Barriers and enablers to policy action: Gambling Related Harm in NSW

(Featured image credit : Rawpixel)

By Andrew Reid and Dr Amy Bestman

In March this year, poker machines across Australia were switched off due to COVID-19. This was the first time since 1956 that poker machines were not operating in this country. However, as restrictions around pub and club closures have eased, experts have raised concerns about the harm that may occur.

Australians spend more on gambling per person, than any other nation in the world. With losses of $12 billion per year (or $1500 per person), venue closures have resulted in significant savings. However, in New South Wales (NSW), $91.6 million was lost through poker machines, one week after venues had reopened in June. This was a 31% increase in poker machine losses in hotels from the previous year and more than the average weekly income for NSW Clubs compared to the same time last year.

While we are waiting on data to see the full impact of this on the NSW population, consistent with what we know about poker machine use in Australia,  these losses are highly likely to come from those from low socio-economic areas. This is particularly the case for groups more likely to experience gambling-related harm, including ethnic groups, youth, those with substance abuse or misuse issues, and those with poor mental health, who are living or working in the Fairfield Local Government Area (LGA). 2018-2019 figures revealed Fairfield LGA had the highest per capita gaming machine profits for clubs and hotels combined in Greater Sydney ($2,447)(see Figure 1).


Figure 1: LGAs in Greater Sydney with highest per capita gaming machine net profits in clubs and hotels ($), 2018-19

Source: Liquor and Gaming NSW, note 16; and ABS.STAT, Estimated Resident Population by LGA (ASGS 2018)

One legitimate strategy to address this issue is to adopt and implement a public health  approach. In the case of NSW, this requires some action for policy change.

Barriers

Gambling tax revenue

In 2018-19, the NSW government received close to $2.5 billion in tax revenue from gambling. This was an increase of $105 million from the previous year. Recent NSW Treasury figures indicate over the next 10 years, $85 billion will be lost on NSW poker machines, and the government will collect $22.5 billion in gaming machine tax. In 2017-18, the gambling tax made up some 8% of the overall state revenue. Despite the significant community harm from poker machines, the increasing reliance on this lucrative revenue stream has made it difficult for policy change.

Industry pressure

Domestic experience up to now shows the gambling industry has an increasing amount of power to prevent, reverse, or influence policy change if it does not serve their interests. This is enacted in many forms, including intense lobbying and providing consistent and substantial financial donations to policymakers. Between 1998 to 2018, available data reveals the gambling industry donated a total of $7.7 million to political parties (see figure 2). As a result, despite some sweeping reforms in 2018, NSW’s gambling policy remains oriented towards the industry-friendly concept of ‘responsible gambling’ instead of addressing public health determinants such as the addictive nature of these machines, industry marketing and promotion practices.

Figure 2: Total declared donations for the Tasmanian and NSW branches of the AHA, ClubsNSW, Crown Resorts, and Federal Group

Source:  Australian Electoral Commission, 2019

Enablers

Common goal

The NSW government and others share a commitment to reducing gambling-related harm, including breaking the disadvantage cycle. The disadvantage cycle refers to the transmission of disadvantage from one generation to the next or situations where one source of disadvantage causes another, compounding the effect. Evidence shows having a common goal around the action for change makes it politically palatable and increases the likelihood of policy change. This is because it removes competition, creates, and strengthens unity among stakeholders. In this environment, it is arguably easier to amend existing government policy. What is now needed is to reduce the number of available poker machines through strengthening existing legislation introduced in NSW, by increasing limits on the number of machines in specific geographic areas. Current measures mean that areas such as Fairfield LGA with high levels of poker machines and gambling-related harm, are not permitted to have any further Poker machines licences. Extending these measures to additional high-density NSW areas will be important in reducing community harms.

Engaging and building partnerships

Research studies have found that engaging and building relationships with a wide range of stakeholders facilitates policy change. As a result of this process, stakeholders gain a better understanding of the issue, are more readily able to identify policy options, tailor existing measures according to the current political environment, and assess the chances of policy success there and then. Examples of this occurring in NSW can be seen in Fairfield with the Fairfield Community Action Group on Gambling Harm, and in Western Sydney with the Western Sydney Community Forum. However, more engagement and relationship building needs to occur for increased support for policy change. 

Well thought-out solutions

Research indicates that policy change is more likely to occur when potential solutions are clearly costed and show how they will reduce gambling harm. For reducing gambling harm, coordinated, evidence-based, and evaluated multifaceted approaches that recognise multiple contributing factors, are needed. These include issues such as gambling products, accessibility, nature and conduct of venues, environmental and social aspects. Moreover, acknowledgement is needed that gambling-related harm is not an issue of personal responsibility, but a shared one among individuals, community groups, businesses, and governments at all levels. 

Conclusion

Gambling harm is a global issue. However, “Australia is a world leader in gambling losses”. The majority of those losses come from poker machines. NSW has around half of the country’s poker machines, and its clubs and pubs generate over $6 billion a year through individual’s poker machine losses. Despite COVID-19, not much has changed in NSW. Gambling profits and losses continue to rise. More research is needed to examine the full impact of this on the NSW population. However, existing evidence suggests already vulnerable groups from low socio-economic areas are likely to be most affected. To effectively reduce gambling harm in NSW, a public health approach to problem gambling is necessary. Policies and solutions must go beyond  ‘personal responsibility’. At present, policy change barriers include increasing reliance on gambling tax for state revenue and the gambling industry’s growing influence in the policy process. People’s well-being must always come before profits. To increase the likelihood of policy change, stakeholders must continue to work towards a common goal; engage further to build an extensive network for support; and implement well-thought-out solutions.  

Authors’ information

Andrew Reid is a Research Officer at The Centre for Health Equity Training Research and Evaluation (CHETRE).

Dr Amy Bestman is a Research Fellow, in the Injury Division at The George Institute for Global Health Australia.

Alcohol consumption during COVID-19 significantly impacts vulnerable communities: The case study of Miller

by Andrew Reid

A national YouGov poll commissioned by The Foundation for Alcohol Research and Education (FARE) found one in five (20 percent) Australian households buying more alcohol than usual since the COVID-19 outbreak in Australia. Within these households, 70 percent are drinking more, with 34 percent drinking now daily. This is  likely to be a result of job loss, financial stress, family pressures, social isolation, declining mental health and a loss of structure and routine during the pandemic.

While we are waiting on further research and study results to uncover the full extent of the impact caused by alcohol consumption during COVID-19, it is highly likely those Australians who are already poor, unemployed or underemployed, with high levels of existing debt, suffering homelessness, or facing existing difficulties with access to health and social services, will be most affected. This is supported by available evidence that suggests disadvantaged communities have more significant alcohol-attributable harms compared with individuals from advantaged areas for given levels of alcohol consumption, even after accounting for different drinking patterns, obesity, and smoking status at the individual level.

Community profile of Miller

Miller is a suburb within the Liverpool Local Government Area (LGA). In 2016, Miller had a population of 3,237 people, an unemployment rate of 15.5% more than double that of NSW (6.3%), 3.9% of the population were Aboriginal and/or Torres Strait Islander, 43.4% of Miller residents were in social housing, many with multiple and complex needs. Miller remains one of the most socio-economically disadvantaged suburbs in the state with the SEIFA Index of Relative Social Disadvantage (IRSD) score of 701 in 2016.

Alcohol Related Assault

Figure 1: Incidents of Alcohol Related Assault, July 2018 – June 2020, Miller

(Source: New South Wales Bureau of Crime and Research Statistics (BOCSAR), 2020)

The latest figures for incidents of alcohol-related assault from New South Wales (NSW) Bureau of Crime and Research Statistics (BOCSAR) show incidents of alcohol-related assault in Miller in May 2020 increased to 58.5 compared to 13 for NSW (see Figure 1). 

A breakdown of the data reveals incidents of alcohol-related assault (non-domestic assault) in Miller in May 2020 also increased to 58.5 compared to 4 for NSW. Compared to this time last year (May 2019), incidents of alcohol-related assault (non-domestic assault) in Miller was 0 compared to 8.5 for NSW

Incidents of Assault (Domestic Assault)

BOSCAR data for the same period (May 2020) showed incidents of assault (domestic assault) in Miller increased to 117 compared to 30.3 for NSW. While this may be due to several factors, existing evidence has found this could be linked to alcohol consumption. In 2010, research revealed alcohol was “present” in 41% of domestic assaults in NSW. Other studies since have found alcohol was involved in up to half of partner violence in Australia and 73% of partner physical assaults. The same studies also pointed out that alcohol features prominently in police data, although not all jurisdictions keep consistent records.    

Significant factor – access and availability of alcohol

There currently are 2 packaged liquor outlets and 1 hotel in Miller.

While the NSW Government COVID-19 restrictions forced the pubs and clubs to close between March 23, 2020 and 1 June 2020, Miller residents were still able to purchase alcohol from packaged liquor stores. The normal trading hours for one of these outlets in the area includes Monday to Saturday, 8:00am to 9:00pm and Sunday, 10:00am to 8:00pm. These alcohol outlets in Miller are in a Statistical Areas Level 1 (SA1) quadrant of approximately 280 households belonging to the lowest 1 percent of the most disadvantaged quantile in NSW.

In addition to this, Miller residents also had the option of buying alcohol online. In April 2020, Retail Drinks Australia reported one national retailer’s deliveries were up 300% from December 2019 to March 2020, while the size of the average order had increased by 50%. Around the same time, the Commonwealth Bank data showed a 34 percent increase in spending on alcohol over a week from March 27, 2020, compared to the same week in the previous year.

Despite no locally available data, Miller residents may be subject to the unsavoury and illegal delivery practices of some of the most popular online alcohol retailers in Australia. A study in January 2020, found 69 percent of these retailers advertised that they were willing to leave alcohol unattended at an address without verifying the purchaser’s age.

Conclusion

Alcohol consumption during the COVID-19 pandemic has the potential to impact all Australians. However, it can potentially further affect vulnerable communities. More research is needed to understand the full extent of the impact on these communities. In the case of Miller, preliminary data shows alcohol has contributed to an increase in incidents of assaults (non-domestic) and, most likely, incidents of assault (domestic assault). Access and availability of alcohol is a major contributing factor. Therefore, there needs to be more action taken around managing the economic and physical availability of alcohol, as well as provision of support for disadvantaged communities. We must remember this is an avoidable burden on our communities.  Let’s act now before it is too late!

Further challenges for new migrants and humanitarian entrants in COVID-19

By Andrew Reid

There is a concern that COVID-19 may exacerbate inequality towards vulnerable groups, including migrants and refugees. Here, I highlight a few from past experiences between 2006 – 2011 as a Non-Government Organisation (NGO) project and casework officer. My role included assisting and supporting Australian permanent residents within the first five years of arrival. This group included humanitarian entrants, family stream migrants with low English proficiency; and other selected visa subclasses. This group was located in Outer and Inner Western Sydney, under the Settlement Grants Program (SPG), now known as Settlement Engagement and Transition Support (SETS), funded by the Federal Department of Home Affairs.

Information and service access issues

SETS workers from 78 providers across Australia, funded under SETS – Client Services for the period 1 January 2019 to 30 June 2022, during this COVID-19 period, will necessarily be delivering services ‘from home.’ As a consequence, the SETS target group, including 20,102 humanitarian entrants that are settled in all states/territories between 1 January 2019 to 31 December 2019 (see figure 1 below), are likely to receive less face-to-face casework, interaction, and access to services at a time of even greater need to address their current settlement issues and concerns.Permanent Settlers (All Streams) in all States/Territories with a Date of Settlement* between 01 January 2019 and 31 December 2019

Figure 1: Permanent Settlers (All Streams) in all States/Territories with a Date of Settlement* between 01 January 2019 and 31 December 2019

There are a number of translation and interpreting services in Australia,
such as the Federal Government Translating and Interpreting Service (TIS) operating 24/7 and the NSW Multicultural Health Communication Service, that cover a very large number of languages. The Federal Government on 11/3/2020 announced a $30 million public information campaign. However, with increased demand many new migrants and refugees may find it more difficult than usual to get the necessary information, assistance, and support when needed. There are more than 21% of the population who speak languages other than English at home, and 6% that either speak little English or none at all. It is likely that there will be longer wait times from increasing demand in this COVID-19 period for such essential services.

A significant number of new migrants and humanitarian entrants that have resettled in Australia, particularly in the past 5 years, struggle with accessing information and services on their own. COVID-19 has forced a large number of Australians to ‘self-isolate’ or ‘stay at home.’ This has made it much harder for this population group. One contributing factor to this is the considerably diverse educational backgrounds of recently arrived humanitarian migrants. Some have relatively few years of education. Research, in 2017, found that 15% had no formal education and a further 18% had six or fewer years of schooling). Another contributing factor is digital exclusion. Research in 2019 has shown recently-arrived Culturally and Linguistically Diverse (CALD) migrants who had arrived under the humanitarian immigration program recorded a lower level of digital inclusion than the national average, primarily due to very low levels of affordability.

Older people in this population group are particularly at risk of not understanding and adhering to the required course of action needed to keep people safe and reduce the spread of COVID-19. As Associate Professor Robyn Woodward-Kron, at Melbourne University, explains, “some of the older migrants in Australia have had very little schooling, so they need reliable information that they can understand.”

It is particularly important that there is a ‘coordinated and creative’ approach involving a diverse range of stakeholders including community leaders, different multicultural organisations and community groups to develop the required information and disseminate it in appropriate and effective ways.

Health impacts
Increased Survivor’s Guilt

Research in 2019 found humanitarian migrant populations remain at high risk for mental illness over the first 3 years of resettlement in Australia. One contributing factor to this is survivor’s guilt. This is a sense of deep guilt a person may experience because they have survived a life-threatening situation (i.e., wars, natural disasters, and other traumas), when others have not. COVID-19 may be likely to increase survivor’s guilt among newly arrived migrants and refugees to Australia. This could be exacerbated by numerous domestic and overseas news reports of the alarming speed and spread of COVID-19 across the globe as well as fears of the unknown and for the welfare of friends and family left behind in home countries and refugee camps. Survivor’s guilt is a symptom of Post-Traumatic Stress Disorder (PTSD). Thus COVID-19 could potentially raise the positive screening of PTSD above the 52.4%, shown in a 2019 study, among the humanitarian migrant populations in Australia.

Further stigma

Stigma is already identified as one of the critical barriers to help-seeking for mental health or other health advice, particularly amongst refugee men in Australia. History and international experiences suggest COVID-19, like other pandemics (i.e., Spanish Flu and Ebola), could very well increase this stigma in the recently-arrived CALD migrant population who entered the country under the humanitarian program. This could mean less COVID-19 testing, social rejection, denial of services, and reduced treatment opportunities for Australian new migrants and refugees. Moreover, it can also lead to elevated depressive symptoms, stress, and substance use within this population group. Therefore, COVID-19 can effectively cause further stigma, which can result in mental and physical harm. This could include increasing the present prevalence estimates for depression and anxiety above the current 20% for migrants and 40% for refugees.

A final note, although COVID-19 is having significant impacts on the Australian community, newly arrived migrants and humanitarian entrants are at risk of experiencing increasing challenges as a result of this pandemic.

 

The social gradient of COVID-19

by Andrew Reid and Siggi Zapart

While COVID-19 does not discriminate, the impacts of the virus will not be equitably distributed. Vulnerable populations living in low socioeconomic disadvantaged communities will feel its health and educational impacts far more strongly than those living in more affluent areas.

 Health impacts
 Reduced access to essential healthcare

Some health experts suggest the COVID-19 pandemic could infect up to 70% of Australians. Based on estimates of current infection, more than 45,000 Australians will have COVID-19 by 10 April, 2020. At least 2,254 people would require ICU beds, (more than the current Australian capacity of 2,229). People in lower socioeconomic disadvantaged communities generally have poorer health and higher rates of heart and respiratory disease, and chronic illnesses. This means they could make up a large proportion of people likely to need ICU beds, and/or find it a lot harder to receive critical healthcare for their other illnesses in their local hospitals.

Furthermore, the Australian Government’s plan to implement a ‘whole-of-population telehealth’ approach will disadvantage vulnerable populations who do not have access to smartphones or computer technology due to lower income or education levels. The ‘whole-of-population telehealth’ includes phone and video mental health, allied health, and primary health consultations. Moreover, even those with internet access will be disadvantaged due to inferior NBN service types(see graph below). Research conducted in 2016 showed only 29% the most disadvantaged areas across Australia (SEIFA decile of 1) had fibre-to-the-premise (FTTP) – considered the best broadband technology solution available – or fibre-to-the-node (FTTN) connections. In the least disadvantaged(SEIFA decile of 10), 93 % had FTTP or FTTN. This is clear evidence that optimal NBN service increases as the SEIFA decile increases. Hence, even though telehealth is covered by Medicare, people living in disadvantaged suburbs are likely to miss out on the much needed essential services.

Impact on mental health

The continuing upward trend in the number of confirmed COVID-19 cases across Australia is causing increased anxiety and stress among disadvantaged communities. This is due to multiple and simultaneously occurring factors including, risk and uncertainty associated with the virus; feeling of powerlessness in the current situation; inconsistent messaging and confusion about social distancing measures; separation from loved ones due to quarantine or self-isolation; loss of freedom, and increased boredom; low income reducing to no income; and the type and condition of housing many people in these areas reside in. Most residents in these communities live in low-cost private rentals, social housing, and for some (many with disability, health or mental health issues, victims of domestic violence, people recently released from prison etc.) and social housing bedsits. The pandemic can potentially raise the Australian adult rates of poor mental health(currently 20%) and high or very high psychological distress (13%).

Educational impact

Across Australia, some states have closed schools, commencing school holidays early. Others like NSW have kept them open but encouraged parents to keep children at home. All schools are preparing for online learning, though at this stage, options for school attendance will be available for those that need it in some states.  However, given the low attendance rates (20-30% last week), it seems many parents think it safer to keep their children at home. For students in vulnerable communities, online learning could lead to increased barriers to education. Not all will have access to computers, the internet, or quality technology, such as wireless networks at home or quality NBN service. Many students might have mobile phones, but these may not be enough to engage with the curriculum or complete required tasks. Shools could send home lessons and resources for parents to use, but many parents in these communities would struggle, or not feel confident to teach their children at home.

In addition, the Federal Government’s closure of public libraries and community centres will hurt the educational outcomes of children in disadvantaged communities as these facilities provide a safe environment to facilitate lifelong learning. Public libraries offer free or affordable access to the internet, computers, printers, photocopiers, and a wide range of educational resources. Several community centres host Learning Clubs, i.e., after school programs designed to provide extra assistance to primary and secondary students in developing academic skills, such as homework, numeracy, and literacy. Not having access to these facilities and programs will prevent a large number of children in these disadvantaged communities from participating in learning, completing online school assignments, and having the right to a high-quality education experience.

So, a final note, although COVID-19 is impacting the entire population, those doing it tough already are and will continue to experience even more severe consequences as a result of the pandemic.

Preventing Alcohol-Related Harm: What’s Changed?

By Andrew Reid and Joan Silk

 

Second Forum: Friday, March 23, 2018

The Centre for Health Equity Training Research and Evaluation (CHETRE) through Community StaR in partnership with Liverpool Community Drug Action Team (CDAT), recently held our second public forum on Preventing Alcohol-Related Harm. It was almost five years on from our first forum, Alcohol-Related Harm in Our Community, also held in Miller, New South Wales (NSW). We wanted to discuss the changes since 2013 and provide an information update and further insight into preventing alcohol-related harm. Several important changes had happened in the past five years including the introduction of the ‘lockout laws’ in Newcastle and parts of Sydney after several alcohol-fuelled one-punch killings including that of Thomas Kelly in 2014.

Uncle Malcolm Maccol, a local Aboriginal Elder, performed the Welcome to Country, and the Honourable Paul Lynch M.P., NSW state member for Liverpool, officially opened the event at Miller Community Centre. The forum was facilitated by Norman Booker, an experienced health professional and consultant. The sixty people in attendance at the forum shared concerns, questions and comments throughout the event.

 

Not all good news

The good news is that there have been some positive (and hard-fought) changes. Since the ‘lock-out laws’ came into effect, serious injuries from alcohol-fuelled violence have significantly reduced in the Kings Cross and Sydney Central Business District (CBD) Entertainment Precincts. Stricter restrictions on access and availability including on the sale of packaged liquor have been shown to work. However, the NSW Government has not implemented changes in other areas of the state. A highlight of the event was the comprehensive and inspiring Northern Territory plan for addressing alcohol-related harm.

 

More needs to be done

The forum’s three keynote presentations by Emeritus Professor Ian Webster AO, Dr. John Crozier, and Dr. Criss Moore generated knowledge, inspiration, insight and a strong desire to work together closely and effectively to reduce alcohol-related harm in our community. We look forward to a broad implementation of the evidence based measures discussed by our speakers and thank them for generously sharing their expertise and encouragement.

 

Key Issues:

Mental health and Alcohol-Related Harm

Professor Ian Webster‘s keynote presentation discussed the nature of alcohol-related harm and the crucial link between mental health, suicide and alcohol. This highlighted the urgent and growing need for health and related services to address dual mental health and alcohol and other drug (AOD) presentations. For example, in the period 2011–2015, forty percent of male suicides and thirty percent of female suicides were attributable to alcohol use. More national attention on the issue is required, and governments at all levels must work together to prevent such tragedies. The most marginalised and disadvantaged groups are often the most severely impacted. In many parts of Australia, this includes, but is not limited to, the homeless and Indigenous communities. For instance, the overall rate of suicide among Aboriginal and Torres Strait Islander people in 2015 is more than two times higher than the rest of the population.

 

Marketing and supply of alcohol

As well as detailing the daily economic and horrific health costs of alcohol-related harm, Dr John Crozier’s presentation provided shocking examples of the cynical and sophisticated strategies the alcohol industry uses to widen access and entice customers, including the promotion of online shopping and home delivery. He also covered the blatant tactics alcohol companies use to attract young people. He highlighted the detrimental effects on communities of the increasing availability of alcohol and the ever-expanding range of beverages and alcohol outlets. For every 10,000 litres of alcohol sold through Australian outlets, domestic violence increases by twenty-six percent.

He concluded that private industry profits while the public purse ‘picks up the pieces’.

 

Community Power

Despite the ‘mighty and powerful’ alcohol industry, there have been some significant community victories. Dr. Criss Moore spoke about a group of Casula residents who successfully managed to win a three year battle with a prominent hotelier wishing to establish a late night hotel and gaming venue in their residential suburb. She highlighted the power of community – people power, and gave examples of the organisational methods of a diverse community that stands together to challenge the powerful. Residents held street corner meetings, door knocks, rallies, letters and petitions to raise awareness and action. Tony Brown, chair of the Newcastle CDAT and key activist for the successful Newcastle ‘lockout laws’ and Dr. John Crozier gave much assistance and support to the residents. Dr Moore emphasised the critical importance of building and maintaining relationships with those in the neighbourhood, and beyond.

 

Tackling the availability of alcohol – the ADF toolkit

Damian Dabrowski from the Alcohol and Drug Foundation (ADF), the funding body of this forum, was also present to demonstrate a toolkit that community and others can use to assist in having their voices heard in the decision-making process of regulating the availability of alcohol. See the ADF website at https://adf.org.au/

 

Next steps: Where to from here?

The Q&A panel following the keynote addresses and discussions at the forum suggested that having stronger restrictions on the availability and advertising of packaged liquor is one important way forward in reducing alcohol-related harm. A number of participants also applauded and were inspired by the action of the NT government in addressing alcohol-related harm in a comprehensive, innovative and evidence-based plan. As well as a national response, local action is needed. Local Community Drug Action Teams (CDATs) such as the Liverpool CDAT can help facilitate this and we invite interested community members and service workers to join us.

CHETRE, through Community STaR will continue to work with Liverpool CDAT and others to address critical issues in the AOD space to help improve the health and general well-being of the community.

Hospital Entrances for Well-Being

The Face of the Hospital

Hospitals are under increasing pressure to deliver best innovative healthcare within tight budgetary constraints. While some attention has been given to improving care through the design of emergency departments, operating theatres, and patient rooms, very little attention has been extended to hospital entrances as the ‘healthy face’ of the facility.

 

More than positive perceptions of service

The physical design of the built environment not only can deliver positive results in perceptions of service but also for general human well-being. Well-designed hospital entrances including entry gardens, which are defined as visually pleasing green spaces designed like gardens located near hospital entrances (Yüel, 2013) can improve social capital and reduce stress for patients, visitors and staff. This is indicated by the preliminary findings of our pilot study of the front entrance of Liverpool Hospital, one of the largest hospitals in New South Wales (NSW), Australia. These initial results suggest significant contributing factors include poor signage, lack of seating and shade, amount and closeness to vehicle traffic as well as an inadequate amount of green space.

 

Not new, but a slow resurgence

While the belief that plants and gardens are beneficial for patients in healthcare environments is not new (in some cases more than a thousand years old) and appears prominently both in Asian and Western culture, this notion became less prevalent from the 1900s as hospital administrators and architects looked at traditional architecture, buildings primarily, as the first and foremost line of defence in reducing the risk of infection and serve as functionally efficient settings for new medical technology (Ulrich, 2002). However, in recent years, there has been a resurgence in the idea of having gardens in healthcare settings. This is primarily being driven by the increasing need to create functionally efficient and hygienic environments that also have pleasant, stress-reducing characteristics (Ulrich, 2002).

 

Next Steps

The preliminary findings of the CHETRE literature review and pilot study of the front entrance of Liverpool Hospital, NSW, Australia, show hospital entrances are so much more than mere gateways to health services. Apart from improving perceptions of service, it can contribute to the general well-being of patients, visitors, and staff. Hence, the design of hospitals’ entrances should be considered just as important as other parts of the built environment. However, more research is needed in this area to measure and illustrate this accurately. This is by no means a new concept, but thankfully there has been a slow and steady re-awakening of this idea, in recent years, in the pursuit of building and maintaining functionally efficient and hygienic hospital environments with welcoming and stress-reducing characteristics.

 

 

Ulrich, R. S. (2002). Communicating with the healthcare community about plant benefits. In C. Shoemaker (Ed.) Proceedings of the Sixth International People Plant Symposium. Chicago: Chicago Botanic Garden.

Yüel, G. (2013). Hospital Outdoor Landscape Design. In M. Ozyavuz (Ed.), Advances in Landscape Architecture (pp. 381-398). USA: InTech.