Active and Healthy Case Della Comunità: Model Research for Spatial Requirements of Waiting Spaces

Abstract

The built environment is one of the determinants of health as it acts as a promoter of healthy lifestyles. This research deals with design solutions to promote healthy and active ageing in socio–healthcare facilities for primary care in Italy. This three-year research study aims to develop Design Guidelines for waiting spaces in Casa della Comunità (CdC: House of the Community, a new model of primary care facility in Italy) to promote good health and well-being in sustainable cities and communities. In accordance with these goals, the study applied different research methods in three main phases: Background research, starting from three fundamental groups of theories derived from the scientific literature to define a Theoretical Framework; data collection and field research, dealing with technical analysis of international best practices, as well as perceptive analysis through interviews and questionnaires conducted with the staff, patients, and caregivers of the socio–healthcare facilities, in order to define spatial requirements for waiting spaces; and finally, the results phase, involving the development of tools and design solutions of health-promoting waiting spaces according to the Sustainable Development Goals (the Design Guidelines were applied in two experimental pilots: a VR-based pilot and a physical pilot conducted at an existing CdC in Florence, Italy). In this contribution, we focus on the background and field research phases, describing the process leading to the outcomes of the second phase: spatial requirements for CdC waiting spaces.

1. Introduction

The Italian health reform DM 77/2022 [1] is promoting the spread of local socio–healthcare facilities on the national territory to support well-being and health promotion in communities. The House of the Community (Case della Comunità, or CdC) is a new model of primary care facility [2] with the aim of treatment, prevention, and health promotion, focusing on chronic diseases and continuous care for the elderly. In this facility, there is an integration between the social and health field, involving social assistants, general practitioners, and nurses and medical specialists who work together to address the needs of complex chronic patients. CdCs are physical places where all people should be equally welcomed and have access to health and social knowledge and assistance. For this reason, the configuration of spaces and the characteristics of the environment are very important and should aim to promote comfort and well-being [3]. CdCs are public healthcare buildings that should be completely “accessible” to represent a “collective resource” [4,5,6] and promote equity and inclusion.

It is now consolidated in the scientific literature that the built environment influences public health, as it acts as a promoter of healthy lifestyles [7,8] that are represented by performing physical activity [9], having a healthy diet, and being involved in positive social interactions. Healthy lifestyles help to prevent chronic diseases (such as cardiovascular diseases, diabetes, and some types of cancer) and physical and cognitive decline [10]. Thus, actions aimed at supporting fragility and combating loneliness also benefit from the design of a health-promoting and inclusive built environment.

In this process of favouring comfort, well-being, and inclusion, waiting spaces can have a specific and crucial role, using the time of waiting to encourage people to interact with the space to promote health and the social community. Despite a growing understanding of the importance of the built environment for health, there remains limited research on how specific architectural features of waiting spaces can impact well-being in the context of primary care, and there is no evidence in relation to this about the design of Case della Comunità. Moreover, our research offers a contribution of spatial models for both new construction and existing facilities, which represent the majority of Italian healthcare buildings, while also increasing sustainability by promoting the idea of reuse.

For this reason, this research, as part of the Age-It project (Next Generation EU—“Age-It—Ageing well in an ageing society” project (PE0000015), National Recovery and Resilience Plan (NRRP)—PE8—Mission 4, C2, Intervention 1.3) for active and healthy ageing [11], deals with the study of waiting spaces of local socio–healthcare facilities for primary care (CdCs), proposing sensory-based waiting environments which promote health according to the Sustainable Development Goals, as follows: reducing stress before healthcare interventions and favouring relations with professionals; supporting physical and mental well-being and rehabilitation by providing psychological support and promoting physical activity; favouring the prevention of chronic diseases and the promotion of healthy lifestyles. Moreover, in this period of rapid demographic change and increasing demands on healthcare systems, rethinking the role of waiting environments is not only a matter of comfort but also a question of public health and social sustainability.

This research has been conducted for three years in three main phases, as summarised in the diagram in Figure 1: background research, data collection and field research, and results and application (tools and solutions).

Each phase has generated the next one: the background research was the basis for the definition of a Theoretical Framework, a tool to lead the data collection and the field research phase (technical and perceptive analysis), while the field research phase generated case study sheets and space and perceptive requirements, which represent the basis for the development of the Design Guidelines.

The Design Guidelines present strategies and solutions to design CdC waiting spaces. These have then been applied in two pilots:

• A virtual model of a sensory waiting space, built in collaboration with STIIMA CNR (Intelligent Industrial Technologies and Systems for Advanced Manufacturing, Italian national research council), IRCCS INRCA (Innovative Models for Ageing Care and Technology), and UNICATT (Catholic University of the Sacred Heart);
• A physical pilot was implemented by the renovation of waiting spaces of an existing CdC in Florence.

These two pilots are going to be validated within the next year, and feedback will be used for a final revision of the Design Guidelines, to verify the efficacy of this design tool to support professionals.

In this contribution, we focus on the background and field research phases, going into depth about the processes leading to the outcomes of the second phase: space requirements for CdC waiting spaces. A future publication will focus on the third phase, presenting the Design Guidelines for healthy and active waiting spaces in CdCs.

2. Background: Fundamentals of Research in the Specific Context of CdC

As presented in the introduction, the research aims to support the design process of waiting spaces to achieve the following: (i) reduce patients and caregivers/visitors’ stress, in particular during the waiting time, in the phase preceding the healthcare service; (ii) support people’s psychological comfort; (iii) promote healthy and active ageing and prevention of chronic diseases (Figure 2).

These main goals refer to three fundamental groups of theories (Figure 2) we identified from the scientific literature, which represent the main principles of the research.

The first group of theories refers to the concept that the built environment has an impact on people’s health by altering stress levels [22,23,24]. Del Nord 2006 [12] dedicates one chapter to “the stress and the stressors in the hospital” [25], referring to the factors of the physical dimension of the space which contribute to altering people’s stress to improve the healthcare experience and affect their health. It refers to four specific dimensions of the environment at the building scale, which can have an impact on stress/health:

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Stimulation refers to creating a balance between sensory stimuli. Overwhelming (e.g., noises, strong lights, etc.) causes stress in people; at the same time, a low stimulation causes sensory deprivation and boredom.

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Coherence refers to configuring a comprehensible and clear building layout to avoid stress;

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Affordance refers to the ability of an environment to induce the right behaviours and functions/activities;

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Control refers to the ability of a person to modify the environment to adapt it to the person’s specific needs.

All physical elements such as light, temperature, smells, sounds, colours, textures, etc., act as sensory stimuli for users in the space, engaging their body and senses in interacting with the environment [26]. The information received through our senses shapes our perceptions of the environment and influences our emotions, thoughts, and behaviours [27].

Multi-sensory rooms and equipment deal with stimulation and self-regulation of senses (especially for individuals with vulnerabilities) to generate positive sensations and emotions, reduce stress, promote relaxation and sense of choice, and control acquisition or recovery [28,29,30]. There are many examples of sensory rooms in healthcare settings, hospitals and care centres, as presented in Bellini, Setola, 2024 [31]. Del Nord, in the chapter “the environment and the perceptive-sensory factors” [32], suggests operative guidelines for the design project to ensure the environment acts as a healing resource that satisfies the physical and psychosocial needs of all the users and contributes positively to healthcare outcomes and caregiving.

Among these salutogenic properties of the environment, the second group of theories refers to those environmental characters that allow patients, caregivers/visitors and the staff to have “restoration” [13,14,15,16] (by colours, nature, art, etc.) and to employ “coping” [17] to manage stress conditions. “Restoration” refers to the process of recovering cognitive and emotional energies by interaction with the environment, achieving physical and mental balance [33]. The restoration process can occur when a person is observing or experiencing nature or art to generate well-being and influence human health [34]. The role of art in healthcare settings is widely recognised [35], particularly in reducing stress, pain, suffering and feelings of isolation. Relating to waiting spaces, art can reduce the perception of time passing and the anxiety of waiting, as well as encouraging interaction with the staff [36,37]. The concept of “coping” concerns what a person does (from a cognitive, emotional and behavioural point of view) to face a critical condition. Research has well demonstrated that the environment has an important role in the process of stress/coping. The ability to control the environment and the development of social relations are two main resources of coping [17].

Finally, the third group of theories refers to the concept that the Casa della Comunità has health promotion as its main mission. For this reason, the design of this facility should be based on theories of health-promoting architecture and health promoting buildings [18,19], interpreting the concept of health promotion [20] through the built environment [38], e.g., active design [39], promotion of physical activity, Healthy Buildings approach [21].

Starting from these groups of theories and following the Requirement Classes of the Building System (UNI 8289:1981) [40], this research focuses on the Well-being and Usability classes, also according to the Guidelines for the Humanization of Healthcare Spaces [41] (Figure 2):

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Psycho-emotional well-being and the needs for privacy, concentration, social interaction, continuity with the home environment, mental disengagement (positive distraction and restoration), psychological support, control, information and involvement;

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Environmental well-being, i.e., the conditions that guarantee physical and sensorial well-being: acoustic, thermo-hygrometric, visual, olfactory, and tactile well-being;

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Usability, i.e., the set of conditions that allow the use of spaces, furnishings and equipment in adequate conditions. More specifically, we analyse the layout and configuration of spaces to favour.

These fundamentals (theories and requirements) have been guiding our research and its application in the specific context of Casa della Comunità (CdC), to be able to define Design Guidelines for health-promoting waiting spaces in these facilities. In fact, in Italy, the layout and architectural features of CdC are still not widely explored because it represents a new model of socio-healthcare facility. Therefore, these spaces should be very different from typical waiting spaces of other healthcare buildings, such as hospitals or clinics. There is a lack of specific guidelines about waiting spaces in this new architectural model. In Italy, architects in the healthcare field commonly refer to UK Building Notes as one of the most complete design guideline tools. Considering that CdC model of facility can be assimilated to primary care facilities, we can in part refer to UK Health Building Notes 11-01, 2013 [42] which deals with “Facilities for primary and community care services”, giving “best practice” guidance on the design and planning of new healthcare buildings and on the adaptation/extension of existing facilities. However, the notes regarding waiting spaces are quite essential and synthetic. Health Building Notes 00-01, 2014 [43] and 00-03, 2013 [44] provide more details about waiting spaces, but they refer to “General design guidance for healthcare buildings” and “Clinical and clinical support spaces”, so not specifically to primary and community care services. Moreover, these documents do not explore the main idea we propose about health promotion through the built environment and during waiting time. There are some studies regarding the idea of health promotion in these spaces, which are more based on health literacy [45] and the divulgation of health information [46,47,48], not specifically on the primary care context (such as dental clinics) [49,50], and mainly in a passive way [8]. Some studies are promoting the importance of information to promote physical activity in primary care contexts [9,51,52] and using waiting areas and sensory design principles to encourage physical and cognitive training [53], but it is still a field that should be explored in the architectural context and in the related integrated technologies.

In Italy, we could not identify complete and effective tools for professionals to drive the design of CdC buildings and, more specifically, CdC waiting spaces. There are some Italian documents which aim to describe the context of the CdC, defining this new model and giving some indications to design CdC facilities, as follows. However, as mentioned before, the promotion of health through these spaces is not explored.

Brambilla and Maciocco, 2022 [2] introduce the process of transformation of Case della Salute in Casa della Comunità, after the Italian health reform DM 77/2022 [1], but this does not represent an operational tool for professionals to use in designing CdC buildings (nor waiting spaces). Prima la Comunità, 2021 [54] published a document which is a sort of identity card of the CdCs, expressing aims and mission, stakeholders involved, and governance, roles and organisational systems/management, but it does not refer to the architectural features of CdC spaces.

Agenas, 2022 [55] presents the “Directional document for the meta-design project of the Casa della Comunità”, referring to the aims and strategies of the project of a CdC, presenting its functional areas and some general references to the architectural and technological features. Although waiting spaces are mentioned in the document, it does not present specific requirements for these spaces. Peretti and Torricelli, 2023 [56] is a document about “Houses and Hospitals of the Community”, also presenting in that case the context and then some operative design strategies for the CdC, identifying five main architectural topics to be provided in a CdC, which should be “a place with meaning, flexible and adaptable, integrated into the local area, which respects the environment and puts people and quality care at the centre”. However, waiting spaces are not mentioned in the document. Finally, Quintelli et al., 2025 [57] proposes a new architectural and urban model called a “Community Health Center” as an evolution of the Casa della Comunità and identifies waiting spaces as one of the “components of the typological device” to be designed in the compositional framework. Therefore, this publication proposes some layouts of waiting spaces but it does not go into detail about all the aspects dealing with environmental characters of the spaces and does not refer to the idea of health promotion.

In conclusion, this research could make a contribution in this field, aiming to fill this gap in design guideline tools. To be able to develop Design Guidelines, it is necessary to define spatial requirements for CdC waiting space, which are the object of this paper.

3. Methodology

The next sections will describe in detail the methodology and tools that have supported the development of space requirements: (i) Theoretical Framework; (ii) Technical Analysis; (iii) Perceptive Analysis; (iv) Integrated Requirements.

These methods and the related tools can be applied to different contexts, starting from background theories that are valid for every typology of healthcare buildings, aiming at people’s well-being, physical and psychological comfort, and health promotion. Emphasising that the research starts from these universal principles (e.g., the impact of the built environment on stress levels or the use of Sensory Design) makes the approach robust and transferable at a conceptual level. When the context changes, it will be necessary to adapt the technical analysis by selecting best practices to be aligned with the specific context of the new research (see Section 3.2.1), but the method used for the analysis (Case-based design/reasoning—CBR, see Section 3.2) will still be valid. Regarding the perceptive analysis, it will be necessary to adapt questions in the case of a specific target group of users in the healthcare facility being analysed.

3.1. The Theoretical Framework

As anticipated in the background section (see Section 2), the Background research identified three fundamental groups of theories derived from the scientific literature. These theories represent the core principles of the research and were used to establish and define a Theoretical Framework (Figure 3). This framework serves as an operative tool to guide the data collection and subsequent analysis of best practices, enabling the definition of spatial requirements for health-promoting waiting spaces. This Theoretical Framework is based on three main areas of investigation: (i) Territorial primary care and CdC, (ii) Waiting Areas, (iii) Sensory Design.

First of all, we focused on local primary care facilities, such as Case della Comunità/Case della Salute. As anticipated in the first section, it was not possible to find operative documents, such as Design Guidelines, in this field, as it represents a new model of healthcare facility. Moreover, there is little research in the area of health promotion in these spaces, particularly in the waiting areas. For this reason, it was necessary to broaden our research, also examining Primary Care facilities and Community Centres to identify existing design solutions in waiting spaces for health promotion, consistent with the WHO (World Health Organisation)’s idea of age-friendly and healthy cities [58]. Moreover, we decided to expand this research, looking at good examples (best practices) of waiting rooms in healthcare facilities for outpatient departments, medical and healthcare centres. Finally, Sensory Design was identified as a suitable approach to solve both the goals of comfort and health promotion by obtaining relaxing, homely and customisable environments for different types of users [31]. Therefore, we decided to explore this field, collecting sensory solutions found in welcome and waiting spaces of both outpatient departments and primary care facilities. The use of Sensory Design has been investigated in the literature across a wide range of settings, such as health and education [31], especially concerning mental health, managing distress and anxiety. There are also many examples of sensory rooms in healthcare settings, hospitals and care centres [59]. Conversely, there is a lack of similar experiences in the area of primary care, so we decided to spread the research in other contexts, in which sensory environments are commonly used, such as children’s hospitals, geriatric facilities, physiotherapy, etc., to collect effective solutions to be applied to CdC settings.

In these areas of investigation, starting from the background research, we were able to identify different categories of collection and analysis (see Section 3.2.2 for description). For the first two areas:

• Efficacy of Layout Configuration [12,22,23,24,25,60];
• Environmental Comfort, Control, Familiarity and Affordance [12,22,23,24,25];
• Restoration, Sensory Stimulation [13,14,15,16,17,26,27,28,29,30,31,32,33,34,35,36,37];
• Sociality Promotion [18,19,20,38];
• Active and Healthy Ageing [18,19,20,21,38,39].

For the third area of investigation (Sensory Design), as described in Bellini, Setola, 2024 [31]:

• Space Models;
• Relaxation Strategies;
• Movement Promotion;
• Technology Integration.

3.2. Technical Analysis

We identified a gap in the literature regarding guidelines for the design of CdC and the promotion of health through waiting spaces. Starting from case-based design [61] theory, the authors analysed relevant European case studies to derive innovative solutions to be applied in the design of waiting spaces in the primary care context and to address these gaps through the application of significant technical-design solutions in this specific context:

• Identification of invariants that are common in case studies (welcome and waiting spaces of various types of social and healthcare facilities, e.g., hospital, clinic, health centre, etc.) and that can be translated into input for the project;
• Innovative ideas related to other contexts or different users, to be reinterpreted and applied to the project. To explore innovation, Sensory Design was identified as a suitable approach to both provide comfort and promote health in waiting spaces, by creating relaxing, welcoming and customizable environments for different users through the integration of digital technologies.

Case-based reasoning (CBR) is a cognitive model developed in the fields of artificial intelligence and cognitive psychology, which has given rise to a theory of how we reason in problem solving [61]. In accordance with this model, to solve or understand a new problem, we can learn from existing good solutions to find answers to a similar problem. The goal is to capture what is common among a variety of similar solutions and formulate rules that are generally applicable [62]. Case-based design is the application of CBR to the design process, using elements of previous design solutions in developing new design solutions [63]. “Cases” are represented by existing architectures or design solutions used as sources of knowledge.

3.2.1. Selection Criteria

For the first and the second area of investigation, best practices were chosen among healthcare buildings with innovative design solutions and characteristics in at least two or three categories described in paragraph Section 3.2.2, so much so that they could be defined as “Best Practices” (Figure 4). In particular, they were selected among hospitals with an outpatient department, outpatient clinics, health houses, or local primary care facilities that presented interesting or innovative solutions for welcome and waiting spaces. European buildings were selected in order to evaluate examples close in size and social and cultural context, designed and built since the 2000s. Specialised healthcare facilities were excluded, such as emergency departments, cancer centres, paediatric hospitals, dental clinics, etc., as they would represent different solutions for requirements and context. The research was carried out through literature review and online search engines on dedicated portals (e.g., google, archdaily, healthcare design, pinterest, architect magazine, architecture for health, dezeen, etc.) using some keywords: hospital AND outpatient AND waiting spaces; european AND hospital AND outpatient AND waiting spaces; (different countries) hospital AND outpatient AND waiting spaces; outpatient department AND elderly; house of community; community hospital; community centre; primary care; medical centre; healthcare architecture AND waiting spaces; healthcare architecture AND elderly.

For the third area, the authors collected Sensory Design examples in European healthcare facilities, built since 2010, according to the criteria presented in Bellini and Setola, 2024 [31].

In total, 37 case studies were selected: 20 for the first and second areas, as summarised in

Table 1. Case studies analysed in the technical analysis phase: waiting spaces of European healthcare facilities, built since the 2000s.

	Case Study (Web Sites Accessed on 30 July 2025)	Place	Year	Designer	Area (mq)
a1	Tergooi Medical Centre https://www.archdaily.com/1001687/tergooi-medical-center-wiegerinck	Hilversum, The Netherlands	2023	Wiegerinck, Arnhem, The Netherlands	55.000
a2	Dijklander Hospital https://www.archdaily.com/995948/dijlander-hospital-revitalization-bureau-ira-koers-and-plus-studio-roelof-mulder?ad_medium=gallery	Purmerend, The Netherlands	2022	Studio Roelof Mulder and Ira Koers, Amsterdam, The Netherlands	1.780
a3	Bijgaardehof Co-Housing and Healthcare Centre https://www.archdaily.com/988277/bijgaardehof-co-housing-and-healthcare-center-bogdan-and-van-broeck	Ghent, Belgium	2022	Bogdan & Van Broeck, Brussels, Belgium	9.375
a4	Health Municipal Clinic in Liffol-Le-Grand https://www.archdaily.com/1006257/health-municipal-clinic-in-liffol-le-grand-studiolada	Liffol-Le-Grand, France	2021	Studiolada, Nancy, France	615
a5	CAP Riells i Viabrea https://archello.com/project/cap-riells-i-viabrea	Riells i Viabrea, Spain	2021	Comas-pont Arquitectes, Barcelona, Spain	566
a6	Steno Diabetes Center Copenhagen https://www.archdaily.com/1006085/steno-diabetes-center-copenhagen-vilhelm-lauritzen-architects-plus-mikkelsen-architects-plus-sted	Copenhagen, Denmark	2021	Vilhelm Lauritzen Arch. + Mikkelsen Arch. + STED, Copenhagen, Denmark	18.200
a7	Taverny Medical Centre https://www.archdaily.com/932080/taverny-medical-center-maaj-architectes	Taverny, France	2020	Maaj Architectes, Paris, France	1.095
a8	Hospital Nova https://www.theplan.it/architettura/hospital-nova-l-ospedale-del-futuro-che-pensa-fuori-dagli-schemi	Jyvaskyla, Finland	2020	JKMM Architects, Helsinki, Finland	116.000
a9	Health Centre at Gibraleón https://www.archdaily.com/956493/health-center-at-gibraleon-javier-terrados-estudio-de-arquitectura	Gibraleon, Spain	2020	Javier Terrados Estudio de Arquitectura, Sevilla, Spain
a10	Lindesberg health centre https://whitearkitekter.com/project/lindesberg-health-centre/	Lindesberg, Sweden	2020	White Architects, Gothenburg, Sweden
a11	Health Municipal Clinic In Audun-Le-Roman https://www.archdaily.com/1000868/health-municipal-clinic-in-audun-le-roman-studiolada	Audun-Le-Roman, France	2019	Studiolada, Nancy, France
a12	The Jean Bishop Care Centre https://www.archdaily.com/909641/the-jean-bishop-integrated-care-centre-medical-architecture	Kingston upon Hull, UK	2018	Medical Architecture, London, UK	2.761
a13	Luz Saúde Vila Real Hospital https://www.archdaily.com.br/br/945349/hospital-luz-saude-vila-real-openbook-architecture?ad_medium=gallery	Villa Real, Portugal	2018	OPENBOOK Architecture, Lisboa, Portugal	6.800
a14	Zaans Medical Centre https://www.archdaily.com/874330/zaans-medical-centre-mecanoo	Zaandam, The Netherlands	2016	Mecanoo, Delft, The Netherlands	38.500
a15	Närsjukhus in Angered https://www.sweco.se/projekt/angereds-narsjukhus/	Gothenburg, Sweden	2015	Sweco, Stockholm, Sweden
a16	Porreres Medical Centre https://www.archdaily.com/189622/porreres-medical-center-maca-estudio	Porreres, Majorca, Spain	2011	MACA Estudio, Guadalajara, Jalisco, Mexico	900
a17	Orbis (now Zuyderland) Medical Centre https://dezwartehond.nl/en/projecten/orbis-zuyderland-medisch-centrum/	Sittard-Gele, The Netherlands	2010	De Zwarte Hond, Groningen, Rotterdam, Cologne and Berlin	73.850
a18	Kentish Town Health Centre https://modulo.net/it/realizzazioni/kentish-town-health-centre	London, UK	2009	Allford Hall Monaghan Morris, Lndon, UK
a19	Centros Municipales de Salud https://www.archdaily.cl/cl/02-208005/3-centros-municipales-de-salud-en-madrid-san-blas-usera-villaverde-estudio-entresitio	Madrid, Spain	2008–2010	Estudio Entresitio, Madrid, Spain	5.430
a20	Heart of Hounslow Polyclinic https://commercialpropertyphotography.com/health-care/heart-of-hounslow-medical-practice/	London, UK	2007	Penoyre & Prasad (now Perkins&Will), London, UK	8.800

, and 17 for the sensory area [31].

Through the technical analysis, case studies were summarised in 37 Case Study Sheets, which illustrated the contribution of each best practice in the categories defined by the Theoretical Framework in order to highlight the best solutions in designing waiting spaces for application to the CdC context.

3.2.2. Observation Criteria

Aiming at the research objectives, case studies in the first and second areas of investigation were analysed on the basis of the five categories:

• Efficacy of Layout Configuration: solutions to configure welcome and waiting areas to optimise the use and quality of healthcare environments. In this category, the authors evaluated the type of spaces, their position and relation with the healthcare services, their integration and connection with the entrance, the configuration of the distribution areas and public spaces, and the clarity and comprehensibility of the routes;
• Environmental Comfort, Control, Familiarity and Affordance: the effective use of colours and materials to promote comfort and a sense of familiarity, recognizability, and welcoming. The authors analysed design solutions for light (natural and artificial), ventilation and all the aspects that impact the environmental well-being; furnishing solutions to promote the sense of welcoming and homeliness; the ability of control by the patients/caregivers/visitors; the affordance capabilities of the proposed furnishings;
• Restoration, Sensory Stimulation: strategies for support and recovery through art, nature or other regenerative elements; the variety of sensory stimulations and the possible regulation of stimuli;
• Sociality Promotion: promotion of a functional mix and design solutions to foster relationships and a sense of community;
• Active and Healthy Ageing: strategies and design solutions to promote active design (e.g., through the use of stairs), healthy food, Healthy Buildings construction, etc.

Figure 5 represents an example of one of the Case Study Sheets in the first and second areas of investigation.

As regards the Sensory Design area of investigation, the following analysis criteria were followed:

• Space Models: Designing the building according to a multisensory approach; sensory equipment diffused in public spaces; sensory atrium or sensory waiting spaces; snoezelen rooms; portable sensory equipment;
• Relaxation Strategies: specific elements of the project which represent targeted solutions to reduce stress, promote psychological comfort and support restoration;
• Movement Promotion: solutions to favour the interaction between the person and the space (or the object) and encourage movement and physical activity, in accordance with the idea of active and healthy waiting time;
• Technology Integration: devices and automation technologies which promote the control of space by the person, the regulation of sensory stimuli, and the interaction between the person and the environment. The authors also analysed the integration of these elements into the environment through the architectural project.

Figure 6 represents an example of one of the Case Study Sheets in the Sensory Design area of investigation.

3.3. Perceptive Analysis

A semi-structured interview model was submitted to healthcare professionals (40 persons among doctors, nurses, management and administration) of the relevant healthcare facilities to collect data on the use and perception of the waiting spaces. The interviews were conducted in INRCA facilities in Ancona, Casa della Comunità Le Piagge (Florence), Casa della Comunità Morgagni (Florence), Department of Multidimensional Medicine of Florence.

Then, a semi-structured interview model was submitted to patients (41 persons) and caregivers (26 persons), at the same facilities where the interviews with healthcare professionals were carried out, obtaining qualitative results to be integrated into the Design Guidelines.

The interviews posed questions about three main topics: the spatial configuration; the presence of sensory elements that could improve relaxation or mental distraction (e.g., music, projections, coloured lights, etc.); and health promotion (e.g., having information on health, doing physical activity, etc.).

During the interviews, pictures of different waiting rooms (

Table 2. List of images used to discuss with patients and caregivers during the interviews.

	Case Study	Typology of Space	Web Sources (Accessed on 30 July 2025)
im01	Zaans Medical Centre	Waiting area near the medical rooms. This is an example of a waiting space where people can see the doors of the medical room during waiting time. Colours are vivid, artworks are present on the walls, and the furniture is coloured, modern and homey.	https://www.archdaily.com/874330/zaans-medical-centre-mecanoo/594ce485b22e38e9290004a9-zaans-medical-centre-mecanoo-photo?next_project=no
im02	Luz Saúde Vila Real Hospital	Waiting room filtered by a timber frame screen. The colours of the room are warm and the lights are soft.	https://www.inap2.com/kr-sq/gallery/gallery_e951861bd33b87c365b190e678d03048/
im03	Porreres Medical Centre	Waiting room on the first floor. It is an example of the model “waiting in a separate room”. All the walls of the room are yellow, the seats are simple, and at the end of the room there is a big window looking outside in an urban context.	https://www.archdaily.com/189622/porreres-medical-center-maca-estudio/5016efad28ba0d235b00053b-porreres-medical-center-maca-estudio-photo
im04	Tergooi Medical Centre	Waiting room next to a green courtyard. It is a good example of favouring relations with comfortable and homey furniture. Sofas are oriented in different directions to let people look at each other or outside at nature. The walls are white and clean.	https://www.archdaily.com/1001687/tergooi-medical-center-wiegerinck/6475318820e8d30376dd6c9e-tergooi-medical-center-wiegerinck-photo
im05	Tergooi Medical Centre	Waiting pod integrated into the wall of a corridor. Walls are white and the pod is highlighted by the orange colour. While sitting, it is possible to look outside through the windows on the opposite wall.	https://www.archdaily.com/1001687/tergooi-medical-center-wiegerinck/647531883d39be5bd4fa41e0-tergooi-medical-center-wiegerinck-photo
im06	Health Municipal Clinic in Liffol-Le-Grand	Waiting room on the second floor. The walls are white and the room is filtered by a timber screen, which filters the large amount of natural light. As seats, the typical “Liffol chairs” are used, which are a symbol of the local culture.	https://www.archdaily.com/1006257/health-municipal-clinic-in-liffol-le-grand-studiolada/64f0b142bbf563583c72ac19-health-municipal-clinic-in-liffol-le-grand-studiolada-photo
im07	Zaans Medical Centre	Waiting area on the first floor. It is an open space, connected with openings to different floors. All the walls are characterised by big art illustrations. Furniture is homey, coloured and oriented to make people interact.	https://www.oneclub.org/awards/adcawards/-award/27298/zaans-medical-centre-healing-environment/
im08	Steno Diabetes Centre Copenhagen	Waiting area along the glazing wall, looking at the green courtyard.	https://www.archdaily.com/1006085/steno-diabetes-center-copenhagen-vilhelm-lauritzen-architects-plus-mikkelsen-architects-plus-sted/64ed052452867b5c9aedc962-steno-diabetes-center-copenhagen-vilhelm-lauritzen-architects-plus-mikkelsen-architects-plus-sted-photo
im09	Dijklander Hospital	Waiting area in the street of the hospital. Plants and greenery are growing around the seats, creating some green rooms where people can wait.	https://www.archdaily.com/995948/dijlander-hospital-revitalization-bureau-ira-koers-and-plus-studio-roelof-mulder/63dd1e07e8dab046150a93c5-dijlander-hospital-revitalization-bureau-ira-koers-and-plus-studio-roelof-mulder-photo
im10	Zaans Medical Centre	Waiting area around the green courtyard. The big glazing wall creates a direct connection between the interior and the exterior.	https://www.archdaily.com/874330/zaans-medical-centre-mecanoo/594ce8a8b22e3898a7000814-zaans-medical-centre-mecanoo-image?next_project=no
im11	Taverny Medical Centre	Waiting area in the green courtyard. It explores the idea of waiting outside.	https://www.archdaily.com/932080/taverny-medical-center-maaj-architectes/5e211fc03312fd970e0003cf-taverny-medical-center-maaj-architectes-photo

) selected in the technical analysis were shown to respondents to support questions about the space and facilitate the discussion. Pictures were selected to respond to the related question of the interview to support people’s comprehension; the criteria of selection and the composition of the interview will be described in a future publication we are working on, focusing only on the definition of perceptive requirements.

After the interviews, a questionnaire model was also submitted to patients and caregivers, which provided more quantitative data on specific questions about the waiting spaces’ configuration.

Perceptive requirements are the result of the co-design analysis and will be described in another publication related to this specific topic.

3.4. Integrated Requirements

The Theoretical Framework was used to select and analyse case studies. The results of the technical analysis were represented by spatial models and environmental characters identified as invariants in designing waiting rooms and as points of innovation to be applied in the primary care context of CdC. These aspects were discussed in the co-design phase, by showing pictures of best practices selected (Table 2) and discussing the results of the technical analysis with users. Moreover, both the results of technical and perceptive analysis were summarised by the five categories of the Theoretical Framework, defining spatial requirements for designing health-promoting waiting spaces (Figure 7) and then to develop Design Guidelines.

4. Results and Discussion: Space Requirements

In accordance with the aim of this paper, in this section we present the results of the definition of space requirements for active and healthy waiting spaces.

Space requirements represent the result of both technical and perceptive analysis, mixing indications derived from the study of best practices and qualitative responses with the interviews related to the point of view of patients, caregivers and staff regarding waiting spaces’ models of the technical phase.

Space requirements form the basis for the development of Design Guidelines, which represent the final result of the research. Design Guidelines are briefly presented in this contribution to illustrate the impact of the previous research phases in reaching this operative tool.

4.1. Efficacy of Layout Configuration

4.1.1. Case Studies Results

According to the different layouts of the healthcare facilities analysed, we identified eight different models of waiting spaces based on the configuration layouts (

Table 3. Models of waiting space layouts derived from the analysis of case studies. The red represents the waiting spaces, the yellow the corridors/connections, and the blue the outpatient area. The arrows represent the users’ paths. The proportion of spatial models is calculated on the total number of case studies analysed.

	Model	Diagram of the Spatial Model	Case Studies	Proportion Among Case Studies
M01	Waiting in the main hall		a11, a12, a13, a15, a16, a18	30%
M02	Waiting in the main street		a02, a08, a10, a14, a20	35%
M03	Waiting around the courtyards		a01, a05, a06, a07, a09, a12, a14, a15, a19	45%
M04	Waiting in the courtyards		a06, a08, a12, a14, a15	35%
M05	Waiting in a separate room		a04, a11, a13, a16, a19	35%
M06	Waiting room in front of the outpatient area		a01, a04, a06, a13, a14, a16, a18, a19	40%
M07	Waiting corners		a02, a12, a14, a15, a17, a20	30%
M08	Waiting in the corridor		a01, a08, a12	15%

). In the table, we also present the references to the case studies where the different layouts are applied to show the recurrence of the spatial models.

Waiting areas may be situated directly in the atrium (M01), articulated through various seating arrangements to foster social relations, while simultaneously guaranteeing privacy, contingent upon different users’ needs (referring, for example, to case studies a12, a13 in Table 1). This area can also be characterised by colours (a12, a16), art or nature, to enhance comprehension and recognizability.

Alternatively, waiting areas may be developed along “the street” (M02), which runs longitudinally through the whole healthcare facility, establishing differentiated waiting corners along the path, such as small designated resting points. Nature assumes a crucial role in this area, such as creating “green rooms” through flower beds with tall vegetation that segments the spaces (a02), or using flower beds with low-spreading plants (a10), as well as art that can be spread along the path, such as artworks, sculptures, lighting systems (a08, a14) or large multi-level walls (a14, a18). Social interaction may be facilitated by furniture, such as through seating oriented to look at each other or positioned around a table to encourage relationships; similarly, games or art placed along the route (a10, a14, a17) promote shared experiences and dialogue. The street can be on a single level, double or triple volume, overlooking the other floors through galleries and raised connections (a08, a17, a18, a20), also creating larger areas of interaction such as a central big square (a18, a20) or smaller ones at various floors, creating a connection by stairs or slides that lead from one floor to another (a14).

Another recurring typology is represented by waiting spaces built around patios or courtyards (M03), which are highly amenable to green landscaping (a01, a05, a06, a07, a09, a14, a15), to maintain continuous contact with nature and encourage distraction during the waiting time. Courtyards can be accessible (M04) or non-accessible. They can have different shapes and dimensions: for instance, long and rectangular spaces facilitate the provision of natural yet indirect, non-dazzling light internally, and may offer seating along the openings (a5, a9), thereby preserving a connection with nature even when external access is not utilized. Smaller and more contained spaces, with the same dimensional relationship between waiting and green space, can project the exterior into the interior and expand the space up (a19), also thanks to big transparent glass openings. When accessible, these areas function as places for rest and relaxation, featuring seats in a structured greenery (a07, a14) or in a wild and more natural context (a01, a06); they may include covered spaces to host artworks (a08) or to carry out different activities, such as yoga, children’s play, etc., (a15). Green courtyards can represent the core of the structure, also having a function linked to health promotion, physical and mental support activities and sociality (a06, a15).

A different model can be represented by a well-defined waiting space, such as a separate waiting room (M05), which operates autonomously from the other areas of the healthcare facility, while maintaining visual contact and access control of the relevant healthcare services/spaces. For example, this typology involves the placement of several rooms in different areas of the building, adjacent to the healthcare services/spaces, completely separated and oriented outwards to sustain the relationship with the surrounding context and landscape (a11, a16). These waiting areas can be highlighted by colour to facilitate recognisability, both from inside and outside (a16). They can be closed and contained, to favour privacy and relaxation, supported also by dim light (a11) or other sensory elements. Alternatively, the spatial separation may be less pronounced, establishing a filtering element (M06), such as glass walls (a13), wooden slats (a13), or a semi-transparent perforated surface (a04), which allow light to filter through and preserve the visual continuity with the different areas, thereby fostering interaction among users and ensuring the visibility of outpatient entrances, reducing stress.

The last typology is designated as “the corner” (M07). This model encompasses several configurations, serving as some waiting points situated within a larger space, positioned along circulation paths or around the courtyards, and identified by colour, specific seating elements (a2, a12, a17), or artworks (a15); niches/pods open to corridors or other public spaces, built into the walls or with an independent structure, identified by colours or materials (a12); additionally, furniture creates a point of rest, such as armchairs featuring higher backrests and sides, designed to envelop the user, thereby enhancing privacy (a12, a14, a17).

Model M08 is highly prevalent in the existing healthcare; however it should be avoided in new designs due to several critical issues, such as lack of privacy, high level of pedestrian traffic, noise pollution, lack of space, and challenges facilitating social interaction. Nevertheless, we decided to analyse this model within the Design Guidelines because we are also referring to the refurbishment of existing buildings.

The definition of the eight spatial models (Table 3) is a significant result of the technical analysis, which serves as the foundation for discussion during staff interviews, to understand their opinion regarding the impact of configuration on the perceived waiting experience across the different models. The staff themselves emphasised the importance of “the organisation of spaces to enhance the perceived quality of the facility and consequently of the healthcare service, as well as reducing stress and fostering relationships of patients/caregivers with the staff”. A clear and comprehensible layout is paramount in the design process.

The most contentious element determining the varying layouts of waiting spaces is the visibility of the healthcare service entrance door from the waiting area: on the one hand, observing the door facilitates monitoring and can thus reassure the patient, for example, that they will not miss their turn; on the other hand, this constant visibility can induce anxiety, as it prevents patients from fully distracting themselves and relaxing, thereby maintaining a persistent state of stress. It is perhaps more important for the patient to be certain they are in the correct location (with the provision of appropriate information via both spatial layouts and signage), and to know that a member of the staff will call them, or at least that they can have access to call systems for the scheduled visit/exam. In this regard, the waiting room may be designed as a completely separate room, offering the distinct advantage of being a private place where patients/caregivers can relax and distract themselves.

It is highly recommended to have a secluded area away from the main corridors to promote calm and privacy during waiting, while avoiding waiting directly in the corridors, as “it is a transit point and, consequently, various health, pathological, and social situations may be observed,” which can generate anxiety. This also promotes privacy, not looking at the doors during waiting and ensuring visual and acoustic privacy.

The configuration of waiting spaces should be as varied as possible to meet the different needs of users. For example, some people prefer seclusion (such as a seating area in an alcove), while others prefer a shared space where they can more easily pass the time, talk, and interact with others. The waiting area should foster relationships between patients or caregivers, for example, by having a connected coffee or tea area, which promotes greater conviviality. Open large space is also suitable for people with dementia or Parkinson’s, where they can move freely and safely. In any case, it is important to be able to find privacy in an open space, to recreate a sort of intimacy between the caregiver and the patient, to have the opportunity to read, for example, and to distract oneself, reducing the feeling of waiting time.

Outdoor waiting is a very interesting model, but it is affected by weather conditions, so at least some coverage is required, and obviously it cannot be the only waiting area. It is beneficial to have space for walking while waiting, to “promote active ageing,” or an area dedicated to “sensory stimulation”; “this could also be a corridor/greenhouse containing plants”. In any case, it is important that the green area be adjacent to the waiting room to maintain a connection.

Greenery can also be imagined within waiting areas, to “mentally escape and thus reduce rumination regarding the procedures patients are about to undergo” and to create “privacy” between seats. However, it is important to have big windows to allow proper oxygenation, that there are no flowers that can cause allergies and infections, and that maintenance and cleaning are guaranteed. The sight of greenery already positively influences the waiting experience.

4.1.2. Interview Results

Regarding the layout, we first discussed the importance of seeing the door with users. This is a rather controversial topic, with the majority saying they are indifferent or, conversely, prefer not to see it, but with a small difference. Caregivers show a similar result, with the majority being indifferent or preferring not to see the door. The desire to see the door is often linked to anxiety of “not seeing what’s happening,” or “losing their turn,” to check they “didn’t make a mistake,” or “to make the visit seem closer”; in general, a sense of control. Many say that if they cannot see the door, a display or call support is necessary. However, the situation is different for caregivers who prefer to maintain eye contact to ensure they can intervene if needed. Those who prefer not to see the door often experience a situation of anxiety or distress caused by constantly seeing the door and waiting for the other person to exit; furthermore, avoiding the door view allows for positive distraction, such as “looking at a beautiful view”.

According to this idea, the use of a filter between the waiting area and the outpatient doors seems to be an effective solution. This allows for monitoring but also ensures a more private waiting experience. On the other hand, the filter used should be pleasant and not too restrictive, like “sticks” or a “barbed wire fence,” which makes the area feel “like a prison”.

Many, however, report the importance of waiting in a large, open space. For this reason, many users dislike a separate waiting room, as it often feels small and cramped. This can be addressed by a large window overlooking the outside, which is always appreciated for its view, natural light, and connection to the outside world. Those who prefer to see the door will obviously find a separate room unpopular, especially if it is far from the outpatient area, but this problem can be addressed for many with a display or call system. The problem of small spaces is they are often associated with the potential for crowding, which is considered very negative. Anyway, there are some who prefer this model because it is separate, quieter, and more secluded.

The connection with the outdoors, and in particular the view of greenery, is greatly appreciated by virtually all users. In this sense, many of them would gladly wait outside to “get some fresh air,” especially if there are many people and it is hot, and to pass the time: “It’s more distracting, you can look around,” “you can completely disconnect from the inside”. Displays and call devices are clearly necessary here as well. Many prefer a situation where the outdoor space is adjacent to the waiting room, to maintain visual control. Finally, many report the problem of waiting outside in adverse weather conditions, such as rain, cold in winter, or heat in summer. They suggest adding seating, activity equipment, children’s games, fountains, social spaces, or connected services such as a cafeteria outside. The advantages of waiting outside for those with children were also highlighted, as it allows for easier entertainment during the wait.

4.2. Environmental Comfort, Control, Familiarity and Affordance

4.2.1. Case Studies Results

The design of patient comfort in healthcare facilities fundamentally relies on the quality of light (natural and artificial) and ventilation. Natural ventilation can be favoured by the use of courtyards and patios, but also through openings on the ceiling, for example, in pitched roofs (a7). Acoustics are also foundational to comfort in healthcare settings. For instance, implementing acoustic false ceilings is recommended in waiting areas to mitigate noise and reverberation (a5, a11).

Spaces, openings and facade design should vary according to solar orientation to maximise comfort and energy saving (a5, a6, a11, a16). The use of large openings or transparent glass surfaces, including on the roof, should be prioritised, particularly in public areas (a1, a2, a4, a10, a12, a13, a14, a15, a16, a17) to enhance natural light and connection with the landscape. Facade shading systems are necessary to regulate incoming light, thereby preventing glare and overheating (a5). An internal filter may also be incorporated to regulate natural light and allow visibility, favouring comfort and privacy (a4). Moreover, indirect light filtered through internal green courtyards ensures a more comfortable light distribution (a8, a9, a14).

Artificial lighting significantly impacts the quality and comfort of the internal spaces of healthcare facilities. Lighting fixtures that are not dazzling and give a warm, welcoming and familiar atmosphere are to be favoured, ensuring a bright, comfortable, and welcoming environment regardless of weather (a8, a13, a17). Lighting elements can also be integrated into the artworks, favouring interaction and navigation (a8).

The choice of colours and materials contributes to the warm and welcoming diffusion of light (a15), such as the use of wood, whereby the light is reflected and acquires a warm tone that offers softer contrasts (a15). The use of warm and neutral colours should be encouraged (a3, a5, a8, a12, a16); these, combined with the use of natural materials, can inspire a sense of familiarity (a8). Colours can liven up the environment and convey a bright and positive tone, particularly near the entrances and along the pathways (a12, a16), promoting the idea of a welcoming and friendly place. For instance, yellow can promote a sense of positivity (a12, a16), while green and other natural hues can foster a warm, bright and welcoming atmosphere (a17); in contrast, cold colours are deemed more functional for staff areas, supporting the creation of a stimulating and appealing work environment (a17). Then, the use of colour can also promote recognisability, comprehension, and navigation.

Wood is highly appropriate (a1, a4, a5, a6, a7, a13, a14) to promote warmth, welcoming, familiarity, and a sense of regional belonging, aligning with the use of local and natural materials (a5, a6, a7). It evokes external nature and provides a positive associative effect, generating feelings of calm and well-being, and positive memories (a15). Then, wood can be used in flooring to distinguish waiting areas, setting them apart from the paths, and imparting a more domestic and comfortable feel (a14). Moreover, wood can be applied to the facade, reflecting from the outside of the building the desire to provide the city with a healthy and environmentally friendly building (a7) and creating a warm character on the outside, also encouraging people to enter (a15). The principle of using local materials also extends to stone, enhancing the integration with the surrounding context and supporting identity and recognisability (a11). This contextual integration is also influenced by the size of the building and its volumes, integrating with the surrounding urban landscape, while making itself recognisable via materials and colours (a18, a19). Indeed, the use of different materials on the façade completely changes the exterior appearance and the interior relationship with the surrounding landscape (urban and natural), allowing designers to either contrast with or complement the context (a19).

The familiarity of spaces, as well as their usability, is also enhanced by furniture. Diverse seating arrangements and different types of seating are appropriate to foster relations and facilitate control by users, facing outwards to encourage engagement with nature. Options such as sofas, chairs with tables (low or high), soft seats, armchairs, and coloured or wooden chairs, promote familiarity, comfort and privacy (a1, a8, a11, a12, a14, a15, a18, a19, a20). Furniture can also reinforce identity and attachment with the community through the selection of iconic and local products (a4). Citizens’ involvement in the design, including for furniture and iconic elements, such as patterns on the internal and external coverings of the building, is also encouraged (a15). Another important role of furniture is to reduce potential imbalance between patient and doctor, for example, through the use of curved elements, such as round tables, where all participants can sit at the same level (a13, a15). Accessories such as lockers (a1) further contribute to user comfort.

4.2.2. Interview Results

According to the staff, brightness in a waiting room positively impacts the waiting experience, particularly mental health. Natural light is preferred where feasible, or artificial lighting that is well-diffused and non-overwhelming (for example, avoiding flickering neon lights). In addition to lighting, openings are considered crucial, both to ensure natural ventilation—especially in crowded waiting rooms—and to provide a view of the exterior (see next section).

Colours greatly help enliven the environment and enhance its aesthetic appearance. Light, non-vibrant colours are favoured over colours that might induce anxiety, such as light blue, which is ideal for relaxation. Colours traditionally associated with healthcare and institutional environments, such as light green or white, should be avoided. It is deemed appropriate to use the same colours for walls and doors.

Materials are very important; for example, wood is a natural, warm, and welcoming material that can be very beneficial in waiting areas, and “Curved lines are also transmitting the same feelings of calm and welcoming”.

These spaces should also convey a sense of cleanliness and order, with linear furnishings. Comfortable sofas or armchairs are preferred for both seating comfort and conviviality. They evoke the idea of a more informal and familiar environment, where, for example, “you could also have a table with magazines to distract yourself while waiting.” The ergonomics of the seats should also be considered to facilitate standing, especially for elderly patients or those with mobility issues. As an example, it is important to have seats with armrests.

However, hygiene, health, and safety standards must always be respected.

According to patients and caregivers, a significant portion of users prefer a familiar environment, through the use of natural materials such as wood and a homier furnishing style. Wood, in particular, is appreciated by most people because it “provides warmth,” is “more welcoming, and less cold.” On the other hand, we did not expect a significant percentage (more than half) of people to be so concerned about hygiene and, for this reason, less inclined to use more domestic fabrics or furnishings. They prefer a functional, easy-to-clean environment that “gives a sense of health,” reflecting the function of this space.

Regarding colours, users prefer soft, pastel, bright, and vibrant colours, provided they are not too strong. Almost all users reject white, except for a few who prefer it above all else, because it “gives a sense of cleanliness” and “makes the space seem more open.” In general, blue is highly appreciated because it “relaxes,” “reminds one of the sky,” “of water,” or “of the sea.” Green is also highly appreciated, and some prefer yellow, but only if it is not too strong, although many say they do not like it.

Regarding lighting, natural light is preferred by virtually all users, as it “reminds one of being outdoors,” “is more vital and joyful,” and allows one to “maintain a connection with the environment and the passing of time,” except for a few who appreciate the use of coloured lights. As for artificial lighting, soft, not-too-bright, warm, “relaxing” lights are preferred, reproducing outdoor light or modulated at different times of the day.

They do not like bare spaces, but they also do not like messy or chaotic spaces that are overcrowded. A modern, linear furnishing style is often appreciated because it is clean and tidy, but it shouldn’t be too cold. Some prefer single, unpadded chairs, as mentioned, but many instead point to the benefits of using sofas because they are more comfortable and, above all, more convivial, as they actively foster social interaction.

4.3. Restoration, Sensory Stimulation

4.3.1. Case Studies Results

Most studies place nature as the principal source of restoration, alongside art and sensory elements.

The relationship with nature can be promoted in healthcare facilities, both inside and outside. Internally, nature can permeate the spaces through indoor greenery, which makes the environment more vital, familiar, healthy and therapeutic (a2, a10), in addition to establishing a filter via taller vegetation, thereby functioning as authentic “green rooms” (a2). Furthermore, an indirect visual connection can be established with the surrounding landscape (a1, a6, a11, a14, a15), green patios and courtyards (a5, a9, a19), or even the sky (a19), facilitated by glass openings in the waiting and connecting spaces. When feasible, it is suitable for green courtyards to be accessible (a1, a5, a6, a7, a9, a14, a15), allowing for a direct relationship with nature, more or less structured, with rest and interaction areas, or spaces equipped for various activities, such as yoga or children’s playing (a15). This approach can be extended across the entire structure, creating a symbiosis between interior and exterior, in a variety of essences and colours, based on the seasons (a6), through larger and smaller courtyards or green terraces hanging in the volumes (a3, a14, a15, a18), and roof gardens (a6, a18). The configuration of green courtyards can also be linked to specific functional areas of the structure (atrium, bar, staff, children, etc.), thereby extending their use outside, and may incorporate distinct sensory stimuli, such as those based on the four elements of earth, air, fire and water (a15). The arrangement of the external greenery is crucial from the perspective of both welcoming and involving citizens. Greenery situated at the entrance (a4, a12) or around the building (a17, a20) allows for creating both a link with and a buffer against the urban context, and it can be freely used by citizens (a15). It can be equipped with pathways and seating (a4), artworks or other elements to encourage interaction and sensory experiences (a12), or connections with other functions such as the café or the waiting area (a18).

On the other hand, nature may be conveyed through art, recreated in different artworks, colours and materials (a8), in graphics and illustrations (a14) or as a pattern that recurs throughout the building, also creating a link with the territory and promoting a sense of identity and belonging (a15).

The illustrations can become intrinsic to the architecture, where the space is fully permeated by art (a14, a17). Otherwise, the colours can liven up the environment, make it less institutional, and foster sensory stimulation (a19, a20). Art can be reproduced in artworks, paintings or sculptures, which invite interaction with the space and positive distraction; facilitate navigation, in focal points of the building such as the entrance or reception, in the waiting rooms or in the paths (a8, a10, a12, a15, a17); create a connection with the city (a3), with sculptures (a10) or street art outside. It is recommended to use artworks by local artists (a12), potentially through rotating exhibitions (a18), and open after closing the healthcare facility to favour visits and awareness of the structure by new groups of citizens (a15).

Sensory stimulations aim to activate the person and generate interest in the surrounding environment, thereby facilitating interaction with spaces and aiding navigation; on the contrary, sensory deprivation can lead to negative outcomes of stress, anxiety, depression and poor motivation, which affect the quality of life [31]. In this category, sensory features aim to relax and support restoration, to foster a positive effect on mental comfort and health. In Bellini and Setola, 2024 [31], case studies in the sensory design field illustrate the impact of sensory environments/features on health promotion. In the case studies of the first and second areas of investigation, sensory perception is encouraged by dim and coloured lighting, and music, for example, by placing a piano (a2) or disseminating sounds and music in the public area. Lastly, intimate spaces, such as sensory rooms, are appropriate for relaxation, containment, and sensory rebalancing (a11).

4.3.2. Interviews Results

Staff emphasised the importance of establishing a comfortable, welcoming, intimate, and safe waiting area where people can relax, allowing time to pass without worrying about when their turn will come. “If you feel more relaxed, you’re also a little more cooperative, perhaps more willing to talk and able to clarify, for instance, symptoms.” It should be a sort of “decompression room.” “A quiet and serene environment, with comfortable seating, paintings or murals on the walls, succulents (which require no maintenance), and soft lighting.” The idea of “being able to involve local young people in creating the mural and have it donated to seniors, to foster the idea of multigenerationalism and the feeling of belonging”, is an interesting concept. Colour, art, and greenery are all good in all their forms. Green elements keep people active and promote mental health. Even the pathways could be imagined as “tree-lined paths, with a view of greenery in the background, which can convey a message of greater tranquillity and health promotion.”

Projections of landscapes and natural scenery, video screens, or touch screens can distract, induce relaxation, and refocus attention, a function also served by background music. The music should be “low-volume, non-disturbing (e.g., loud sounds can create discomfort in people with dementia or make some people nervous), calm, and preferably instrumental, even better if you can choose based on your preferences,” or “sounds of nature, especially water,” “wind, rain, and animals.” Even objects that can be played and interacted with manually, such as a large chess set, are desirable.

In any case, “whether it is a game, entertainment, music, or a connection… The primary objective is to ensure that patients do not perceive they are wasting their time while waiting.”

“A sensory preparation room can be ideal,” “a relaxing, meditative place where you can be alone, even with and for those accompanying you.” “A place where you can stay for an hour and not feel the need to do anything else, a warm, natural, familiar environment, darkened with curtains,” “illuminated by chromotherapy,” with “video projections for distraction,” “comfortable seating, waterfalls and sounds,” with “water, which also provides a sense of coolness.” Such a space “can also improve pain tolerance,” for instance, in the case of invasive tests, “can feel better in case of bad news by the doctor”, “in case of fragility” and for “people with cognitive or behavioural diseases”. In general, a dedicated and “possibly isolated” space is preferred, as it is quieter and more intimate, offering greater privacy; however, some prefer the idea of having sensory elements in a larger waiting room, where they can continue to interact with others, or use a sensory alcove overlooking the waiting area, so as to still be able to isolate themselves somewhat.

As for the staff, art is appreciated by almost all patients/caregivers, as it “distracts”—especially if you’re alone—“stimulates curiosity,” “makes you stop and look,” “makes time pass,” “relaxes and calms,” and “provides a sense of beauty.” Only a few say it “isn’t interesting” or “not relevant,” but no one makes negative comments about it or disdains it.

Nature and the view outside are universally appreciated by all users, as they “are relaxing,” “provides calm,” “openness” and a “sense of respite,” conveys “the idea of being outside,” and allows you to “watch time pass.” Some did, however, mention the importance of seeing the outside, but without having a completely transparent glass wall overlooking the waiting area. This is likely also linked to the cultural context, where it is uncommon to have completely open glass facades.

More controversial is the issue of having greenery within the waiting area; the majority of users appreciate it, but some are concerned about the potential for allergies, the presence of insects, and the potential for debris caused by plants. Above all, they are concerned about the possibility of inadequate maintenance, which could result in the plants becoming damaged or drying out. This can be addressed by choosing plants that are hypoallergenic, highly durable, and require little maintenance, or by using preserved plants.

For the same reason, although most people prefer real natural elements, some prefer the artificial view of nature, such as through screens or video projections, which “allow your imagination to travel.”

This raises the topic of sensory spaces, which are appreciated by almost all patients, and the majority of caregivers because they “relax,” “calm,” “relieve anxiety,” “help you sleep,” “distract you, and stop you from thinking.” Many have never experienced a sensory space, so the results may be partially affected by a lack of knowledge. Some refer to the use of this space not only during the wait, but also after the appointment, or for activities such as those of psychologists, or for specific pathologies and vulnerable users.

They also question whether they can truly relax in such a context. For this reason, the majority prefer a separate space, since it is isolated and “makes you feel more at peace,” and more than one person can use it at a time. For the same reason, the sensory pod is less appreciated. Some also raise the issue of hygiene, having to use it collectively. Those who generally prefer to isolate themselves appreciate it, as they can remain in the waiting room, yet still be isolated and have an individual experience. In this sense, for instance, it can be useful for breastfeeding.

Screens and projections that reproduce natural scenarios are appreciated by almost all users, preferably with background music, as it “distracts and takes you away from your thoughts,” or “travel scenarios that let your imagination soar.”

Music is also appreciated by everyone, but it is important that it be soft and light, just a background. Some people prefer to be able to choose it; otherwise, relaxing music, classical or instrumental, is generally preferred, along with the sounds of nature, especially water, “like a waterfall, ideally real.”

4.4. Sociality Promotion

4.4.1. Case Studies Results

The integration of diverse functions and a robust connection with the surrounding territorial and social context should be actively promoted. Consequently, the decision to situate healthcare facilities in buildings that also have a residential function (a3, a10), or more public functions such as an atelier/carpentry shop (a3), a gallery to exhibit the work of local artists, a space where local groups meet and a base for neighbourhood initiatives (a18), an area for firefighters (a12), a gym, physiotherapy services, a library (a18), spaces for children (a10) or family consultants (a18), outdoor spaces also used by citizens, green areas (a3, a4, a10, a12) or market areas (a4), or the urban square itself (a4, a13). Otherwise, another strategy is to connect to functions already existing in the area, such as cafes, or sports facilities (a5), a contemporary art museum, or an arena for outdoor events (a9). Also relevant is the choice to locate the structure in a central position in the city (a10) or well connected by public transport, for instance by placing itself near the train station (a10).

The public atrium, the street and the courtyards, constitute the principal nexus for connectivity, thereby fostering meeting and exchange among the facility’s different users and establishing a real public space comparable to an urban street or a town square (a2, a8, a10, a14, a17, a18, a20), which are furthermore complemented by public services and functions such as café, hairdresser (a2), and similar provisions.

The establishment of permeability between internal spaces and through paths is crucial for guaranteeing visibility and facilitating relations. It can be provided by the use of transparent walls (a19); filters created with wooden slats (a11, a13) or grilled surfaces (a4); walkways, balconies and views of the double volume of the street (a2, a10, a11, a14, a17, a18, a20); corners or seats along the route that foster relationships during stops and passages (a12, a15). Furthermore, external permeable pathways that promote circulation in the form of tunnels, elevated roads where residents meet, children play, plants grow, etc., (a3) are favourable for developing sociality. Finally, the relationship between inside and outside can promote permeability, for instance by opening and making the central distribution axis transparent, as if it were an urban road (a4).

Likewise, patios and courtyards are a valid strategy not only to maintain the relationship with the greenery, but also to foster relationships between people, both if they are accessible, creating relaxation and leisure spaces where it is easier to meet and relate with other users (a6, a7, a15), and if they are not, placing waiting areas around the open spaces to promote continuous visibility and permeability (a1, a5, a9, a19). Internal courtyards can also be enriched by artworks to improve distraction and restoration (a8), and encourage socialisation (a2), also organising various activities, such as yoga or games for children (a15). This concept can be extended to the common spaces of the hospital by organising various information and awareness-raising activities, distracting and regenerative ones, reading, physical activity, or workshops (a6).

Furnishings constitute another social strategy, enabled through the use of different seating arrangements to maximise usability for various user types, oriented in multiple directions, including tables or low tables (a1, a2, a4, a6, a11, a12, a14, a17, a18, a20), allowing users the autonomy to choose whether to have privacy or social interaction. Tables, chairs and workstations with electrical sockets or for public use (a6) can also allow working while waiting (a2). Designated staff areas also allow for strengthening the relationship between professionals, especially if characterised by furnishings and materials that encourage familiarity and informality (a17, a18, a20).

4.4.2. Interviews Results

In general, the staff considers the presence of a convivial environment to be highly favourable, such as “a fertile intergenerational space,” “useful for both patients and caregivers,” since “talking with others allows them to share and discuss their problems and find comfort,” “distraction, reduce tension,” and “support, especially if they are without a caregiver.” For instance, “it can be helpful to bring together young people with diabetes, with the aim of getting them to know each other and better accept the situation.” Similarly, sharing is very important for pregnant women, as well as for the elderly, who “often suffer from loneliness and need to talk about their illnesses, grandchildren, etc.” However, it is crucial that the waiting room is not overcrowded, mitigating the risk that “one patient’s anxiety can be transmitted to another.” A suggestion proposes implementing a “living room as a waiting space, where people can feel comfortable, looking outside and talking with other people”.

The majority of patients and caregivers emphasise the importance of connecting with others while waiting, “especially if you’re alone,” because “seeing people reduces anxiety,” “keeping others company,” “allowing you to hear about other experiences,” and “taking your mind off what you have to do.” Open spaces are considered optimally suited for this purpose, as they allow individuals to choose whether or not to engage in this interaction and “not necessarily find yourself face-to-face.” Nonetheless, ensuring acoustic comfort is essential, particularly by reducing noise from conversations, “which can be very annoying.” Furthermore, the provision of “a space for privacy” is necessary, contingent upon the specific moment and the person’s mood. A pod is a “cozy space” where one can “seclude and isolate yourself.” It is appreciated by only a few patients and less than half of caregivers, because it is considered “too closed off,” consequently inducing a feeling of being “excluded and isolated.” Some people expressed their willingness to use the pod specifically for breastfeeding.

4.5. Active and Healthy Ageing

4.5.1. Case Studies Results

Health can be promoted by information panels (a15) or screens, as well as by activities, such as courses. The promotion of physical activity should be achieved through dedicated fitness spaces (a6), green courtyards (a6), and active and social spaces in which to encourage movement.

According to the active design approach, stairs should be prominently highlighted, potentially via scenic shaping or strategic central positioning (a4, a6, a14, a15, a20), or even through the colour (a8), materials (a4, a11) or lights (a4, a8), encouraging their use; connecting elements can also include games such as a slide (a14). Conversely, elevators can be relegated to a secondary area, contrasting with the intended centrality of the staircase (a4, a11).

Slow and green mobility should be prioritised (a12), the provision of slow traffic areas (a1), bicycle parking near the entrance (a20), guarded and covered (a3), reducing car parking spaces (a3), charging points for electric vehicles and foldable bicycles (a18), and access to public transport (a3).

The provision of healthy food and accessible, potable, free water should be suitable. To promote healthy behaviours, spaces dedicated to awareness-raising of healthy eating (a6) can be provided, also through an educational kitchen where families can learn to cook healthy meals (a15), or a city market with local products (a4).

4.5.2. Interview Results

The staff like very much the idea of promoting health during waiting; the main goal is defined as enhancing “improve patient/caregiver’s health literacy and make them feel relaxed after waiting”.

All staff expressed interest in the idea of “information points” where patients could “know where to go,” obtain information on the “needs of seniors,” or generally promote healthy lifestyles, in various forms: video seemed the most suitable solution, through a projection, a monitor, or a touchscreen, which could also be interacted with; posters or “something large on the walls”; and pamphlets and brochures, which could also be “picked up and taken home.” Most, however, preferred something shared over individual tablets. Informing could “be useful for distracting, shifting attention, and passing the time.” It is important to provide information “on nutrition, exercise, and social engagement”; on “prevention, such as smoking cessation, or the promotion of specific diets, which, for instance, reduce vascular risk, including by providing recipes”; “education for expectant mothers”; “on gender-sensitive medicine for young people, including by organizing peer training or meetings with the public”; on “other patients’ experiences, through video stories, which can provide reassurance, particularly for young diabetics, to facilitate acceptance of the disease”; “on interventions to be performed or on specific pathologies, such as in-depth analysis, again through videos, of anatomy, since many things are often taken for granted when talking to the patient”; “on how to use the devices”; “on local itineraries that can be taken for patients with mobility difficulties to encourage walks, for instance in the woods, which reduce behavioural disturbances.” “Disseminating this information within a quiet, peaceful, and intimate setting is certainly more beneficial.” It would also be interesting if “they could watch these videos both before and after healthcare services, even at home, to prepare or, conversely, get suggestions for continuing the treatment.” Language should be simple, and explanations should be “with cartoon-like illustrations” or presented “in a fun, entertaining, and interactive way.”

Similarly, interaction and play can engage people and encourage them to exercise. The idea of “going outside and engaging in physical activity” is particularly positive, combining exercise with the opportunity to “see plants and stimulate the senses,” such as “a walk along a tree-lined avenue,” or a “wellness trail,” even with covered areas. This would be ideal, especially for diabetic patients.

We also discussed the opportunity of using passive training equipment, such as seating elements which make people stay in a position in order to activate the muscles and restore their motor function. As an example, we were showing a picture of MyActiveBench by the Italian company (Metalco s.r.l.) [53], a “standing” seat for correct posture and active muscle tone, specifically designed and conceived for “fast recovery” moments. Anyway, passive training equipment has been less successful, as the staff appear concerned about the safety of using the devices independently, imagining elderly patients and/or patients with mobility issues. However, some are very interested in the idea and have proposed using these devices for caregivers, suggesting including an educational message on how to use them. They are considered more suitable for use in a dedicated physical activity area, especially outdoors, in the area adjacent to the waiting room.

Staff consensus regarding the implementation of physical and cognitive self-testing devices remained polarised: an interactive screen/projection aiming at making people do individual tests such as getting up from a chair, walking, lifting weights, bending and stretching, etc. [53] to understand their healthy and active ageing level and a dedicated cognitive training interface to experiment their neuro skills. The staff think self-testing can be very useful for some patients (e.g., diabetics), on the other hand there is concern about doing the tests independently, due to the patient’s interpretation of the results and the worry and anxiety it may generate. Some of the tests considered useful, especially thinking about healthy and active ageing, are represented by “the test of balance, the analysis of movement, the speed of walking, the memory test”.

The majority of patients and caregivers were interested in having access to information about health promotion. They preferred screens/video projections as a means of communication because they were more immediate and engaging, offering brief, “commercial-like” information, since people do not read and share, thus fostering greater relations. They also referred to multiple shared screens, but not individual tablets that would perform the same function as a phone.

Among patients, those who responded that they preferred not to have this information cited concerns and anxiety about the procedure, preferring to distract themselves while waiting and escape from their current state. Some also preferred to receive this information from the doctor, as it was targeted and “safe.”

Those who proposed using paper-based support instead referred to the possibility of taking the information home for further study at a later time.

The majority of patients reported they would not use passive training equipment, while almost the half of caregivers said they would; this result may also be attributed to the age of the interviewees. In general, several patients stated “they want to be comfortable” while waiting and performing physical activity at home or in the gym, or at most outside, even being intimidated by the idea of doing so in front of other people. Some said they “prefer the idea of a walk rather than sitting in a position like this, as they need to release their anxiety.” Many reported that they do not consider these devices suitable for the elderly.

Regarding movement, the majority of patients and caregivers said they would enjoy playing and interacting with various devices “to pass the time.” Some also enjoyed light physical activity. This is certainly considered beneficial for children. Again, reference is made to the embarrassment of doing these activities in front of others, so they would be happy with a dedicated or screened area.

Finally, regarding the idea of being able to perform self-tests (physical and cognitive), more than half of patients and the majority of caregivers are in favour of using these devices. Many are concerned that they lack professional interpretation and may fail to constitute “serious and reliable information,” or data “based on a doctor’s directives.”

4.6. From Space Requirements to Design Guidelines

Starting from these results, Design Guidelines for waiting spaces have been developed and organised through the same five categories, which also represent the drivers of a good design of health-promoting spaces. Design Guidelines are structured according to “Design Strategies”, which aim at proposing general strategies to promote health through the built environment, and “Design Sheets”, which present specific spatial requirements and solutions for the waiting spaces. The eight spatial models are used in a transversal way as a field of application of the Design Strategies, and they are detailed in the Design Sheets where specific spatial requirements are presented for every model, according to its morphology and environmental characteristics.

The objective of Design Strategies is to indicate the actions necessary to promote healthy and conscious lifestyles and behaviours through the built environment and to design waiting spaces able to improve people’s health and well-being conditions and, more specifically, healthy and active ageing.

Strategies considered useful in promoting healthy and active ageing through waiting spaces are the following:

• Create easily accessible places and routes;
• Involve, welcome and encourage sociality;
• Create environments for the person’s psychological comfort and support;
• Promote active waiting time;
• Promote health and activate healthy behaviours.

The objective of the Design Sheets is to provide design indications regarding the waiting areas and the integration of digital devices in these spaces, as an operational tool of concrete support for architects and designers for both the refurbishment and the new construction of waiting spaces.

Design Sheets developed are the following:

1.  

Inclusion systems;

2.  

Nature as restoration;

3.  

Relax spaces and Sensory scenarios;

4.  

Sitting and spaces for relations;

5.  

Sitting and spaces for privacy;

6.  

Children’s area;

7.  

Breastfeeding area;

8.  

Movement and soft physical activity;

9.  

Passive physical activity;

10.

Auto-assessment for prevention of chronic diseases;

11.

Cognitive training;

12.

Knowledge and information on health.

Both Design Strategies and Design Sheets may serve as an opportunity to promote dialogue between different actors involved in the co-design process of a CdC, in supporting the definition of the framework of needs of the organisational system of CdC and developing the briefing phase of the design.

Design Guidelines will be presented in a future publication, presenting an answer to a gap in tools to support professionals in designing healthy-promoting waiting spaces and in the specific context of CdC, which represents a new model of healthcare facility, not yet comprehensively investigated.

4.7. Limits and Future Developments of the Research

This study is subject to some limitations inherent to its design and scope. First, data collection and analysis of this part of the research relied exclusively on qualitative methods. The research was conducted within the Italian context, focusing on case studies situated in Europe, as it was aligned with the Italian context of local primary care health facilities (CdC). This limits the generalizability of the findings to other national or non-European settings. A promising area for future research involves the evaluation of the application of spatial requirements and Design Guidelines to different sociocultural and economic contexts, such as different countries, considering the needs of different communities and the adaptability of this tool. Moreover, the selection of case studies and interviewed participants introduces potential sources of bias, as the process was not randomised but rather purposive, aimed at capturing contexts closely aligned with the objectives of the study. While this approach is appropriate for exploratory research and for gaining in-depth insights, it may not reflect the full diversity of experiences or practices present elsewhere. Interviews report people’s perceptions of different spaces, which can differ a lot, especially regarding sensory features. In this research, the interviews were conducted with both female and male people of different ages (from 18 to 85 years old), but we did not consider specific groups of users, especially regarding disabilities. Interviews conducted with experts supported the consideration of different needs, but they cannot be completely representative for all people and their specific needs, especially in the case of frailty. In the future, Design Guidelines can be evaluated by specific users’ needs groups to enhance the universality and effectiveness of the design of CdC waiting spaces.

These limitations have been considered in the interpretation of the findings, and future work in this broader research project will employ complementary quantitative methods and expanded sampling to enhance the transferability and rigour of the findings.

This study highlights how thoughtfully designed waiting spaces in healthcare facilities can actively support well-being and healthy ageing. As we move forward, such research will become even more relevant: our environments are not just backgrounds; indeed, they shape experiences, emotions, and health outcomes. Future studies in this field will likely explore new ways to blend technology, nature, and inclusivity, making everyday places healthier and more responsive to people’s needs. The emphasis on inclusivity in healthcare design ensures that all individuals feel included and valued, contributing to the creation of welcoming, empowering, and health-promoting environments for all. The continued development of research on health-promoting built environments is crucial for creating spaces that promote active living, inclusivity, and well-being, thereby directly addressing contemporary health challenges and advancing sustainable healthcare models.

5. Conclusions

This contribution presents a portion of a three-year research project dealing with waiting spaces to promote good health for all people in the social community.

We were focusing on the background and field research phases (Figure 1), describing how we used these methods to define spatial requirements for active and healthy waiting spaces in Casa della Comunità, a new model of territorial socio-healthcare facility in Italy.

The Background research focused on the identification of three fundamental groups of theories derived from the scientific literature, which represent the core principles of the research and were used to establish and define a Theoretical Framework as an operative tool to guide the data collection in the subsequent phases. The Theoretical Framework was based on five categories: Efficacy of layout configuration; Environmental Comfort, Control, Familiarity and Affordance; Restoration, Sensory Stimulation; Sociality Promotion; Active and Healthy Ageing.

These categories represent the first result of our study and summarise the main principles for active and healthy waiting spaces in a Casa della Comunità.

A Mixing Method approach based on Technical and perceptive analysis was used to define space requirements for waiting spaces in CdC. The technical analysis was based on the Case-based design/reasoning (CBR) approach to identify innovative design inputs from existing solutions. International case studies of waiting spaces of primary care facilities were selected and analysed by the five categories of the Theoretical Framework. The technical analysis was useful to analyse best practices and identify invariants, which can be translated into input for the project according to these categories.

According to this approach, a result of the technical analysis has been the definition of 8 layout models for waiting spaces, based on the configuration layouts (Table 3) which differ regarding the place of the waiting area (e.g., main hall, corridor, courtyard, etc.), the typology (e.g., separate room or waiting corner), and the relation of the waiting spaces with the outpatient area.

The space requirements (and consequently the Design Guidelines) have been correlated to these spatial models of waiting areas, both in the existing structures and in the new ones, to detail the recommended interventions to get active and health-promoting waiting spaces.

These layout models and the case studies’ invariants were also used as a basis of discussion in the perceptive analysis, conducting interviews with the staff, patients and caregivers by iconic pictures to improve the comprehension of their needs during waiting. By mixing methods it has been possible to clarify people’s preferences about different spatial models, such as waiting in an open space, in a separate room, or directly outside, expressing advantages and disadvantages of each layout; characters of the environment to be used as drivers for designing waiting spaces, such as colours, materials, lights, or furniture; activities people prefer to do during waiting time, such as relaxing, chatting, reading, playing, walking around or performing physical activity; interests people have about health and its promotion, such as improving knowledge in this field, testing their physical and mental level of ageing, etc.

As a result of these two phases (Figure 1), spatial requirements have been summarised according to the five categories, defining different spatial models and environmental characters to be developed in the Design Guidelines.

Design Guidelines have been developed and organised through the same five categories which also represent the drivers of a good design of health-promoting waiting spaces in Casa della Comunità and are structured according to “Design Strategies” and “Design Sheets”. Design Guidelines will be presented in detail in a future publication as an effective tool for professionals in order to design healthy and active environments able to keep all people in good health in a new model of healthcare facility, which actually presents no evidence about optimal design.

Contribution and Originality

Going into depth with the application of the spatial requirements through the five categories, we can identify different contributions and elements of originality of this study.

In the first category (Efficacy of Layout Configuration), we focused on spatial models derived from the analysis of existing healthcare facilities, to be able to differentiate the application of spatial requirements according to the morphology and the environmental characteristics of each model. This system also considers the opportunity of enhancing existing buildings, which represent the majority of healthcare facilities in Italy, and increasing sustainability with the idea of reuse and refurbishment. The spatial models will also form the basis of Design Sheets, operative tools for professionals to design CdC waiting spaces, included in the Design Guidelines.

The second (Environmental Comfort, Control, Familiarity and Affordance) and the third (Restoration, Sensory Stimulation) categories are already thoroughly described in the scientific literature [12,13,14,15,16,17,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37]; our contribution was to confirm and enhance these theories by the analysis of case studies and the application to the specific context of CdC waiting spaces. We also gave strength to these concepts by reporting people’s opinions about the impact of the environment on comfort, restoration, familiarity and well-being.

The fourth category (Sociality Promotion) can be included in the idea of social cohesion, dealing with the general concept of health promotion, which also represents the main originality of this contribution, as expressed in the fifth category (Active and Healthy Ageing).

Therefore, one of the greatest originalities of this paper is represented by the idea of interpreting the concepts of active and healthy ageing [11] through the built environment. While the concept of health-promoting architecture and health-promoting buildings [18,19] are explored in the literature, showing the contribution of the built environment to prevent illnesses and chronic diseases and to support the healing process, limited research has focused on how healthcare buildings can interpret the concept of health promotion in terms of building design [20]. This study has made a contribution to this field and applied these concepts to the specific context of CdC, whose mission is strictly connected to health promotion.

Moreover, we have introduced the concept of “active waiting time” and “widespread health promotion in waiting spaces”, focusing on the design of CdC waiting spaces and enhancing the activation of positive behaviours and healthy lifestyles by performing healthy activities during waiting time, favoured by the built environment. According to these concepts, the idea of transforming passive waiting time into an opportunity of improving knowledge about health [45,46,47,48] and healthy lifestyles [8], performing physical activity [9] and cognitive training [45], and increasing social cohesion was very much appreciated by all users (staff, patients, caregivers).

Therefore, with this project, we have enhanced the capacity of aesthetics of the built environment to influence health, moving away from the pathogenic model of health that is often dominant in the healthcare sector [20].