Health Design Unicare Røros

Life beyond cancer A rehabilitation garden to promote the social, physical and mental health of cancer survivors at Unicare Røros

Mari Kummernes / pnh587 Health Design 2023 / MSc Landscape Architecture

LIFE BEYOND CANCER

Abstract More and more individuals are surviving cancer due to advancements in medical technology. However, many cancer survivors continue to face challenges and long-lasting side effects of both their illness and treatment. Some patients are in need of rehabilitation, and there is a growing recognition of the benefits of incorporating nature into the rehabilitation process.

The project includes a design proposal, based on an evidence-based design model, for a rehabilitation garden at Unicare Røros in Norway.

The design aims to promote social, mental and physical health among this group, and aid them in the face of life beyond cancer.

Table of content Background

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Context

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Problem and aim

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Method

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Target group and Research status

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Theories

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Models

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The Case Area

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Questionnaire and SWOT

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SET Pyramid Analysis

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8 PSD Analysis

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Evidence-based program

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Conceptualization

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New site

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Reflection

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References

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INTRODUCTION

Background Cancer - a feared disease Cancer is a feared disease caused by abnormal cell growth that can result in malignant tumors. It affects 1 in 2 people worldwide, and has over 200 different variations. The most common types are lung, breast, prostate and bowel cancers, and the treatment typically involves chemotherapy and radiotherapy (“Cancer,” 2017).

30%

of the 300 000 cancer survivors in Norway are living with long-term effects (“Det er ikke nok å bare overleve,” 2021)

Long-term effects

An overlooked group

As cancer treatment can damage healthy cells, this can lead to long-term effects that can hinder daily activities, work, and long-term life quality. Common health concerns include:

Due to improved cancer treatment, the number of cancer survivors is on the rise.

However, an overlooked problem is the late effects of cancer and cancer treatment, and about 100 000 survivors in Norway are living with long-term effects.

Cancer-related fatigue (CRF): chronic exhaustion that isn't relieved by sleep Decreased muscle mass: especially common after hormone therapy

There is an enormous demand for improved care after treatment and rehabilitation to improve the physical and mental issues this group is facing. Cancer rehabilitation might involve exercise, pain management, dietary guidance, and psychological counseling. (“Det er ikke nok å bare overleve,” 2021).

Memory problems: trouble remembering or concentrating, often called “chemo brain” Lymphedema: swelling due to disrupted lymph fluid drainage Pain: chronic pain can linger for years Emotional difficulties: anger, guilt, anxiety or depression (“Long-Term Effects of Cancer,” n.d.)

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INTRODUCTION

Context Norway Unicare Røros is a healthcare facility situated in the municipality of Røros, located in Trøndelag, Norway, which is home to around 5 600 inhabitants. The landscape is hilly with larger mountain ranges towards the north and east towards Sweden. Unicare is conveniently located near the town center in the west, and is surrounded by vast farming and woodlands to the east (Stokkan and Haugen, 2023).

Trøndelag

Oslo

Trondheim

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1: 10 000 A4

Røros Church

Røros Museum

Farming fields

Slegghaugene Scene for Elden

Røros nursing home

Unicare Røros

Woodlands Kindergarten Røros

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INTRODUCTION

Problem

Aim

Unicare Røros is the leading facility for cancer rehabilitation in mid-Norway. The indoor facility offers physical and social activities with varying degrees of demand.

However, the opportunities of the outdoor areas are underutilized. These spaces consist mostly of exposed, plain lawns, and a forest with no paths and limited access.

The aim of this project is to design a rehabilitation garden, based on EBHDL, at Unicare Røros for cancer survivors to promote life quality and well-being. This garden should offer environments of varying demands to promote self-efficacy, and support the social, physical and mental health of these participants.

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INTRODUCTION

Method The EBHDL-model This project aims to follow the structure of Evidence-Based Health Design in Landscape Architecture (EBHDL), which includes four steps:

By working in a manner based on evidence, landscape architects can help ensure that the design delivers the intended health outcomes and accessibility (Gramkow et al., 2021).

1 Evidence collection: target group, human health, environment and use of nature

In this project, the first step will be based on a three-fold evidence collection, including literature research, a questionnaire given to participants, and finally, a site analysis. This project will not involve the fourth step of implementing and evaluating the design.

2 Programming: aim of design, design criteria and design solutions 3 Design: conceptualization, designing, construction, occupation 4 Evaluation: evaluation post-occupancy, new knowledge and design adjustments

PROGRAMMING

Literature research

Questionnaire

Site analysis

2 EVIDENCE COLLECTION

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DESIGN

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EVALUATION

Based on the EBHDL-model (Gramkow et al., 2021)

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T A R G E T G R O U P, T H E O R I E S & M O D E L S

Target group The participants at Unicare Most participants stay at Unicare for one week and up to a few months. The average age of participants in the cancer group is 55 years for women and 60 years for men.

Characteristics of the participants between 2022 and 2023 have been provided by Unicare Røros:

Secondary target group: relatives and friends The aftermath of cancer can also have a significant influence on the close relatives or friends of the cancer patient, which all will have differing relationships to the disease.

Research shows that close relatives often experience psychological distress and unmet needs, leading to poorer health (Sandén et al., 2019).

Research status The role of nature in patients` lives: A systematic review and qualitative meta-synthesis Blaschke (2017) explored if nature-based interventions support cancer patient's recovery processes, and if the patients seek and value these interventions.

Blaschke found that participants often sought to get away from their daily treatment and wanted to connect with the outside world.

They especially viewed nature as important for creating a more optimistic outlook on life.

Nature and gardens were associated with safety and privacy, and a place where patients could gain some amount of control.

Patients also found structured nature activities, such as gardening, to be a platform for forming and strengthening social connections.

Finally, the study also found that activities in nature resulted in physical benefits for the patients, including increased physical activity, healthier diets and improved fitness.

Opportunities to connect with nature can in these ways ease the strain related to the patient's diagnosis and treatment (Blaschke, 2017).

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T A R G E T G R O U P, T H E O R I E S & M O D E L S

Theories Self-Efficacy Theory Albert Bandura 1977 The theory of self-efficacy describes a person's belief in their abilities and capacity to accomplish specific goals. Banduro proposes four sources of self-efficacy:

Soft fascination environment can capture attention effortlessly

1 Mastery of experiences: succeeding in a challenging task

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2 Vicarious experiences: observing other people mastering a challenge 3 Verbal persuasion. encouragement from others 4 Affective and psychological state: a person's psychological mindset and mood (Bandura, 1977) Reinforcing the sources of self-efficacy in the environment can improve participants` confidence and independence.

Attention Restoration Theory Kaplan & Kaplan 1989 Kaplan & Kaplan proposes that spending time in nature can reduce mental fatigue, as nature requires less cognitive resources compared to busy, modern life. For the environment to have a restorative effect, it must possess extent, being away and compatibility, that sustains soft fascination (Kaplan and Kaplan, 1989).

The implementation of ART may benefit patients struggling with concentration and mental fatigue as a side effect of cancer treatment.

Compatibility Extent Being away the opportunity wanting to be providing an exposed to the escape from to feel environment daily activities immersed Three levels of engagement Keniger et al. 2013 Keniger et al. describes three levels of engagement with nature: Indirect engagement: e.g. nature views through a window Incidental engagement: e.g. walking outdoors Intentional engagement: e.g. outdoor therapy, gardening These ways to engage with nature can improve physical and psychological health, and social connection (Keniger et al., 2013).

Given the diverse abilities of the participants at Unicare, it is important to explore ways to strengthen all three levels of engagement.

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T A R G E T G R O U P, T H E O R I E S & M O D E L S

Models 8 Perceived Sensory Dimensions (PSD`s) The aim of this model is to identify which types of environments are the most effective in restoring our well-being after experiencing stress, by classifying natural environments based on how humans perceive them. The 8 Perceived Sensory Dimensions are:

Restorative environment

7 Nature: untamed and undisturbed nature, free-growing grass Culture: cultural and historical allusions, ornamental plants and kitchen gardening Prospect: flat terrain in an open space with well-kept grass Social: a social arena Space: open and free space, abundance of trees and lack of roads/paths Rich in species: rich in natural flora, as well as insects and birds

The Supportive Environment (SET) Pyramid The SET Pyramid explains that individuals in various life situations have varying levels of executive function, and their environmental needs will therefore differ as well.

The pyramid depicts a need for environments with low demands and minimal disruptions at the bottom, and a more challenging environment towards the top of the pyramid, when executive function increases (Stigsdotter and Grahn, 2002).

Refuge: a secluded sanctuary, providing shelter or safety

For stress recovery, the study identified a strong correlation between the combination of refuge, nature and rich in species, with low levels of social presence (Stigsdotter & Grahn, 2010).

Ex e Ne cutiv ed ef en for s unct vir up i on po on me rti nt ve

Serene: peaceful and calm environment

Outgoing involvement Active participation

Emotional participation

Directed inwards involvement

Based on the SET model Grahn 1991

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S ITE & S ITE ANALYS I S

The Case Area Field

The entrance and parking spots characterize the west side of the facility. An established path called `Dørstokkmila` wraps around the the facility, surrounding green lawns.

Outside of the indoor pool is a seating area, as well as a hut, and further south by the gym, there is a small activity park. A small forest with limited accessibility borders the path on the east side of the facility, and in my project, I will explore how this area can be enhanced to create new garden rooms and increased contact with nature.

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A Hut

Activity park

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Seating

Forest

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Pool

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Entrance area

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S ITE & S ITE ANALYS I S

Questionnaire

Which functions would you like the outdoor areas at Unicare Røros to have? (you may choose multiple answers and/or add your own)

Participants at Unicare Røros were sent a digital questionnaire on the 3rd of March 2023. 13 responses were collected, and have been translated from Norwegian to English by me.

Would you want to spend more time outdoors in connection with rehabilitation?

Do you meet any challenges when spending time outside or participating in activities outside?

“I struggle with my balance, and need places to sit down”

“I struggle with anxiety”

“I struggle with breathing when the wind is strong outside”

“I struggle to overcome steep hills”

“I struggle with being in activity because of fatigue”

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S ITE & S ITE ANALYS I S

SWOT Analysis The SWOT Analysis is based on my own analysis of the site, and considers the strengths, weaknesses, opportunities and threats of the site.

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Access to wild nature Established main path Soundscape characterized by nature sounds Close to hiking and skiing trails

W

Little use of room division and variation of experiences Need for more various types of challenges Little opportunity to enter, stay and do activities in forest

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Creating appropriate and motivating challenges for the participants Making it easier for different people to find joy in nature

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Funding Climatic conditions ➔ Snow November-April ➔ Lowest temp: - 32 °C ➔ Highest temp: 28 °C (“Historiske værdata for Røros som graf - Siste 13 måneder,” n.d.)

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S ITE & S ITE ANALYS I S

SET Pyramid Analysis A considerable area inside the property boundary is inaccessible to the participants, including parking spaces, and forest areas without paths. The area along Dørstokkmila provides the most supportive environment, but is still exposed.

Seating areas and the hut provide spaces for outgoing involvement, while the activity park supports active participation. Overall, there is a lack of spaces for directed inwards involvement.

Outgoing involvement Active participation Emotional involvement Directed inwards involvement Area with low accessibility

1: 1500 A4

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S ITE & S ITE ANALYS I S 1 Prospect + social (supporting)

8 PSD Analysis `Prospect`, with flat terrain and well-kept grass, dominates the area in proximity to the facility, while `social` and `culture` dominate some hotspots. The unavailable areas have characteristics of `space` and `nature`. Seen in connection with the SET Pyramid, there is a lack of accessible PSDs that support a restorative environment.

2 Space + serene (supporting)

3 Prospect

4 Social + culture (supporting)

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5 Nature + refuge + rich in species

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1: 1500 A4

Photos provided by Unicare Røros

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PROGRAM AND DESIGN

Evidence-based program Human health

Activities in green spaces

Evidence

Design criteria

Design solution

Green spaces have positive impacts on human health in multiple ways: 1) Providing psychological restoration and improving mood, 2) Encouraging physical activity and health 3) Encouraging social contact and activity (Keniger et al., 2013)

The design should offer green spaces with possibilities for psychological restoration, physical activity, and social contact.

New trails in the forest, with benches for being alone

Self-efficacy Mastery of experiences, vicarious experiences, verbal persuasion and affective and psychological state affects a person's self-efficacy (Bandura, 1977)

The design should offer environments with possibilities to master challenges, as well as model learning

Forest activity park and new trails offer varying challenges, and opportunities for all four sources of self-efficacy

Three levels of engagement Keniger et al. describes indirect engagement, indicental engagement and intentional engagement with nature, which can improve physical and psychological health (Keniger et al., 2013)

The design should promote all three levels of engagement with nature

Greenhouses to improve indirect engagement

Attention restoration theory According to ART, people have both directed and undirected attention. Directed attention when focusing on tasks can be tiring, while undirected attention happens effortlessly, and can help the individual recover from mental fatigue (Kaplan and Kaplan, 1989)

The environment should be restorative and offer these components: Being away Extent Fascination Compatibility

The design offers areas for undirected attention in the forest. Here one can experience all four components of ART

Perceived sensory dimension (PSD) Green space is perceived in certain dimensions. The combination of refuge, nature and rich in species is interpreted to be the most restorative (Stigsdotter & Grahn, 2010)

The eight PSDs should be present in the design, and should be used to program areas that meet specific needs

Areas that target physical health: prospect, culture, space Areas that target social health: social Areas that target mental health: refuge, nature and rich in species

SET Pyramid Individuals will have varying levels of executive function, and their environmental needs will therefore differ (Stigsdotter and Grahn, 2002)

All four levels of the SET Pyramid should be represented in the design

Directed inwards involvement in outer layer Emotional Participation in outer/middle layer Active participation in middle/inner layer Outgoing involvement in inner layer

Forest activity park Social spots near nature

Old (grey) and new trails with different levels of demand

New trails to improve incidental engagement Forest activity park to improve intentional engagement

Areas with strongest presence of undirected attention

SET levels and PSDs are all represented

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PROGRAM AND DESIGN Benches (red) and hammocks (blue)

Target group Evidence

Design criteria

Design solution

Fatigue affects between 61-99% of cancer patients receiving treatment (van Weert et al., 2008)

The design should have frequent places to rest

Frequent benches with backrests and armrests along trails Hammock meadow

Many cancer patients experience limitations in physical performance, such as decreased muscle strength and problems with balance (van Weert et al., 2008) (Bula et al., 2023)

Creating spaces to promote muscle strength, balance and coordination. Paths with varying lengths

Activity park and forest activity park with varying degrees of difficulty/challenge

30% of cancer patients experience reduced participation in social activities (van Weert et al., 2008)

The design should accommodate and promote social activities

Areas for socialization - the hut, garden and activity park

Patients struggle breathing in strong winds (questionnaire response)

The design should aim to reduce wind in some areas

Opportunity to stay in greenhouses

Evidence

Design criteria

Design solution

Living plant material is important to therapeutic qualities, and one should avoid artificial materials and hard surfaces (Stigsdotter, 2010)

The design should aim to use natural materials, such as wood

Activity elements and benches are made of wood rather than artificial materials

Cancer patients might be sensitive to the sun (Stigsdotter, 2010)

The design should provide places with lighter shade

Sails and trees provide areas with lighter shade

Water elements can have a calming effect, and promote stress-reduction (Stigsdotter, 2010)

Incorporation of water elements

The garden has ponds, as well as a reopened stream along the path

Greenhouses can have a positive effect on cancer patients (Stigsdotter, 2010)

Incorporation of a greenhouse

Social hot spots

Paths with varying lengths

More vegetation along paths and seating to reduce wind

Shaded areas and new trees

Environment/use of nature

Stream and ponds

Two greenhouses

The garden has two greenhouses for cultivation purposes, as well as a place to rest

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PROGRAM AND DESIGN

Conceptualization Ex e Ne cutiv ed ef en for s unct vir up i on po on me rti nt ve

Field

Outgoing involvement

8 PSD`s

Active participation

Emotional participation

Directed inwards involvement

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The 8 PSDs can be integrated with the SET Pyramid to support the different levels of the pyramid.

This model promotes more fluid transitions between levels of the pyramid, which might reduce overwhelm among participants.

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in nt Pool

The model should align with the functions of the facility, with areas for directed inward involvement connected to the participant rooms and more demanding areas connected to the gym and pool.

In this conceptualization, the accessibility to the forest increases, creating spaces for soft fascination, mastery of experiences and incidental and intentional engagement with nature.

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PROGRAM AND DESIGN

New site

Cantine

Main entrance

Pool Gardening

Hammocks Hut

Gym Activity park

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Forest activity

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Ponds

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Pergolas

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DØRSTOKKM

Life beyond cancer

ILA

1: 750 A4 Mari Kummernes 25.03.2023

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PROGRAM AND DESIGN

Inspiration Terapihaven Møllebæk

Frederiksberg Sundhedscenter

Terapihaven Møllebæk

PROGRAM AND DESIGN

Pergolas

Walk along stream

Ponds

Outer layer

Ponds Pergolas

The outer layer of the garden stretches from the patient rooms and along a reopened stream and ponds. This layer corresponds to directed inwards involvement and some emotional participation, dominated by nature sounds and calmness.

Walk along stream

The walk along the stream

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PROGRAM AND DESIGN

Activity park

Forest activity

Hammocks

Middle layer

Hammocks

The middle layer stretches from the gym, along the expanded activity park, and to the hammock meadow, providing spaces for emotional participation and active participation.

Forest activity Activity park

The forest activity park

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PROGRAM AND DESIGN

Garden

Seating

Hut

Garden

Inner layer

Hut Seating

The inner layer by the indoor pool consists of social hot-spots and social gardening activities, supporting active participation and leading involvement.

Raised flower beds in the garden to grow food, as well as ornamental plants

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LIFE BEYOND CANCER

The new rehabilitation garden

Reflection The aim of my project was to design a rehabilitation garden at Unicare Røros for cancer survivors, to support the social, physical and mental health of these participants. To achieve this goal, the garden was designed using the EBHDL-model to provide environments of varying demands.

As the target group was cancer survivors, the Self-Efficacy Theory, Attention Restoration Theory and Three levels of engagement were important to implement in the design. The 8 PSDs and the SET Pyramid were utilized as design tools, and all levels are represented in the design proposal. The design includes three layers of varying demand, with new pathways and spaces that facilitate activities near and in nature.

A challenge in this project has been to find a balance between accessibility and creating opportunities for personal development.

According to the Self-Efficacy Theory, participants should be offered challenges, but at the same time, the design needs to meet the needs of individuals with physical limitations.

If this project was to be constructed, it would be beneficial to engage staff and participants and Unicare Røros to minimize problems with accessibility, and further explore how the garden could benefit individuals with varying physical abilities.

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LIFE BEYOND CANCER

References Bandura, A., 1977. Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review 84, 191–215. https://doi.org/10.1037/0033-295X.84.2.191 Blaschke, S., 2017. The role of nature in cancer patients’ lives: a systematic review and qualitative meta-synthesis. BMC Cancer 17, 370. https://doi.org/10.1186/s12885-017-3366-6 Bula, A., Tatar, K., Wysocka, R., Chyrek, K., Piejko, L., Nawrat-Szołtysik, A., Polak, A., 2023.

Effect of Physical Activity on Static and Dynamic Postural Balance in Women Treated for Breast Cancer: A Systematic Review. IJERPH 20, 3722. https://doi.org/10.3390/ijerph20043722 Cancer [WWW Document], 2017. . nhs.uk. URL https://www.nhs.uk/conditions/cancer/ (accessed 3.28.23).

Det er ikke nok å bare overleve [WWW Document], 2021. . Alt om din helse. URL https://www.altomdinhelse.no/sammen-mo t-kreft/det-er-ikke-nok-aa-bare-overleve/ (accessed 3.24.23).

Grahn, P., Stigsdotter, U.K., 2010. The relation between perceived sensory dimensions of urban green space and stress restoration.

Landscape and Urban Planning 94, 264–275. https://doi.org/10.1016/j.landurbplan.2009.1 0.012 Gramkow, M.C., Sidenius, U., Zhang, G., Stigsdotter, U.K., 2021. From Evidence to Design Solution—On How to Handle Evidence in the Design Process of Sustainable, Accessible and Health-Promoting Landscapes.

Sustainability 13, 3249. https://doi.org/10.3390/su13063249

Historiske værdata for Røros som graf - Siste 13 måneder [WWW Document], n.d. . Yr. URL https://www.yr.no/nb/historikk/graf/5-10380 /Norge/Trøndelag/Røros/Røros (accessed 3.24.23).

Kaplan, R., Kaplan, S., 1989. The experience of nature : a psychological perspective.

Keniger, L., Gaston, K., Irvine, K., Fuller, R., 2013.

What are the Benefits of Interacting with Nature? IJERPH 10, 913–935. https://doi.org/10.3390/ijerph10030913 Long-Term Effects of Cancer [WWW Document], n.d. . MD Anderson Cancer Center. URL https://www.mdanderson.org/patients-fami ly/life-after-cancer/long-term-effects.html (accessed 3.24.23).

Sandén, U., Nilsson, F., Thulesius, H., Hägglund, M., Harrysson, L., 2019. Cancer, a relational disease: Exploring the needs of relatives to cancer patients. International Journal of Qualitative Studies on Health and Well-being 14, 1622354. https://doi.org/10.1080/17482631.2019.1622 354 Stigsdotter, U.A., Grahn, P., 2002. What Makes a Garden a Healing Garden?

Stigsdotter, U.K., 2010. Modelprogram for terapihaver til fremtidens Kræftrådgivninger.

Stokkan, J., Haugen, M.O., 2023. Røros. Store norske leksikon. van Weert, E., Hoekstra-Weebers, J.E.H.M., May, A.M., Korstjens, I., Ros, W.J.G., van der Schans, C.P., 2008. The development of an evidence-based physical self-management rehabilitation programme for cancer survivors. Patient Education and Counseling 71, 169–190. https://doi.org/10.1016/j.pec.2007.11.027

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LIFE BEYOND CANCER

Figure list

Icons

Figure 1. Sekeres, M.A., M.D, 2020. Coronavirus and the Cancer Patient. The New York Times. https://www.nytimes.com/2020/04/08/well/live/coro navirus-and-the-cancer-patient.html

All icons were downloaded 09.03.2023 from https://www.flaticon.com.

Figure 2. Outline of the map of norway vector image on VectorStock. Alvindom04. https://www.vectorstock.com/royalty-free-vector/o utline-of-the-map-of-norway-vector-39490779 Figure 3. Map of Trøndelag county within Norway, 2017. Bjarkan. https://commons.wikimedia.org/wiki/File:Norway_ Counties_Tr%C3%B8ndelag_Position.svg Figure 4. Downloaded from Norgeskart 09.03.2023. https://www.norgeskart.no Figure 5. Kayak. Photos of Unicare Røros Gjesteovernatting. https://www.kayak.com/Roros-Hotels-Unicare-Ror os-Gjesteovernatting.476276.ksp Figure 6. Living Maples, 2022. How Nature Access Improves the Quality of Life in Older Adults. https://livingmaples.com/mag/impact-of-nature-on -quality-of-life/ Figure 7: Songmor, P. Morning in pang oung with the light and reflection steam over the lake with pine tree forest nature background. https://www.gettyimages.dk/detail/photo/morningin-pang-oung-with-the-light-and-reflection-royal ty-free-image/1352038664?adppopup=true

Alzheimer icons created by Freepik Cancer icons created by lakonicon Chemotherapy icons created by wanicon Energy icons created by Pixel perfect Environment icons created by Dendysign Family icons created by Ndut_Design Forest icons created by Smashicons Garden icons created by Freepik Happiness icons created by Kalashnyk Infected icons created by teguhats Injury icons created by Freepik Lake icons created by Freepik Leaf icons created by Pixel perfect Man icons created by DinosoftLabs Mountain icons created by Freepik Nature icons created by Freepik Nausea icons created by Freepik Park icons created by Freepik Physical activity icons created by Mayor Icons Physical therapy icons created by Chattapat.k Pond icons created by Freepik Project icons created by dDara Radiotherapy icons created by Freepik Rural icons created by Freepik Sea icons created by kerismaker Tired icons created by Freepik Trust icons created by Freepik Walk icons created by Backwoods Weak icons created by Iconjam

Figure 8. Downloaded from Norgeskart 09.03.2023. https://www.norgeskart.no Figure 9. Vedfelt, K. Woman flexing muscles in front of superhero shadow. https://www.gettyimages.dk/detail/photo/woman-fl exing-muscles-in-front-of-superhero-shadow-roy alty-free-image/1301343014?adppopup=true

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