Understanding Knowledge, Attitudes, and Practices Related to One Health in Recovery Spaces

Abstract

A well-designed physical environment can contribute to increased safety, health and social cohesion. For people seeking recovery from substance use disorder (SUD), the built environment plays an essential role in overall health and wellbeing by shaping emotional regulation and contributing to a sense of belonging. It is thus important to explore biological and psychological responses to the built environment for those seeking recovery support at a Recovery Community Organization (RCO) or Collegiate Recovery Program (CRP). This research explored the knowledge, attitudes, and practices (KAP) of RCO/CRP directors related to the One Health framework. More specifically, this study examined perceptions toward integrating One Health-aligned design (OHAD) approaches into built environments, and the extent to which these approaches were being applied. Additionally, the study investigated implementation barriers and design strategy adaptations throughout facilities to meet the diverse needs of individuals within recovery spaces. Findings from the study contribute to a deeper understanding of recovery staff knowledge of and attitudes toward OHAD approaches, as well as the features their organizations offer and barriers to implementation, informing future studies on interior design and architectural layouts in therapeutic environments.

1. Introduction

Therapeutic design strategies have been utilized in a variety of spaces for decades; however, there is limited research in the context of recovery support services [1]. Recovery Community Organizations (RCOs) and Collegiate Recovery Programs (CRPs) represent organizations offering non-clinical recovery support services in the general community and college environments, respectively [2,3]. However, there is a documented need for policies, research and tools to address environmental factors that affect health, especially in disadvantaged and vulnerable communities [4]. In the current study, we specifically explore the extent to which One Health-aligned design (OHAD) approaches are being applied and what barriers may prevent improvements to recovery spaces.

The One Health framework recognizes the close connection between the health of humans, animals, plants and our shared environment [5]. This interconnectedness extends beyond zoonotic diseases, which is how the One Health concept is frequently framed, to encompass behavioral and mental health conditions [6]. This interconnectedness is evident in built environments that incorporate biophilic spatial design practices and animal-friendly policies that may promote mental and emotional well-being [7,8,9]. Further, these plant-related practices and animal-related policies applied to environments shared with humans are clear examples of One Health. Trauma-Informed design and biophilic design principles both recognize the role of the environment in promoting positive emotional well-being [10,11]. Emerging evidence highlights the natural and built environment as a critical, yet underutilized, determinant in supporting long-term recovery from substance use disorder (SUD). Specifically, environments where autonomy is supported or encouraged may help to reinforce identity reconstruction and promote personal long-term recovery [12]. Attention to the physical space and autonomy therein can be especially useful in providing trauma-informed care, an important consideration in recovery spaces, as individuals in recovery may have been disproportionately exposed to trauma [13,14,15].

Although the built environment is recognized as a social determinant of health (SDoH), limited research directly applies the One Health framework in the context of RCOs and CRPs [16]. Historically, healthcare settings have been the primary focus for therapeutic design research, while limited research has been conducted in nonclinical settings [17,18,19,20]. This focus primarily on healthcare has left a gap in understanding how environmental designs can offer additional support to recovery-oriented spaces. Recovery support services designs have the potential to promote safety, health, and social cohesion [21], but more research is needed to explore the knowledge, attitudes, and practices (KAP) of RCO and CRP directors in relation to One Health.

1.1. Community-Based Recovery Support Services

RCOs are nonprofit organizations offering non-clinical recovery support services to individuals in recovery from a variety of SUDs [22]. Services include recovery coaching, mutual help groups, social activities, skill building workshops, and linkages to treatment [23]. RCOs offer built spaces where individuals receive recovery services, with emerging evidence highlighting benefits related to recovery capital and enhanced well-being [24,25]. Research suggests RCOs serve high-needs populations [26] who could benefit from an understanding of the elements comprising the physical space that have the potential to shape mental health outcomes [27]. Though some studies have examined built spaces in clinical settings [28], less attention has been paid to non-clinical recovery settings.

Similarly, limited attention has been given to the built environment in CRPs. Much like RCOs, CRPs offer recovery support services but do so on college campuses with the goal of supporting college students in recovery [3]. CRPs have grown exponentially in recent years, offering services such as peer support, academic assistance, social activities, and a recovery-supportive community for college students [29]. Despite this recent growth, many college campuses operate without CRPs, and students on campuses with CRPs are often not aware of their existence [30]. Moreover, budgets for CRPs vary widely both in terms of magnitude and prioritized spending categories [29], making it essential to explore how extant spaces can be enhanced to provide optimal recovery services at a low cost.

Studies have shown both RCOs and CRPs are positively associated with clients’ recovery capital and quality of life [3,24]. Despite these demonstrated benefits, previous research has focused largely on staff and client characteristics, organizational features, and benefits for clients [2,3,26,29], without considering the built environment and its ability to shape staff and client well-being. This gap is especially consequential, given that people who use drugs and who are in recovery are especially vulnerable to environmental stressors [31]. A One Health perspective offers a promising way to address this gap by highlighting how the built environment of recovery support services exists within a broader ecological context and contributes to the health and well-being of all involved.

1.2. One Health and the Built Environment

The One Health framework is commonly described as a collaborative and transdisciplinary approach with goals of achieving optimal health outcomes by recognizing the connection between animals, humans, plants, and a shared environment [5]. One Health is a global, interdisciplinary approach that promotes communication and collaboration among human, animal, and environmental health sectors [32]. Principles of the One Health framework emphasize interconnectedness when addressing components of the built environment, which includes buildings and infrastructure [33]. The built environment also shapes interactions with the natural environment and affects health and general wellbeing [7,34,35].

Examples of OHAD implemented in the health sector include natural lighting, greenery, healing gardens, and access to nature [36,37,38,39,40,41,42,43]. In architecture, the use of natural lighting is identified as an essential element [44]. Additionally, patients in hospital environments reported greater trust in their caregivers when natural light was present [45]. This emphasizes how incorporating environmental design significantly impacts psychological outcomes, increasing the probability of better health outcomes. Using the One Health framework, health professionals have a chance to reframe and further advance and improve health outcomes for humans and animals globally [32]. Such design strategies thus have the potential to enhance healing and well-being in spaces built for therapeutic purposes.

Despite these examples of evidenced practices and positive outcomes related to OHAD approaches, little research has focused specifically on recovery organizations [46] with most of these works having been instead inclusive of clinical settings and providers. These design strategies, which can promote healing and well-being [19,21], have thus been underexplored in non-clinical recovery settings, especially regarding understanding service provider perspectives, despite people in recovery being especially sensitive to environmental stressors [31]. To this end, the current study aimed to describe knowledge, attitudes, and practices related to OHAD approaches among directors of community recovery programs in the state of Georgia. Using a mixed-methods survey approach, we captured the extent to which respondents were knowledgeable about the One Health framework. In addition, we explored the extent to which directors have agency to alter client spaces, barriers to implementation of spatial design improvements, and the extent to which clients can provide feedback about spatial features. These findings are intended to highlight the potential for both research and practice incorporating the One Health framework to design a wider variety of spaces beyond clinical settings. Further, these findings highlight the barriers that prevent directors from modifying environments even when knowledgeable and interested in One Health-informed approaches to client spaces.

2. Data and Methods

2.1. Participants

Directors were selected due to their direct experience with recovery support services and insight into daily operations of recovery spaces. We obtained a sampling frame of RCOs from the statewide RCO in Georgia, as well as a list of CRPs from the Association of Recovery in Higher Education. The sampling frame contained 47 RCOs and 3 CRPs. To further contextualize any potential differences between recovery directors in Georgia compared to other regions, we include demographic information about respondents and the spaces themselves in Table 1.

Table 1. Organization Demographics.

Variable	M/%	SD	Min.	Max.
Organization Type
Recovery Community Organizations (RCO)	90.00%	0.31	0	1
Collegiate Recovery Programs (CRP)	10.00%	0.31	0	1
Program length
Time in operation (years)	3.70	1.56	1	6
Funding Sources
Federal	33.33%	0.48	0	1
State	80.00%	0.41	0	1
County	3.33%	0.18	0	1
Restricted	30.00%	0.47	0	1
Unrestricted	63.33%	0.49	0	1
Private	53.33%	0.51	0	1
Settlement	3.33%	0.18	0	1
Director Age 1
25 to 34	11.11%	0.32	0	1
35 to 44	37.04%	0.49	0	1
45 to 54	37.04%	0.49	0	1
55 to 64	14.81%	0.36	0	1
Director Gender 1
Woman	66.67%	0.48	0	1
Man	29.63%	0.47	0	1
Non-binary/other	3.70%	0.19	0	1
Director Race and Ethnicity
White	70.00%	0.47	0	1
Black	13.33%	0.35	0	1
AIAN	10.00%	0.31	0	1
MENA	3.33%	0.18	0	1
Mixed-race	3.33%	0.18	0	1
Mexican/Mexican American	3.33%	0.18	0	1

Notes: ¹ Three directors did not provide information for these variables.

2.2. Survey Design

This survey was conducted as part of a larger survey of 49 total questions. For the purposes of this paper, only questions related to One Health were targeted to better understand KAP for RCO/CRPs specific to this topic, including an overarching investigation into knowledge and attitudes with a more focused look at the practices currently implemented regarding One Health-align design. Items were developed by a team of interdisciplinary researchers with several areas of expertise including One Health and interior design. This survey was intended to serve as an exploratory survey of recovery organization directors in the state of Georgia with the purpose of being foundational for future work among larger, more generalizable, sampling frames. To date, no previous research has explicitly explored One Health integration into spatial design in recovery organizations, making this study novel and exploratory in nature.

The survey inquired about demographics such as organization names, description categories of organizations, county where organizations were located, director roles, years in the role, years of experience, years organizations had been in operation, funding, and other relevant items. After respondents were provided brief definitions, including the definition of One Health, directors were asked the extent of their knowledge, attitudes and practices related to this topic. In addition, a series of questions gauged the extent to which respondents believe associated factors contribute to client recovery. A series of items followed regarding organization priorities, desired design features for improving accessibility, autonomy and ability to make spatial changes, barriers to making desired changes, and detailed information about client-spaces. Lastly, we collected director demographic information regarding age, gender, identity as being in recovery from an addiction, and race/ethnicity. See Appendix A for all items in the survey.

2.3. Analytic Measures

2.3.1. Organization Demographics

To better differentiate contexts across RCOs and CRPs, we included several demographic questions about the organizations. Demographic characteristics about recovery organizations were collected in the survey, including the name of the organization, categorization as a RCO (90%) or CRP (10%), and county location.

2.3.2. One Health Knowledge

After being presented with a brief definition of One Health (“The health of people, animals, and the environment are all connected. It means that to keep humans healthy, we also need to care for the health of animals and the world we share, like our water, air, and soil.”), respondents were asked to report their level of knowledge about One Health ranging from Strongly Disagree (1) to Strongly Agree (5). Worth noting, our intention with this item was not to assess the extent to which respondents were familiar with the term “One Health” nor its specific definition, but more so to capture the extent to which these general ideas and principles are familiar regardless of label.

2.3.3. One Health Attitudes

To capture the extent to which respondents perceive OHAD approaches as important for recovery, we included a single Likert-scale item ranging from Strongly Disagree (1) to Strongly Agree (5): “I believe designing recovery spaces with One Health in mind can benefit both people and the planet.”

2.3.4. One Health Practices

One Health practice was represented in our KAP survey by the extent to which directors were able to practice this type of design in their organizational spaces. Further, to have greater specificity by physical feature, we asked respondents to report from 1 (none at all) to 5 (a great deal) the amount of decision-making freedom they have regarding the following: furniture selection and arrangement, paint colors, décor, lighting modifications, interior renovation/remodeling, and outdoor space design/use. Cronbach’s alpha indicates high inter-item reliability for these items (0.91). We also included an open-ended question asking what impedes the ability to make changes in any of these aforementioned areas.

2.4. Thematic Coding

Thematic coding using grounded theory was conducted individually by three researchers and validated collectively to develop question-based themes across all qualitative survey questions. Coders grouped responses into themes that varied diversely from question to question. Five open-ended questions were asked among RCO/CRP directors:

• What (if anything) limits your ability to make changes in any of the areas listed in the prior question?
• List and describe the rooms in your space for your clients.
• How does your organization currently address environmental sustainability in its building design or maintenance?
• Do clients have a way to provide feedback about the design or feel of the recovery environment? If yes, please describe below.
• If you could redesign one aspect of the recovery center to better support healing, what would it be?

3. Results

3.1. Descriptive Statistics

We targeted directors from these organizations due to their experience with recovery support services and insight into daily operations of recovery spaces. Following Institutional Review Board (IRB) approval, we emailed each RCO and CRP in the state of Georgia using a Qualtrics survey (N = 50). Thirty directors from the fifty total across the state of Georgia, United States, including RCOs (n = 27) and CRPs (n = 3) from the sampling frame participated in the survey, comprising 60% of total organizations. To obtain additional surveys from organizations that did not respond, we subsequently followed up with additional emails and a phone call. All survey respondents were compensated with a $50 gift card for their time. Our sample was inclusive of both urban (60%) and rural (40%) sites across the state of Georgia (see Table 1). On average, programs had been in operation for 3.7 years (SD = 1.56 years). Funding sources for operations included any combination of support from state (80%), federal (33.33%), county (3.33%), restricted (30%), unrestricted (63.33%), or private (53.33%) sources. Specifically, one organization reported having received funding from the Opioid Abatement Settlement Grant (3.33%). Directors in the sample were predominantly between the ages of 35 to 54 (74.08%), women (66.67%), and white (70%). In addition to the basic demographic statistics contained in Table 1, respondents also provided supplemental information about their organizations and spaces. As noted in the table, several items did not have full response rates from the sample. As we are only presenting descriptive statistics, however, we retain all respondents possible for each item.

Table 2 includes focal descriptive measures related to the One Health framework knowledge, perceived benefits of OHAD approaches for recovery, and director autonomy to alter client recovery spaces as they see fit. Overall, directors reported a moderate knowledge of One Health principles (M = 3.40, SD = 1.10).

Table 2. One Health.

Variable	M	SD	Min.	Max.
Knowledge: One Health framework	3.40	1.10	1	5
Attitude: Perceived benefit One Health spaces	4.48	0.83	2	5
Practice: Decision autonomy with furniture 2	4.07	1.21	2	5
Practice: Decision autonomy with paint 2	3.71	1.53	1	5
Practice: Decision autonomy with décor 2	4.21	1.20	2	5
Practice: Decision autonomy with lighting 2	3.75	1.53	1	5
Practice: Decision autonomy with interior renovation 2	3.25	1.43	1	5
Practice: Decision autonomy with outdoor space 3	3.42	1.72	1	5

Note: ² Missing information for 2 respondents. ³ Missing information for 4 respondents.

Regarding attitudes, directors displayed strong agreement with the idea that designing recovery spaces with One Health in mind can benefit both people and the planet (M = 4.48, SD = 0.83). Related, the extent to which directors could alter client spaces varied considerably. On average, directors most often could make decisions regarding furniture (M = 4.07, SD = 1.21) and decor (M = 4.21, SD = 1.20), other spatial decisions were endorsed to a lesser extent with interior renovation (M = 3.25, SD = 1.43) and outdoor spaces (M = 3.42, SD = 1.72) having the lowest averages (Table 2). In the qualitative responses, directors provided more nuance in terms of their ability to make changes to the space, known barriers to spatial changes, and desired modifications.

When asked to describe the RCO/CRPs spaces and rooms for clients, qualitative responses revealed a considerable variation, resulting in 25 distinct codes that reflected the diversity of RCOs physical environments. Responses differed across organizations in both function and availability of spaces. The most prevalent theme, identified at half of the organizations (n = 15), was the presence of a meeting room. These spaces commonly were described as flexible, multipurpose environments used for group programming and client services, often including movable tables, presentation technology, and open seating arrangements. For example, one respondent described, “An open and inviting meeting room with plenty of accessible seating and tables. It seats over fifty people.” While another noted, “This large, flexible space allows us to host peer support meetings; recovery celebrations; workshops; training sessions; and community forums.”

Additional commonly reported spaces included media rooms and kitchens, which supported both programming and client comfort. One RCO described their room as a “media center with computers and broadband access.” Another referenced their kitchen as, “Kitchen for cooking self care; kitchen table for shared meals; and team building.” One respondent also noted the presence of a theater room, describing it as a “theatre room with 100-inch tv and surround sound with 10 reclining theater seats.” Others identified specialized spaces such as a gym and a therapy office.

Library or resource-lending spaces also emerged as a theme, encompassing areas where clients could access educational materials, borrow resources, or access a clothes closet. These were often described as, “Resource room for applications; GED training,” and “library stocked with multiple recovery literature from numerous pathways; clothing closet both men and women.” Office space was also frequently mentioned, typically referring to private or semi-private spaces. Basic facilities such as bathrooms and laundry areas were noted as important with one respondent saying, “Our laundry space removes a significant barrier for individuals rebuilding their lives.”

A small number of RCOs reported dedicated spaces for children to play, with one RCO specifically identifying a nursery, which was coded separately as a design-specific space due to its targeted function. Notably, the level of details provided in responses varied considerably. While some RCOs offered general descriptions of available spaces, others included detailed specifications such as room dimensions and layout. This variation further reflects differences in available space, funding, and overall organizational resources.

3.2. Sustainable Practices

One specific example of the application of One Health principles was an open-ended question related to sustainability. Based on qualitative responses, sustainability varied between organizations. The focus on sustainability gravitated towards unfamiliarity and general building maintenance. The most common response was an absence of practices, with nine RCOs stating they were “not doing” any sustainability practices. Others expressed uncertainty about if practices were in place or simply ‘unknown’. Further, sustainability was noted by a few respondents primarily as lower power consumption such as turning off lights and maintaining stable temperatures (See Table 3). Other RCOs described sustainability as regular building maintenance, such as changing filters. Less frequently mentioned was donating items or receiving donations, water filtration, and solar energy. Sustainability among RCOs was limited in scope and familiarity with sustainable practices, and some cited space ownership as a barrier.

Table 3. Thematic Analysis Coding Results.

Survey Question	RCO/CRP Responses (n = 30) 1	Thematic Code Count 2
What (if anything) limits your ability to make changes in any of the areas listed in the prior question?	25
Approval needed		5
Fiscal resources (no money)		11
Nothing limiting ability		3
Space capacity (not enough space)		3
Space not owned (could include shared space, renting, government)		11
Staff Capacity		1
List and describe the rooms in your space for your clients?	25
Accessibility features (ADA compliance, compliant bathrooms)		2
Art area (music, drawing, painting)		4
Bathroom (all types)		5
Cafe		1
Classroom (wheeled tables and chairs, large space setup like a class)		1
Conference room (table space, whiteboards for open discussions and planning)		2
Entry area (welcoming space, waiting area, check-in)		3
Game room (video games, TVs, arcade games)		3
Garden/Greenhouse (outside gardens, greenhouse for outside plants)		2
Gym		1
Kids area (anything related to kid/family)		4
Kitchen (any culinary space)		10
Laundry (washer/dryer)		5
Library/Resource Lending (clothing closet, books, things to borrow, games, tables for workshops)		7
Lounge space (TV, fellowship room, lounge, comfortable seating/chairs, soft seating, moveable table/chairs, access to snacks)		7
Media room (computers, recording studio)		10
Meeting room (rolling tables, tv’s for presentations, large open seating space)		15
Nursery (specific for nursery/babies)		1
Office space (flexible lighting, exterior windows, individual offices, computer access)		6
Porch/Outdoor area (large outdoor space,		3
Private room		1
Relaxation room (mediation space, calming, reflection space)		2
Theater room (large TV and reclining seats)		1
Therapy office		1
Unknown/Don’t Know		3
How does your organization currently address environmental sustainability in its building design or maintenance?	23
Donation		1
Exploring efforts		2
Low power consumption (maintained temp)		4
No environmental sustainability practice		9
Plants		2
Recycling		2
Regular maintenance (changing filters)		2
Reuseable		1
Solar		1
Space rented		2
Unknown/Don’t Know		5
Water quality (water filters)		1
Do clients have a way to provide feedback about the design or feel of the recovery environment?	24
Peer review board		1
No client feedback mechanism		8
Open door policy		3
Suggestion/comment box		3
Survey		5
Verbal feedback		3
Yes (feedback available; peer review board)		10
If you could redesign one aspect of the recovery center to better support healing, what would it be?	25
Accessibility		1
Bigger facility		2
Change or more color (paint, furniture)		1
Fixtures		1
Food areas		1
Change of furniture		2
Incorporate animals		2
Lighting options (lighting control, natural light)		5
More green space		4
More nature		1
More open space indoors (high ceilings)		3
New facility altogether		2
Outside area		2
Plants		1
Pool		1
Regulation/Relaxation space (meditation, quiet room, private, psychological/emotional safety)		4
Room redesign		3
Separate rooms		1
Sound options (sound machine, music)		1
Temperature control		1
Unknown/Don’t Know		1
Updated structure		1
Windows		1

Notes: ¹ A total of thirty responses were received; non-response or blank responses were not counted in the qualitative count. ² Thematic codes reflect multiple aspects of participant responses rather than a single site or center.

3.3. Barriers to Implementation

Open-ended responses to barriers to implementation appeared to be consistent with the financial constraints faced by RCO/CRPs. A lack of financial resources and non-ownership of space emerged as the primary response themes for this question. These findings align with well-known financial barriers and constraints of operating a nonprofit 501(c)(3) organization, with respondents frequently citing limited funding as a barrier. Non-ownership of space typically referred to a shared space, government-owned, or a rental space, which restricted the ability for organizations to make physical modifications. As one respondent noted, “The building is owned by another entity and it is a historic building so we are limited in what can be done with the space,” while another stated, “We rent the building; so remodeling is not available to us.”

In addition to spatial limitations, the need for external approvals also arose as a theme with one respondent explaining, “My role does not include making those decisions.” Space capacity was identified by three of the RCOs as an additional constraint, particularly in terms of insufficient physical space to support programming needs. Although only one RCO explicitly identified staff capacity as a barrier, it is possible that this represents a broader, underreported challenge across RCOs.

3.4. Redesign Aspirations

When asked about one aspect desired for redesign to their organization to support healing, diverse responses were captured. The breadth and depth of responses ranged from environmental, structural, and comfort-related changes. The most frequent response was related to lighting (see Table 3), which ranged from increased lighting control to more windows to enhance natural lighting. Some directors emphasized natural spaces such as directly stating a need for more “green space”, while others indirectly referenced plants and nature. Organizations focused on a desire for relaxation spaces including meditation, quiet rooms, or private spaces to support clients. Structurally, some directors mentioned a need for more physical space that could allow for inclusion of more indoor openness, redesigning room layouts, and expanding or separating rooms to better accommodate client needs. For example, one director stated: “I wish we had windows and a separate room instead of one big open concept lounge.”

Other directors indicated their desire for larger or entirely new facilities, confirming previously mentioned findings of financial and physical space barriers. Additionally, other ideas included changes to furniture, outdoor areas, adding a food area, improved accessibility, incorporating animals, changing fixtures, adding a pool, and better sound or temperature controls. These findings highlight a strong interest in enhancing physical and sensory spaces for RCOs/CRPs despite the barriers and constraints mentioned throughout the survey.

3.5. Client Feedback

Further, our survey sought to understand mechanisms for client feedback. Most organizations had implemented a feedback mechanism, with ten organizations stating they had feedback in place utilizing written and/or verbal feedback, while eight noted they did not have any feedback pathway at their organization. Most RCO/CRPs collected feedback through surveys, described as, “We provide survey feedback on every room,” and, “We have an end of year survey…” Verbal feedback, suggestion boxes, and open-door policies were mentioned but less frequently. Verbal feedback included examples such as “they can speak with staff but nothing posted.” This could introduce constraints as clients would have to feel comfortable seeking out staff to provide feedback.

4. Discussion

The current study provides an analysis of RCO/CRP director perceptions of OHAD approaches in non-clinical recovery support settings. Though the literature has highlighted the link between environmental design and health outcomes, the One Health framework has largely been applied to urban and clinical settings [47,48,49,50]. However, it can be inferred that approaches such as biophilic could also be applied to other settings where healing is prioritized. Quantitative results show that although attitudes about One Health were overwhelmingly positive, knowledge was comparatively limited, and it was difficult for directors to implement design decisions due to autonomy constraints. Qualitative findings added context by describing issues related to funding scarcity and non-ownership of space. Directors also demonstrated variability in the use of space and emphasized redesign priorities related to lighting, green space, plants, relaxation rooms, and outdoor areas.

Overall, the research highlights how RCOs and CRPs represent non-clinical therapeutic spaces wherein One Health principles can be applied to potentially improve health outcomes for staff and clients. These organizations represent spaces in the heart of the community where directors can shape the wellbeing of clients in recovery [2,3,22,26,29]; the built environment offers an additional way to do so [7,34,35], rendering it crucial to better understand OHAD. Community settings where recovery takes place, and the directors who make decisions therein, are especially critical spaces, given that much of the research on therapeutic and healing design has focused on clinical contexts [17,18,19,20].

DeVerteuil et al. [28] explored how therapeutic landscapes in substance use treatment influence clients, but our study provides the first to: (a) integrate OHAD approaches into substance use and recovery contexts, and (b) explore perceptions of concepts of place and space in non-clinical settings where, unlike clinical settings, staff and directors have more autonomy over the environment. The One Health framework has the potential to provide an overarching approach to trauma-informed care through spatial design for people in recovery as directors of these spaces embraced the utility of this type of design. Moreover, one of the most significant findings from the quantitative survey was the contrast between directors’ modest knowledge of OHAD approaches and their strong support for their implementation. Such results show that although directors may understand the benefits of One Health in relation to the crucial link between people, animals, and the environment [50], the leaders were largely unaware of the One Health concept. The gap was especially notable, with mean agreement regarding the design’s benefits exceeding self-reported knowledge of the approach by over a point on a five-point scale (M = 4.48 against M = 3.40). In the qualitative responses, directors discussed components of OHAD approaches by mentioning natural light, green space, meditation rooms, and outdoor areas, all of which connect to the natural environment [51,52,53]. Persuasion about the benefits of this type of design may thus be less useful than training on what it is and how to implement it.

Though directors largely agreed on the benefits of OHAD, they were often constrained in terms of what they could and could not do to their organization’s space. In this study, practice is assumed to be operationalized by the level of Director autonomy. Directors had more autonomy regarding decisions about furniture and décor but less when it came to paint, lighting, outdoor spaces, and interior renovation. In other words, staff in these community-based organizations have less control over aspects of the environment that directly affect well-being [18,54,55,56,57]. These constraints were often related to funding shortages and external approval requirements rather than director preferences as were confirmed by the qualitative results. Many organizations reported operating in rented spaces, facing financial constraints, having limited autonomy over design decisions, or requiring external approval to modify their environments. These challenges reflect broader disparities in the built environment experienced by vulnerable communities [4], as well as the scarcity mindset often associated with non-profit organizations [58], demonstrating how these issues extend to recovery support spaces. The construction or renovation of RCO/CRPs should prioritize opportunities for user control over their environments and meaningful connections between indoor and outdoor spaces. In situations where ownership or financial constraints prevent such autonomy, the features directors can control, e.g., furniture and decor, can feasibly be changed to promote healing [51,52,53].

The qualitative findings provided insight into how OHAD approaches were or were not incorporated into the built environment of recovery support services. Meeting rooms were frequently mentioned as multipurpose spaces where people could gather for recovery services, demonstrating the supportive nature of these community-based organizations [2,26]. The most mentioned redesign priorities that aligned with One Health principles [59] were lighting improvements, green space, and relaxation rooms, while two directors aspired to incorporate more animals in their recovery spaces. These three priorities have empirical support regarding positive health outcomes in clinical settings [34,40,45,56], meaning directors identified priorities consistent with the literature without having much knowledge of One Health specifically. Environmental sustainability practices were infrequently mentioned by directors, meaning the ecosystem component of One Health [47,59]) may not be an important consideration for directors of RCOs and CRPs.

5. Limitations

This study had several limitations. First, these data only contained information from organizations in the state of Georgia and therefore may not be representative of recovery organizations in other states/regions. One goal of this work was to develop a baseline of the extent to which One Health principles and spatial design are being incorporated in recovery spaces in Georgia, with the goal being to expand this work further regionally and/or nationally in scope. Second, these data were from the perspective of community organization directors, which may differ from the client perceptions of spaces. Future work should explore client perceptions of space to further explore the extent to which spatial design features and One Health integration are impactful for recovery. Third, the current study specifically focused on One Health knowledge, attitudes, and practices but future work could certainly expand this vantage point by also evaluating the extent to which organizations are incorporating more specific design features. For example, future research could explore nature in spatial design (i.e., biophilic design) and accessibility of spaces (i.e., trauma-informed design; intentional design of spaces) to further expand the literature related to spatial design in recovery spaces. Similarly, future studies could provide a direct assessment of the physical characteristics of recovery spaces, including size, function, and spatial configuration, to further explore links between One Health and healing environments. Fourth, this survey was not pilot tested nor were the items formally assessed for content validity. Last, many of the qualitative responses were short or lacked extensive details. Relatedly, given the small scope of this initial survey, items capturing directors’ knowledge toward and attitudes of One Health relied on sole item measures. Future work may want to employ structured, in-person interviews to obtain more detailed director feedback and insight.

6. Conclusions

This study aimed to better understand OHAD and director perceptions in community-based, non-clinical recovery settings. Specifically, directors were surveyed about their One Health knowledge, perceptions of value, autonomy in design decision making, barriers to implementation, and design priorities. Directors had moderate knowledge of this design approach but agreed that such approaches could be beneficial. They had the most control over furniture and decor and the least control over interior renovations and outdoor space. Lack of ownership of space and limited funding were mentioned as major barriers to design implementation. Lighting, green space, and relaxation rooms were listed as top design priorities, though directors had little autonomy to make changes in these areas.

By embedding One Health elements such as biophilic design into the spatial fabric of community-based recovery organizations, directors have the opportunity to cultivate environments that actively restore the interconnected well-being of people, communities, and local services (see [7,34,35]). RCO Directors are constrained in their ability to modify community recovery spaces, a key finding that highlights barriers to modifying environments in ways that may increase therapeutic benefits to clients. A lack of access to outdoor spaces and general control of organizational spaces was also reported by several directors as a barrier. Adding or designing dedicated outdoor therapeutic nature spaces could be beneficial for many recovery organizations for serving clients in their recovery process which directly aligns with the focus of One Health. Selecting multi-functional furniture and decor that offer features such as folding, portability and durability is a realistic priority that organizations can use to optimize their spaces and serve diverse functions while adding autonomy over the space. In addition, the current work illustrates the potential for elements of One Health to be incorporated into a variety of community-based organizations, such as but not limited to RCOs and CRPs.