and encourage contemplation. The reflection pool has
a depth of only one inch to minimize risk to patients. The pool should have a black bottom. With
a black bottom, depth should not be an issue. The pool is surrounded by a seating wall that
provides an extra measure of security. Further, there is a railing on the back of the seating wall
for additional security.
The garden offers a wide variety of plant types to maximize appeal to the senses. There is an area
devoted to a scented garden, with plants such as Lemon Verbena and Lavender. The scented
garden and other plantings are those that will attract the most birds, bees, and butterflies.
The plan includes several beds where patients can work and do their own gardening. It includes a
shed that houses tools for the patients to use.
The layout of the garden is straightforward and more or less symmetrical so that patients do not
become confused. The square grid on the pavement helps give patients a sense of place and
direction.
The garden is entirely enclosed with secure entry and exit points, for security purposes. As a
measure of privacy, large evergreens are planted in front of patient rooms for privacy.

TABLE 11 KAPLAN’S, ULRICH’S, AND OTHERS FACTORS IN DEMENTIA THERAPEUTIC

GARDEN

CONCLUSIONS
This prototype design has explored how therapeutic hospital gardens can be designed for three
different patient populations: dementia, catastrophic, psychiatric. It has considered how the
designer needs to address differences among these patient populations when designing a garden
for each.
As the thesis shows, therapeutic gardens can in fact promote better patient outcomes. As that
research also demonstrates, making gardens aesthetically pleasing can diminish stress, reduce the
need for medication, hasten the healing process, and make the journey to recovery easier. At
the outset of this thesis, the investigator wished to answer and discover information about
therapeutic gardens and how they could benefit specific patients: dementia, catastrophic, and
psychiatric populations.
The prototype shows how the features of each of the three gardens are responsive to the
Kaplans’ four environmental preference factors (coherence, legibility, mystery, and complexity);
to Ulrich’s four stress reduction factors (movement and exercise, social support, sense of
control, and natural distractions); and to other factors that the three case study garden directors
identified as important (safety, security, and accessibility).
The three plans differ among themselves in that each place relatively greater emphasis on
features. All three gardens, for example, have pathways: in the dementia garden the material in
the pathway change at entry and exit points to alert the user to change (i.e., an indication of
moving from outdoors to indoors); in the catastrophic garden they are broad and circular; and
in the psychiatric garden they follow a grid pattern. Each garden also includes a water feature: in
the dementia garden it serves to soothe; in the catastrophic garden it serves primarily to distract;
and in the psychiatric garden it serves primarily to offer an opportunity for meditation.
All three gardens offer social support, but in somewhat different ways: the dementia garden
emphasizes wall seats and benches; the catastrophic garden emphasizes gardening opportunities;
the psychiatric garden emphasizes intimate seating, while still allowing separate niches for private
meditation. Finally, and critically, all three gardens emphasize sensory appeal (visual, auditory,
tactile, and olfactory) as a means of achieving stress reduction, distraction, and enjoyment.
Future research should attempt to more fully integrate nature with health care facilities of all
types with increasing emphasis on specialized spaces for specific patient populations. It should
consider additional means for effectively bringing nature into the hospital, or at least making it
more readily accessible.

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APPENDIXES
INTERVIEW/QUESTIONNAIRES PAPER
1. I am: (mark one option)
 An employee of the hospital  Visitor
 A patient who is hospitalized in the  A patient who came for a one-time
hospital medical examination
Age ……. Sex M F
2. What do you like the most in the complex?

 Trees, shrubs, plants, natural the  Art and sculptures
character of the area  Walking route, pavements
 Open grass area  Buildings
 Seating areas  Outdoor activities
3. Do you spend time in the garden?
 Yes, very much
 Barely sometimes
 No, not all
4. Why don’t you spend time in the Gardens? if not
 I do not consider it
 I feel unsafe
 It does not help me feel good
5. What activities do you do in the Gardens?
 Relax  walk  Play
 Eat  Therapy  Meeting
 Talk  Wait
 Pass by  Visit
6. How do you perceive the natural environment of the area?

 Peace  activity
 Anxiety  courage
 Anger  nervousness
 Motivation  other
7. Do you feel destructed from your pain when you visit the garden? (For Patients)
 Yes, very much
 Yes, I think about something else
 No, I do not know
8. How do you feel after spending time in the garden? (For Staff and Visitor)

 More relaxed, calmer  Feel better, more positive

 Refreshed, stronger  Religious or spiritual connection
 Able to think/cope  No change of mood
9. What is it about the garden that helps you feel better?
 Trees, plants, nature
 Smells, sounds, fresh air
 A place to be alone or with friend
 Views, sub-areas, textures
 Practical features, benches, etc.
 Do not know
10. What would you recommend improving in the area?
 Trees, shrubs, plants: add more species
 Trees, shrubs, plants: nicer arrangement, composition, aesthetic environment
 Open lawn areas: seeding plants
 Increase the number of seating areas
 Design of the seating areas
 Signs, information tables
 Art, sculptures: modification of existing elements
 Walking route, pavements: modification of the existing pavements
 Facades of the buildings
 Barrier-free elements, a modification for using a wheelchair, etc.
11. Would you like to have small areas set apart for planting herbs, fruits, and vegetables?
 Yes
 Rather yes
 Rather no
 No
 I do not know
12. Do you think visiting the Garden has any effect on the patient? (For Dr)
 Yes
 Yes Partially
 Not at all
 No proof yet
13. Do you have any recommendations for Landscape Architects to Consider in the design
process? (Dr)
-------------------------------------------------------------------------------------------------------------------------
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Therapeutic Landscape Design In The Hospital Environment Of Ethiopia

Thesis · July 2019

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MEKELLE UNIVERSITY (EIT-M)

Introducing Therapeutic Landscape Design In The Hospital

Author: Bereket Alemberhan Besha

Advisor: Jemal Mohammedbrehan (MSc )

A thesis submitted in partial fulfillment of the requirements For BSc In Architecture, at

Author: Bereket Alemberhan Besha

Signature Date…………July 2019

Jemal Mohammedbrehan ________________ ________________

requirements for the Bachelor degree in Architecture.

Author: Bereket Alemberhan Besha

Date: July 2019

Approved by Board of Examiners:

_______________ _______________ ________________

Advisor Signature Date

_______________ _______________ ________________

Examiner 1 Signature Date

_______________ _______________ ________________

Examiner 2 Signature Date

_______________ _______________ ________________

Examiner 3 Signature Date

Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 I

Secondly, I would like to show my gratitude to my School Advisor Jemal Mohammedbrehan

Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 II

2.7.5 Surrounding And Views -------------------------------------------------------------------------------------------- 11

Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 IV

CHAPTER SIX CONCLUSION AND RECOMMENDATION -------------------------------------------------- 59

Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 V

Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 VI

LIST OF ACRONYMS AND ABBREVIATIONS

WHO………………………………………World Health Organization

Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 IX

Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 1

1.1.1 BACKGROUND OF THE STUDY

Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 2

1.2 PROBLEM STATEMENT AND JUSTIFICATION

1.2.2 JUSTIFICATION OF THE RESEARCH

1.3.2 SPECIFIC OBJECTIVES

Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 3

1.3.3 RESEARCH QUESTIONS

1.4 RESEARCH METHODOLOGY

1.4.1 LITERATURE REVIEW

1.4.2 CASE STUDY

1.5 SCOPE OF THE STUDY

1.6 SIGNIFICANCE OF THE RESEARCH

Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 4

1.7 RESEARCH DESIGN

Identify Analyse Principles Standards

Physical Questionaires Universal

FIGURE 1 RESEARCH DESIGN

Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 5

Therapeutic Landscapes is greendspaces in healthcaredfacilities which have a therapeutic

Horticulture is the art or practicedof garden cultivationdanddmanagement.

2.2 THERAPEUTIC LANDSCAPES

Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 6

2.3 HISTORY OF THERAPEUTIC LANDSCAPE

2.3.1 ASCLEPIEIA OF ANCIENT GREECE

2.3.2 MONASTIC INFIRMARIES OF THE MIDDLE AGES

Introducing therapeutic landscape design in the hospital environment of Mekelle 2019 7

Jemal Mohammedbrehan

_______ _ __________

_______ _ __________

_______ _ __________

_______ _ __________