Mind A WELLography™
First Edition
International Well Building Institute

Table of Contents


Copyright© 2017 International WELL Building Institute PBC. All rights reserved.

International WELL Building Institute PBC authorizes personal use of this Mind WELLography™, which includes the ability by the user to download and print a single copy of the Mind WELLography™ for the user’s own education and reference. In exchange for this authorization, the user agrees:

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  2. not to modify the Mind WELLography™; and

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Unauthorized use of the Mind WELLography™ violates copyright, trademark, and other laws and is prohibited.


The International WELL Building Institute also acknowledges the important work of Melcher Media in bringing this document to market in its current state.

Produced By:

Melcher Media
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New York, NY 10011

President, CEO: Charles Melcher
VP, COO: Bonnie Eldon
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Associate Editor: Luisa Lizoain
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Design & Development by Crush + Lovely

Illustrations by Kaarina Mackenzie

Animations by Vita Newstetter

Melcher Media would like to thank Callie Barlow, Jess Bass, David Brown, Dylan Butman, Tova Carlin, Maria Gagliano, Barbara Gogan, Luke Jarvis, Weronika Jurkiewicz, David Kahn, Susan Lynch, Sami Melcher, John Morgan, Lauren Nathan, Julia Sourikoff, Tori Spencer, Saif Tase, Zoe Valella, and Megan Worman.


The International WELL Building Institute (IWBI) and Delos Living LLC (Delos) acknowledge the work of the following IWBI and Delos technical staff that developed and created the WELLographies: Oriah Abera; Niklas Garrn; Trevor Granger; Soyoung Hwang; Michelle Martin; Vienna McLeod; Anja Mikic; Renu Nadkarni; Brendan O’Grady; Chris Ramos; Eric Saunders; Sara Scheineson; Nathan Stodola; Regina Vaicekonyte; Sarah Welton; Kylie Wheelock; and Emily Winer.

IWBI also is grateful for the input and insight provided by the following Subject Matter Experts:

Air: Terry Gordon, PhD; Eric Liberda, PhD; Tim McAuley, PhD; Ellen Tohn, MCP

Water: Eric Liberda, PhD; Tim McAuley, PhD; Margret Whittaker, PhD, MPH, CBiol, FSB, ERB, DABT, ToxServices LLC

Nourishment: Sharon Akabas, PhD; Alice H. Lichtenstein, DSc; Barbara Moore, PhD

Light: Chad Groshart, LEED AP BD+C; Samer Hattar, PhD; Steven Lockley, PhD, Consultant, Delos Living LLC and Member, Well Living Lab Scientific Advisory Board, Neuroscientist, Brigham and Women’s Hospital and Associate Professor of Medicine, Harvard Medical School

Fitness: Dr. Karen Lee, MD, MHSc, FRCPC, President & CEO, Dr. Karen Lee Health + Built Environment + Social Determinants Consulting; Jordan Metzl, MD

Thermal Comfort: Alan Hedge, PhD, CPE, CErgHF; David Lehrer, MArch; Caroline Karmann, PhD, MArch

Acoustics: Arline L. Bronzaft, PhD, Professor Emerita of The City University of New York; Charles Salter, PE

Materials: Clayton Cowl, MD; Matteo Kausch, PhD, Cradle to Cradle Products Innovation Institute; Megan Schwarzman, MD, MPH; Margret Whittaker, PhD, MPH, CBiol, FSB, ERB, DABT, ToxServices LLC

Mind: Anjali Bhagra, MBBS; Lisa Cohen, PhD; Keith Roach, MD; John Salamone, PhD; Nelida Quintero, PhD


None of the parties involved in the funding or creation of the WELL Building Standard™ and the WELLographies™, including Delos Living LLC, its affiliates, subsidiaries, members, employees, or contractors, assume any liability or responsibility to the user or any third parties for the accuracy, completeness, or use of or reliance on any information contained in the WELL Building Standard and the WELLographies, or for any injuries, losses, or damages (including, without limitation, equitable relief) arising from such use or reliance.

Although the information contained in the WELL Building Standard and the WELLographies is believed to be reliable and accurate, all materials set forth within are provided without warranties of any kind, either express or implied, including but not limited to warranties of the accuracy or completeness of information or the suitability of the information for any particular purpose.

The WELL Building Standard and the WELLographies are intended to educate and assist building and real estate professionals in their efforts to create healthier work and living spaces, and nothing in the WELL Building Standard and the WELLographies should be considered, or used as a substitute for, medical advice, diagnosis or treatment.

As a condition of use, the user covenants not to sue and agrees to waive and release Delos Living LLC, its affiliates, subsidiaries, members, employees, or contractors from any and all claims, demands, and causes of action for any injuries, losses, or damages (including, without limitation, equitable relief) that the user may now or hereafter have a right to assert against such parties as a result of the use of, or reliance on, the WELL Building Standard and the WELLographies.

Welcome to WELL

The buildings where we live, work, learn and relax have a profound effect on our well-being: how we feel, what we eat and how we sleep at night. By examining our surroundings and our habits, and making key optimizations and changes, we have the power to cultivate spaces that promote wellness, and support efforts to live healthier, active, mindful lives – a right for every human.

The WELL Building Standard™ (WELL) envisions this reality and opens this critical dialogue. It provides a roadmap and a comprehensive set of strategies for achieving building and communities that advance human health.

WELL consists of a comprehensive set of features across seven concepts (Air, Water, Light, Nourishment, Fitness, Comfort and Mind). Together, these components address the various individual needs of the people inside buildings, while also setting forth a common foundation for measuring wellness in buildings as a whole. The standard was developed by integrating scientific research and literature on environmental health, behavioral factors, health outcomes and demographic risk factors that affect health; with leading practices in building design and management. WELL also references existing standards and best practice guidelines set by governmental and professional organizations, where available, in order to clarify and harmonize existing thresholds and requirements.

The result is the premier building standard for advancing human health and wellness – and a blueprint for creating better buildings that can enhance productivity, health and happiness for people everywhere.

How to Use this WELLography™

WELLographies™ present research relevant to health and well-being in buildings and communities. The sources included span health, wellness, and scientific and professional literature specific to the seven concepts within WELL, and other core focus areas. WELLographies are meant to complement the WELL Building Standard™ (available at standard.wellcertified.com) and provide architects, building managers, engineers, and interior designers, among others, with health- and science-focused background to support and guide their efforts to advance the healthy buildings movement.

WELLographies have three primary goals:

  1. Provide background information for key topics relevant to understanding human health as it relates to the built environment.
  2. Synthesize and present the science that underpins the WELL Building Standard™.
  3. Outline specific, evidence-based strategies that building professionals can apply to create spaces that promote health and well-being in buildings and communities.

There are nine WELLographies:

  1. Air
  2. Water
  3. Nourishment
  4. Light
  5. Fitness
  6. Thermal Comfort
  7. Acoustics
  8. Materials
  9. Mind

The Mind WELLography™ has the following sections:

Mind and the Built Environment, which broadly describes how Mind relates to the human experience in buildings.

Mind and the Human Body, which provides an explanation of the biological mechanisms relating to Mind, describing how the body functions under normal, healthy conditions.

Elements of Mind, which describes environmental conditions or behaviors that are linked to health, focus, or occupant comfort, and that are subject to interventions in building design or policy. Each element includes coverage of associated health effects as well as solutions, interventions that can be implemented to impact the element. Some solutions may address several different elements.

Explanations of Solutions, which provides a definition and/or more detail for each solution.


Advances in medicine and public health have radically changed the global burden of disease in the last 100 years, even eliminating some of the world’s deadliest diseases. While epidemics of infectious diseases like cholera and influenza dominated the 19th century, the 20th century was commanded by a shift in global disability and mortality toward non-communicable diseases (NCDs). Today, NCDs remain among the leading causes of mortality including ischemic heart disease, stroke, lower respiratory infections, and chronic obstructive lung diseases.1

Mental, neurological, and substance use conditions account for 14% of the global burden of disease 2 and depression alone is the leading cause of disability worldwide.3 Unfortunately, most people living with these conditions do not receive necessary treatment.2 In fact, in high-income countries 35% to 50% of people living with one or more mental health conditions do not receive treatment.4 This gap widens in low- and middle-income countries, where 76% to 85% of people living with mental health conditions do not receive the necessary treatment.4 Further underscoring the scope of this public health problem is that mental, neurological, and behavioral conditions are also risk factors for many chronic diseases, including HIV, cardiovascular disease, obesity, several cancers, and diabetes.5 6 This group of conditions is also linked to risk factors such as physical inactivity, disordered sleep patterns, smoking, excess drinking, and both unintentional and intentional injury.5 6

Mental health is defined as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”7

An individual’s mental health status is driven by a host of complex processes, which are collectively a result of the brain’s response to various internal (individual) and external (environmental) conditions.8 These conditions can have both positive and negative implications for physical and mental health, alike. Mental health, in both the short- and long-term is dynamic and fluid as the body works to respond to many influencing factors. Thus, to achieve optimal mental health and well-being, it is essential to discuss, monitor, and manage mental health throughout the life course and consider it in a short- and long-term context.

An individual’s state of mental health can evoke and influence physical and psychosocial responses in the human body.9 These responses are regulated through interactions within and between the nervous and endocrine systems.10 Because these systems influence all other body systems, changes in short- and long-term mental health have the capacity to impact numerous physiological functions and health outcomes. In research, prolonged negative mental states are typically examined in studies of mental health due to the associated adverse health effects.11 12

Mental health plays a vital role in an individual’s overall health and well-being,2 5 6 and as such, an atmosphere that supports mental health and wellness can have significant benefits across the lifespan.

Changes to the environment that directly or indirectly help to reduce stress can help mitigate the adverse impact effects of various stressful environmental, psychosocial, physiological, or psychological triggers. These environmental interventions include: access to natural elements and private spaces,13 integrative modalities known to promote relaxation,13 the feel and degree of sensory control in a space,14 policies and practices that improve sleep,15 and technologies that promote awareness of health status and encourage positive behavioral and lifestyle changes.16

The Centers for Disease Control and Prevention (CDC) identifies three core domains of mental health– emotional, psychological, and social (Figure 1).6 Each domain has unique indicators that can be measured using validated assessment tools that help researchers and health practitioners measure and monitor an individual’s mental health status.

Figure 1: Domains of Mental Health and Well-being.6
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Mental health is shaped and driven by key socioeconomic, biological, and environmental factors.17 These core drivers serve as key leverage points for interventions that support the environmental, social, economic, and biological conditions needed to achieve population mental health and wellness.17

Within the context of this document, we consider “mind” to be “a product” of the brain, encompassing a complex set of the brain’s functions, which collectively work to influence our mental health. The term “mind” is used abstractly in our discussion of mental health, the health effects associated with various states of mental health, and the potential solutions presented in the Mind WELLography™.

Mind and the Built Environment

People interact with their physical, social, built, and cultural environments in a constant and dynamic manner.

The field of environmental psychology and its closely related fields—ecological and architectural psychology—focuses especially on the impact these interactions have on people and their environments. Evidence has grown tremendously indicating that the built environment is an important direct and indirect driver of mental health outcomes at an individual and population scale.18 The Mind WELLography™ presents solutions that aim to address the ways in which the built environment impacts our mental health.

Numerous characteristics of our environment can have a direct impact on mental health, such as housing, crowding, noise, indoor air quality, and even light.18 Indirectly, the built environment can impact mental health through elements associated with an individual’s degree of personal control on their broader social environment, as well as opportunities for mental restoration, which act through various psychosocial pathways and processes.18 For example, research has shown that living in an area of higher residential density can hinder the development of socially supportive connections and thereby increase psychological distress.18 Both the direct and indirect influences of the built environment on mental health are explored in the Elements of Mind section.

Mind and the Human Body

The biological systems that impact human behavior and mental health include the nervous and endocrine systems. These body systems interact with internal and external conditions to shape mental health and human behavior.

The Nervous System

The nervous system consists of billions of neurons that form a communication network that coordinates various systems of the body.19 20 The neuron (Figure 2), a specialized cell that processes and transmits information in the form of electrical and chemical signals, is the functional unit of the nervous system. Neurons communicate via chemical and electrical signals in response to stimuli within the internal and external environment.19 20

Figure 2: Single Human Neuron.19 20
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Stimuli such as light, sound, and touch, as well as chemical signals from other neurons, can trigger an electrical impulse in a neuron.19 20 What distinguishes the nervous system from any other part of the body is the specialization for responsiveness to certain types of stimuli, and the complexity of the neuronal interconnections. The human brain has about 100 billion neurons that each connect with about 10,000 other neurons, yielding roughly some quadrillion synapses (Figure 3).19 20 Once an electrical impulse arrives at a synapse, it triggers the release of a chemical neurotransmitter that travels across the synapse and is detected by a receiving neuron.19 20

Figure 3: Neuronal Communication.19 20
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The shape and size of a neuron is related to its function. For example, axons of interneurons, which connect motor and sensory neurons, are short, while axons that carry signals from the spinal cord to the muscles of the foot may can be roughly a meter long.19 20

Organization of the Nervous System

Divisions of the nervous system, as shown in Figure 4, are based on the specialization and function of the neurons that make them up.19 20 The human nervous system is divided into two major parts—the central nervous system (CNS) and the peripheral nervous system (PNS). The CNS includes the brain and spinal cord (Figure 4). Simply, our neurons transmit the information that flows within, to, and from the CNS.19 20

Figure 4: Human Nervous System.19 20
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The peripheral nervous system (PNS) is the part of the nervous system that connects the CNS to the rest of the body.19 20 The PNS encompasses motor neurons, which relay messages from the CNS to muscles and glands, and sensory neurons, which relay messages from sensory organs to the CNS.19 20

Motor neurons of the PNS are further divided into the somatic and autonomic nervous systems.19 20 The somatic system consists of the nerves that innervate the skin, joints, and muscles and is largely under conscious control. These nerves communicate information from outside the body and carry out voluntary motor responses. The autonomic system contains neurons that innervate internal organs, blood vessels, and glands and largely carries out the automatic (unconscious) regulatory functions within the body, such as the regulation of heart rate, digestion, and glandular secretions.19 20

The autonomic nervous system (ANS) is composed of two parts: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PSNS) (Figure 5).19 20 The SNS prepares the body for “fight or flight” mode by activating the body’s stress response (physical and chemical). During real or perceived emergencies, the SNS helps to mediate vigilance, arousal, activation, and energy mobilization by speeding up the heart rate, increasing blood pressure, and diverting blood to muscles and away from visceral organs.19 20

The PSNS engages the body in a “rest and digest” processes during times when the body is less actively stimulated.19 20 Activation of this system slows the heart rate and diverts blood to activities such as digestion and other “maintenance” processes. Unlike the SNS, much of the output of the PSNS is targeted to specific organs. The two branches, while having opposite physiologic effects on the body, work in a complex balance to affect a variety of biological processes including our mental health.19 20

Figure 5a: Effect of the PNS on Glands and Organs.19 20
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Figure 5b: Effect of the SNS on Glands and Organs.19 20
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The Endocrine System

The endocrine system comprises a collection of eight major glands that secrete chemical messenger hormones throughout the body (Figure 6).20

Endocrine hormones regulate a variety of biological processes such as growth, development, reproduction, and metabolism.20 Compared to the nervous system, the effects of the endocrine system are slower to initiate and prolonged in their response, lasting from minutes to even weeks. The endocrine system is organized into axes, or functional pathways. These functional pathways originate at the hypothalamus, a small organ that exerts its primary influence on the pituitary gland, which then releases chemical signals to peripheral endocrine glands.20

Figure 6: Organs of the Endocrine System.20
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Located at the base of the brain, the hypothalamus receives inputs that drive a wide range of responses from various parts of the brain including the frontal cortex—the “executive” part of the brain.20 The hypothalamus receives sensory inputs from the olfactory (smell), taste, visual, and somatosensory systems as well as highly processed sensory information from the cerebral cortex via the limbic system. The hypothalamus also contains sensors for blood temperature, blood sugar and mineral levels, and a variety of hormones. This powerful organ plays regulates bodily functions in multiple ways:20

  1. helping to maintain a balanced and well-regulated internal environment;
  2. responding to external events that require a change in physiology and behavior;
  3. regulating external day-night light cycles;
  4. providing the connection between the brain and the pituitary gland.

Pituitary Gland

About the size of a lima bean, the pituitary gland is one of the central components of the endocrine system (Figure 7).20 It is located in a small bony cavity at the base of the brain and contains both anterior and posterior lobes, both of which produce specific hormones. The posterior pituitary gland synthesizes and secretes hormones made in the hypothalamus (e.g., oxytocin and vasopressin), which are packaged and transported via axons that connect the two endocrine glands. In contrast, the anterior pituitary gland responds to releasing hormones made in the hypothalamus that travel down a capillary network to specialized cells in the anterior pituitary gland. These specialized cells respond by releasing tropic hormones, which act on specific target tissues.20

Figure 7: Anterior and Posterior Pituitary Glands.20
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Hormonal Systems

When multiple glands work in concert, they form what is called an axis. The endocrine and nervous system axes function with feedback loops that mediate and/or inhibit hormone release (Figure 8).20 The feedback from a target organ in the periphery alters the activity of the hypothalamus through a long feedback loop, while hormones released from the pituitary can also provide feedback to the hypothalamus through a short feedback loop.20

Figure 8: Release and Feedback Routes of Hypothalamic and Anterior Pituitary Hormones.20
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One particular axes of note is the hypothalamic-pituitary-adrenal (HPA) axis, which is responsible for regulating many metabolic processes within the body. Activation of the HPA axis occurs in response to almost any type of physical or psychological stress or stimulus.20 HPA axis activity begins most commonly with the release of corticotropin-releasing hormone (CRH) from the hypothalamus.20 This stimulates the anterior pituitary to produce adrenocorticotropic hormone (ACTH), which in turn activates adrenal hormone production at the adrenal gland, primarily cortisol. Cortisol is a stress-related hormone (also known as a glucocorticoid) that initiates many processes, including mobilization of energy resources within the body.20 The activity of the HPA axis is outlined in Figure 9.

Figure 9: Hormones of the Hypothalamic-pituitary-adrenal Axis.
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The Stress Response

One result of activating the sympathetic division of the autonomic nervous system is increased release of stress hormones (catecholamine hormones, norepinephrine and epinephrine) and glucocorticoid hormones (cortisol) (Figure 10).20 This hormone system is termed the Sympatho-adrenal System, or Sympatho-adrenal Axis, and comprises the endocrine and neuronal structures involved in the sympathetic stress response.21 The physiological effects of catecholamine hormones (Figure 10), like epinephrine, can be observed within seconds, while glucocorticoids (such as cortisol) act over a longer period of time. Together, these two groups of stress hormones account for a large percentage of what happens in the body during and after exposure to a stressor.22

Figure 10: Hierarchy of Stress Response Hormones.22
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Epinephrine and norepinephrine are the two most important catecholamines responsible for the “fight or flight” response.22 The adrenal medulla (tissue in the adrenal gland that contains cells that produce catecholamines) and nerve terminals of the sympathetic nervous system release both epinephrine and norepinephrine. These hormones are produced and stored in secretory vesicles and are readily available for rapid release once a stressor is detected. Catecholamine hormones help prepare the body for action, eliciting physiological effects like increased heart rate, elevated arousal, and release of glucose stores.22

Glucocorticoids are a class of steroid hormones.22 Among this category of hormones is cortisol, which plays a primary role in the stress response. The HPA axis is the primary pathway leading to glucocorticoid release and regulation, although other factors and pathways, such as sex hormones, steroids, or circulating cytokines, can also modulate glucocorticoid secretion. Unlike epinephrine and norepinephrine, glucocorticoids take time to exert their physiological effects (a few of which are described in Figure 10). Due to the nature of the HPA axis, increases in glucocorticoid concentrations can be detected only after about five minutes, creating a lag time between the onset of a stressor and the rise in blood glucocorticoid concentration. Physiological effects of glucocorticoids occur 20 to 30 minutes after the onset of a stressor. Once the stressor has passed, negative feedback will generally start to reduce glucocorticoid concentrations within 30 to 60 minutes, however, many of the newly produced proteins will continue to have an effect beyond that time window.22

Almost every organ and cell in the body is affected by the endocrine system.20

Regulation of Human Behavior and Mental Health

There is much left to be explored and understood regarding the complex processes involved in mental health and wellbeing. Human behaviors, a key component of the discussion of mental health, are influenced in complex ways by the nervous and endocrine systems. Three components of human behavior, affect, mood, and motivation, help us to understand and explain how we experience our environment and the biological and behavioral processes and responses that result.

Affect and Mood

Affect comprises the complex cognitive processes that result from interactions between individuals and their environment.9 Some definitions emphasize that it is specifically the outward expression of emotion or feelings that represent how an environment is impacting an individual.9 Thus, it may also be described as any expressive state elicited by the interaction between people and their physical and social environment.9

Positive affect relates to feelings that reflect pleasurable engagement with the environment, such as happiness, joy, excitement, contentment, relaxation, satisfaction, and other positive emotions.10 In contrast, negative affect relates to unpleasant feelings, such as sadness, anxiety, stress, depression, and other negative emotions.23

Historically, the concept of affect has helped psychologists and other medical professionals understand the role of our emotional experiences in social thinking and behavior.24 Traditional assumptions and theories presented affect as a more primal and reflexive response. More recently, however, the fields of evolutionary, neuro, and cognitive psychology suggest that affect represents a more complex bi-directional biological process that influences and is influenced by social, cognitive, and behavioral factors.24

Mood, distinct from affect, refers to emotional experiences over a more prolonged period of time; however, the two are certainly closely linked and integral in the discussion of human behavior and mental health.25 26


Motivation is also discussed in the context of affect and mood. Motivation encompasses the desire to act in a certain way and begins to unpack the question of “why” humans behave the way they do. There is a growing interest in how an individual’s motivation influences health-related behaviors and how interventions can effectively promote healthy behaviors.

Many factors influence motivation, including personal characteristics (traits, goals, knowledge, skills), environmental conditions, and the interaction of these internal and external factors.27 28 Affect is also closely related to motivation.29 Overall, positive affect is associated with increased motivation, whereas negative affect is associated with decreased motivation.30 In addition, disordered mood is also associated with altered motivation.29

Elements of Mind

Mind, as it relates to the built environment and human health, encompasses an array of elements that include characteristics of the extrinsic environment (extrinsic environmental conditions), characteristics of the individual (personal characteristics), and characteristics of the socio-cultural environment (socio-cultural conditions).

Extrinsic Environmental Conditions

Extrinsic environmental conditions include conditions of a person’s physical surroundings that influence their mental health and well-being.

1. Ambient Conditions

Ambient conditions are defined as the state of the surrounding environment. Here, we use ambient conditions to refer specifically to aspects of the built environment that are related to sound, sight, touch, and smell.

Acoustics. Acoustic comfort is affected by the presence of sound and noise. What may be sound or music to one person can be noise and distraction to another. While a welcomed sound may have analgesic or stress-reducing effects, an unwelcome sound (noise) can cause annoyance, mood disturbances, and even anxiety.31 Additionally, research has shown that exposure to noise can also lead to negative health outcomes such as hearing loss and cardiovascular disease.32 Refer to the Acoustic Comfort WELLography™ for more information on sound and Mind.

Light. Light plays an important role in synchronizing circadian rhythms in humans. Bright light, outdoors and indoors, can affect the internal biological clock, sleeping patterns, energy levels, and mood. Refer to the Light WELLography™ for more information on light as it relates to Mind.

Thermal. Thermal comfort, is a subjective evaluation indicating satisfaction with surrounding thermal conditions, and includes factors such as temperature, humidity, and air speed. Thermal comfort is associated with direct and indirect implications for mental health.33 More specifically, thermal comfort has been linked to psychological processes that are associated with productivity.34 35 Refer to the Thermal Comfort WELLography™ for more information on thermal comfort as it relates to Mind.

Olfactory. Odors can affect mood, cognition, physiology, and behavior.36 Odors appear to have an influence on well-being, and while individual perceptions regarding the pleasantness or disagreeability of odors vary, studies have found that certain odors tend to be more likely to elicit either positive or negative affect among participants. A review of the empirical literature on olfactory effects on mood, physiology, and behavior found that physiological effects associated with odors appeared to be the result of combined psychological and emotional responses to odorous exposures or environments.36

Read More

In contrast to the widely studied and well-known health effects of environmental air pollutants (often odorless), the health effects of exposure to odorous pollutants are less understood. Research shows that odorants can impact health by inducing physical symptoms of the cardiac, respiratory, and gastrointestinal systems and psychological symptoms such as annoyance.40 41

Health Effects

Comfort and Focus

Affect. In a study of the impact of an odorous environmental source on positive affect, participants exposed to pleasant scents set higher goals and were more efficient in performing a clerical coding task, and reported weaker preferences for dealing with future conflicts with others through avoidance and competition.42 In another study, malodorous air pollutants lowered participants’ ability to complete a complex task (proofreading) but was not associated with a deficit for simpler tasks (arithmetic).43

More recent research discusses the role of top down processing that occurs during exposure to odorous air pollution. Researchers believe a key process in the understanding of odorous exposure and health involves higher-order neural processes that can influence affect, physiology, and behaviors alike.40 Researchers investigated this idea by studying a Swedish sample of 1,118 individuals ages 18 to 75. Exposure to environmental odors was assigned to groups based on residency zip code. Findings from this ecological study revealed that exposure level to environmental odor was associated with symptoms such as annoyance and that this relationship was significantly mediated by perception of health risk.40


1. Source Separation

Occupants can reduce discomfort due to exposure to excessively strong or distinct odors by separating odor sources from regularly occupied interior environments.

2. Crowding and Privacy

The experience of crowding in public spaces has been studied as an environmental stressor and has been indirectly and directly linked to physical and behavioral effects.44 45 These effects include biological and psychological signs of stress such as discomfort, aggression, and hormonal imbalance 46 and behavioral effects.47

Seminal research indicates that in conditions of environmental crowding, individuals report unwanted social interactions, insufficient privacy, and social withdrawal.48 In these conditions, our inability to achieve the desired level of privacy for a given situation may induce stress and negative affective states.45 46 49

Several factors influence the degree of privacy individuals are able to achieve. Within the built environment, different types of spaces are better suited to support different levels of privacy. Conditions such as room size, location, and degree of stimulus permeability play a role in the experience of privacy within buildings.47 Research shows that exposure to environmental stressors that threaten our sense of privacy, such as crowding, leads to behaviors (e.g., coping strategies such as social withdrawal)47 that are used to regulate optimum levels of privacy and social interaction within a space.50 When conditions of crowding in the built environment test and challenge an individual’s ability to achieve the desired level of privacy, those conditions can have both direct and indirect implications for mental health and well-being.45

Health Effects

Cardiovascular System

Elevated blood pressure. Evidence from one study on the health effects of chronic residential crowding among urban Indian children ages 10 to 12 years suggests that crowding is associated with elevated blood pressure, but significant results were only noted among boys.48 A later review notes that “crowding has been associated with elevated blood pressure in the laboratory settings and among institutional populations in some but not all studies.”44

Comfort and Focus

Negative affect. In a review of empirical evidence, high residential density in community, institutional, and student populations had an impact on degree of measured psychological distress.18 48 Similar outcomes were observed in children experiencing residence-based crowding.18

In addition, a study of crowding in a prison setting showed changes in behavior and well-being among inmates with increasing density in jail units.51 Other prison studies have yielded similar results.52

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1. Design Interventions

Changes in plan configurations have been shown to influence well-being based on a person’s capacity to regulate the desired degree of interaction and privacy within a space. For example, studies have found that college students report greater satisfaction when working on complex tasks in a private rather than a non-private setting.53 Other studies have shown that perceived crowding in a residential environment can be mitigated by having places to retreat to,54 and in the case of children, also having places to play outdoors.55

3. Locus of Control

Locus of control reflects one’s perception of control and choice. An internal locus of control is the sense that one has control over their own life.56 An external locus of control is the perception that life is ruled by external factors beyond one’s control. Locus of control is an aspect of one’s core self-evaluation, which is a measure of how individuals evaluate themselves and is related to confidence and self-esteem. As is the case with several elements of Mind, locus of control can impact mood and stress and is often measured alongside these other elements.56

In a prospective cohort study following a group of 32 women for five years, study participants were given questionnaires that evaluated stress levels, general health, locus of control, and alienation and powerlessness.57 After adjusting for confounders including age and baseline illnesses, results showed that internal locus of control was inversely correlated with frequency and severity of illness and stress.57

Health Effects

Cardiovascular System

Hypertension. In one study, researchers exposed study subjects to a loud intermittent noise and gave half of the participants a button, which they were told could decrease the noise.58 Regardless of whether or not the subjects pressed the button, those participants who perceived themselves to have control over the noise level were less hypertensive than those who were not given a button.58 In addition, a study of 130 patients with high blood pressure found a direct correlation between locus of control and adherence to the treatment regiment, which in turn improved their hypertensive status.59

Coronary heart disease (CHD). Numerous studies looking at employees with high demands and feelings of low control in the workplace have found increased risks for cardiovascular disease and metabolic syndrome in those with a perception of less control.58

Endocrine System

Stress. Studies have found an association between exposure to uncontrollable environmental stressors, such as acute and chronic exposure to noise, crowding, traffic congestion, and pollution, and deficits in task performance and learned helplessness.60 The perceived inability to control such stressors may lead to a sense of incompetency and learned helplessness, which in turn may diminish the ability to learn new tasks or cause elicitation of depressive symptoms.60

In one study, researchers placed participants who were identified as having a high or low internal locus of controls in a noisy environment.61 Researchers then measured participant stress level (as indicated by cortisol) when they were told they did or did not have control over the noise. Although the participants did not in fact have any control over the noise, the participants with higher perceived locus of control had lower cortisol levels than those with a lower perceived internal locus of control, but only in the scenario when they were told and believed they had control. The study supports the idea that an individual’s stress levels have an inverse relationship with internal locus of control—individuals who perceive they are in control of their environments experience, regardless of whether or not they actually do, have lower stress levels since they perceive themselves to be able to modify environmental stressors.61

Comfort and Focus

Satisfaction and group cohesion. Studies on workplace stress have looked at the relationship between the physical workplace environment and stress, comfort, and job satisfaction, noting that perceived and actual control of ambient conditions at work can help diminish stress and increase job satisfaction.62

A cross-sectional study including 228 adults examined how control over office workspace led to an increase in work satisfaction.63 The participants’ perception of their work environment was assessed to determine how they felt their workspace affected their work as well as their ability to collaborate with their coworkers. The perceived ability to adjust their workspace and the presence of a variety of workspaces, both measures of internal locus of control, was positively correlated with job satisfaction and group cohesion.63


1. Spatial Adjustment

Space and furniture flexibility can increase a sense of control over an individual’s environment. A study of 70 residents of an elder care home showed that subjective well-being was increased after refurbishment of two shared communal spaces.64 The updated spaces were designed to extend the possibilities of controlled interaction by providing more gradation of spaces and furniture that could be easily rearranged to accommodate different levels of privacy.64

Control of the immediate physical environment through personalizing one’s workspace also was shown to enhance well-being in a study of 338 workers at 20 companies in a variety of industries.14

2. Opportunities for Input

When occupants have an opportunity to inform the design of the spaces they use, their input may help improve the suitability of such spaces for the activities that take place within them. Effective architectural programming that aims to understand occupants, their values and goals, and the community at large is essential in creating high-quality spaces.65 In addition, a participatory design process and user-centered design approach can lead to the design of spaces that better serve occupants’ needs, increasing occupants’ satisfaction with the spaces in which they live, learn, work, and play.66

One study examining the impact of soliciting feedback from visitors, staff, and patients of a general hospital wing demonstrated that the opportunity to provide feedback, a proxy for internal locus of control, can improve morale.67 The patients and staff who were able to offer their input reported an increase in satisfaction and morale, compared to those who did not have the opportunity to provide their input. Furthermore, the renovated public spaces and nurses’ kitchen became more heavily utilized.67

4. Environmental Legibility

The concept of environmental legibility refers to “the degree to which a building facilitates the ability of users to find their way within it.”68 Environmental legibility is directly linked to way-finding, which refers to the collective problem-solving processes that allow individuals to reach desired destinations within the spaces in which they live, learn, work, and play. Specifically, way-finding is a person’s ability to understand and mentally represent a physical setting and his or her location within it, integrate this information into a decision, and execute physical behaviors that result in successful movement throughout a space.69 Research has shown that conditions of the physical environment (environmental legibility) may affect way-finding.68

Environmental legibility is determined in part by the space’s physical conditions, such as configuration and signage, which have potential to influence well-being by altering stress levels.70 The layout of a space influences how people move and circulate within the space, and as such, design elements of a space can impact the ability of users to formulate a clear mental image of the environment they wish to navigate, which can subsequently impact successful way-finding.71 Spaces that allow for direct visual access to relevant areas, integrated reference points, and include easily recognizable zones with unique characteristics have been shown to increase spatial legibility and are particularly helpful at enhancing way-finding abilities among clinical populations.72

Health Effects

Comfort and Focus

Anxiety and disorientation. Disorienting spaces where predictions are challenging to make, or that provide conflicting information, or other barriers, are common features of “stressful spaces.”47 The effects of poorly designed spaces have been studied most readily in clinical populations where researchers have found that monotonous architectural compositions and lacking reference points within a space make way-finding more difficult.69 In addition, researchers find that particular design elements including some floor patterns and dark lines or surfaces are associated with heightened anxiety and disorientation.69


1. Design Interventions

Simple and regular floor plans with visually differentiated areas and landmarks with clear visual access to destinations have been shown to facilitate environmental legibility.73 These design features can help orient occupants within buildings and may ultimately contribute to successful wayfinding. In a study comparing way-finding in settings with a symmetrical or asymmetrical plan, study participants had more difficulty finding their way in the symmetrical plan, indicating favorability for spatial differentiation (Figure 11).74 However, some researchers caution against designing spaces that are overly complex in that overstimulation may contribute to poor way-finding.47

Figure 11: Symmetrical and Assymetrical Building Plans.
expand this figure

Well-placed and clear signage also plays a role in assisting people find their way in buildings.75 Signage, particularly in buildings with complex floor plans can reduce wrong turns and backtracking.76

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5. Restorative Spaces

Built environment spaces with restorative qualities are those that provide therapeutic functions such as the potential to reduce stress and cognitive fatigue.47 78 Our built environment may facilitate recovery from mental fatigue by providing space or opportunity for activities that require a less directed mental effort.79 Researchers have identified four key features of restorative places that play an integral role in the relationship between restorative spaces and health outcomes:13

  1. provide the feeling of being away (both physically and mentally) from stressors and activities that induce stress or mental fatigue;
  2. induce a sense of soft fascinations, such that elements of the space hold the attention of an occupant in a low-effort manner;
  3. have “extent” and are able to constitute “a whole other world” to provide the sense of being immersed in the space;
  4. provide compatibility between their purpose and desired uses.

Green space and nature settings are commonly thought of as restorative spaces as they often meet the four key features outlined above and have been associated with positive health outcomes.13 78 80

Health Effects

Nervous System

Mental well-being. Several studies have found that natural environments can have a positive impact on health78 by increasing positive affect, lowering psychophysiological arousal, cognitive fatigue, and stress and improving the ability to perform tasks that require concentration.18 78 81 82 83 84 85 Researchers posit that the four features of restorative spaces outlined above provide an opportunity for cognitive restoration78 86 while an alternative theory emphasizes physiological and emotional changes that take place when exposed to natural environments following a perceived challenge or threat.86

Cardiovascular System

Blood pressure. A study that compared psychophysiological stress recovery and directed attention restoration in natural and urban field settings found that natural settings lowered diastolic blood pressure, among other physiological and psychological health effects.86

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Comfort and Focus

Positive affect. A study that compared psychophysiological stress recovery and directed attention restoration in natural and urban field settings found that natural settings increased positive affect, decreased anger and improved performance on attentional tests, among other physiological health effects.86 Another study among women found an 18-23% reduction in depressive symptoms among those with access to green space compared to those with less access.87

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Productivity and work quality. Some research suggests that exposure to indoor plants may positively affect productivity through a restorative effect on a persons’ ability to direct attention to a task.13 However, some occupational settings challenge these findings. In health care settings for example, spaces with direct access to the outdoors were more likely to be rated as having “restorative potential” than spaces with window views, indoor plants, or artwork.88

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1. Nature Incorporation

Restorative spaces can be incorporated into the built environment in a variety of ways including implementing design strategies that optimize exposure to nature or natural settings. Several empirical studies have found that natural environments can have a positive impact on health by increasing positive affect, lowering psychophysiological arousal, cognitive fatigue, and stress, and improving the ability to perform tasks that require concentration.18 78 81 82 83 84 85 Nature-oriented built environment design strategies include those that provide physical access to natural elements, visual connections with the outdoors, the presence of artwork that incorporates nature into the indoor environment, and sounds or smells that are associated with natural settings.89 90

Connections with nature, such as direct access to the outdoors, window views of natural elements, or exposure to natural elements indoors, are associated with various health benefits including reduced blood pressure and heart rate, and improved attention, mood, and overall happiness,90 reduced job-related stress, higher job satisfaction, and improvements in overall health status.89 A study that compared psychophysiological stress recovery and directed attention restoration in natural and urban field settings found that natural settings lowered diastolic blood pressure, increased positive affect, decreased anger, and improved performance on an attention test.86 Among employees, window views of nature are associated with lower stress levels, higher health status, and higher job satisfaction across an array of workplace settings compared to employees who lack windows or have other types of views.89 In addition, it has been found that exposure to natural artwork has similar positive benefits to actual nature views. In a patient population, positive emotional responses were associated with artwork that depicted nature scenery, while more abstract art was deemed to be emotionally challenging and was consistently disliked by patients.89

Non-visual exposure to nature can also be used as a strategy to incorporate restorative elements into the built environment. Exposure to elements that represent nature, including smells or sounds, are associated with reduced blood pressure and stress hormones, improved cognitive performance, and improved perceptions of mental health and tranquility.90

6. Health Literacy

Health literacy is defined as the degree to which an individual can obtain, process, and understand the basic health information and services needed to make appropriate health decisions.91 Many factors work in synergy to impact an individual’s health literacy and the associated health outcomes: macro-level drivers, such as social and environmental determinants, and more micro-level drivers, such as personal characteristics, knowledge, competence, and motivation.92 Factors that impact health literacy also include sufficient access to health information that is comprehensible at different oral and written health literacy levels.93

Reading, listening, analytical, and decision-making skills are all components of health literacy. Individuals who are health literate use these skills to access health care services, calculate dosages, evaluate potential risks and benefits, communicate with health care professionals, interpret test results, locate health information, and evaluate information for credibility and quality.93 In 2003, 36% of Americans were considered health illiterate, defined by an inability to understand the directions of a prescription label.93 In general, individuals with lower health literacy are particularly vulnerable to poor health due to a lacking capacity to effectively apply educational materials to health-related behaviors.94

In a prospective study on the health effects of health literacy, adults with low health literacy had two times the risk of mortality compared to those with higher health literacy.95 A review of the effects of health literacy on children found that limited health literacy was associated with tobacco use and engagement in violent activities.95

Studies have also shown that individuals with low levels of health literacy and awareness of their condition or options are more likely to be hospitalized and have less favorable disease outcomes.93 A systematic review further examined how health literacy affects health and what interventions have proven to be effective. The review found that low health literacy was associated with high hospitalization (five studies) and emergency care use (nine studies), as well as decreased mammography screenings (four studies) and influenza vaccine use (four studies). Low health literacy was also associated with an inability to take medications properly and understand health messages, including labels.93 Other studies have shown similar results where those with more health literacy had stronger compliance with behaviors targeted at chronic disease management and reduction.96

Health Effects

Endocrine System

Glycemic control. Patients with inadequate health literacy have about two times the odds of poor glycemic control and diabetes complications that results in blindness compared to those with adequate health literacy levels.94

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Diabetes self-care. Studies note that lower health literacy is common among individuals with diabetes and is associated with inadequate diabetes-specific disease knowledge,94 but more research is needed to better understand the implications of health literacy and diabetes outcomes. While some studies suggest an association between health literacy and diabetes self-care,98 others do not.94 A recent study of 345 diabetes patients found that health literacy was positively associated with diabetes knowledge and effective health communication with health care professionals but not the behavioral or health outcomes of interest.94

While the relationship between health literacy and diabetes outcomes remains unclear, its potential influence on overall health-related quality of life warrants further research.98

Cardiovascular System

Blood pressure. In a cross-sectional study of 46,263 hospitalized adults, those with low health literacy (determined by Brief Health Literacy Screen score of nine or less) had a significantly higher risk of elevated blood pressure (adjusted odds ratio of 1.06), extremely elevated blood pressure (adjusted odds ratio of 1.08), and elevated blood pressure without hypertension (adjusted odds ratio of 1.09) compared to those with higher health literacy.99 A second study found similar results across a wider body of literature, noting an association between limited health literacy and worse blood pressure control.100

Respiratory System

Asthma. In a review of 13 studies on the effects of health literacy on asthma, low health literacy was associated with greater difficulty in asthma care. The results of the studies reviewed indicated that those with low health literacy were at a greater risk for asthma-related hospitalizations and asthma symptoms in adults.95

In another study of 175 patients derived from a larger cohort study, lower health literacy was associated with poor longitudinal asthma outcomes, worse physical function, and more emergency department visits compared to those with higher health literacy.101

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1. Distribution of Educational Materials

The World Health Organization (WHO) reports that sharing wellness information via leaflets, posters, stickers, and magnets has been proven to be effective for improving hand hygiene, reducing the spread of influenza, and reducing skin irritation among salon workers in the U.K.92 In addition, the CDC recommends the inclusion of emails or newsletters on health topics as part of company health programs.102 The CDC also stresses that education materials should be accurate, accessible, and actionable in that materials should be presented in a way that users can comprehend what is presented, should be visible and encompass multiple “mediums” of delivery (e.g., text and images), and have solution-oriented messages that provide readers or users with sufficient information that encourages action.103

Personal Factors

1. Behaviors

Our behaviors play an integral role in health outcomes.

Physical activity. The health benefits of physical activity are numerous, from reduced risk of chronic diseases such as cancer, cardiovascular disease (CVD), and diabetes, to better mental health and reduced risk of all-cause mortality, as well as other positive health outcomes, including a better quality of life.104 The built environment has been linked to both physical activity and mental health outcomes. For example, more “walkable” neighborhoods are associated with better mental health among residents.105 For more information about the relationship between the built environment physical activity, and mental health refer to the Fitness WELLography™.

Diet and nutrition. Dietary behaviors and nutritional status are important individual-level factors for mental health. Nourishment is a major driver of obesity, a chronic condition that is bi-directionally linked to mental health outcomes such as depression.106 Additionally, food intolerance can lead to neurological symptoms including brain fog, depression, fatigue, headache, numbness in legs, arms, or fingers,107 anxiety, and seizures.108 For more information about the relationship between the built environment, nutrition, and mental health refer to the Nourishment WELLography™.

Sleep. Sleep is an essential human function that is necessary for optimal health and well-being.109 A healthy amount of sleep is generally a total sleep time of about seven to eight hours each night for adults and nine to ten hours for children and teenagers.110

Many factors influence sleep patterns, including individual factors such as the regularity of an individual’s daily schedule, alcohol, caffeine, and tobacco use, and dietary and physical activity patterns, as well as environmental factors such as temperature, sounds, and light exposure in sleeping spaces.32 111 In addition, although the mechanisms remain unclear, healthy sleep disruption may also be caused by the use of media or other activities and by physiological arousal in response to exposure to bright screen light.112 Collectively these exposures may suppress melatonin and alter the circadian rhythm.112

Altered psychological states and psychological disorders can also affect sleep patterns.111 While sleep disruption is often precipitated by a change in our mental health, this relationship is often thought of as bi-directional, as disordered sleep is also associated with poor mental health outcomes, including anxiety and depression.113

CDC data shows that 30% of adults report an average of less than six hours of sleep per night (compared to the recommended seven to eight hours).110 The data among youth also shows poor sleep outcomes, with 69% of high school–aged children getting less than the recommended nine to ten hours of sleep on school nights.110 Despite the prevalence and consequences associated with sleep loss and sleep-related disorders, it remains a highly overlooked public health issue.109 113

Health Effects

Numerous health effects have been associated with disordered sleep patterns, including poor mental health outcomes, heart disease, high blood pressure, obesity, diabetes, and all-cause mortality.109

Nervous System

Impaired brain function. The National Heart, Lung, and Blood Institute (NHLBI) states that sleep deficiency can affect mental health, general quality of life, and safety.114 Insufficient sleep has been associated with impaired function in certain regions of the brain, which can impact memory, learning, problem-solving skills, decision-making ability, and attention.114

Comfort and Focus

Affect and mood. Lack of sleep has been linked to several psychological states. Depression, mood swings, anger, and feeling stressed can all be side effects of lack of sleep.114 In addition, lacking sleep is also thought to be influenced by acute and chronic mental states. For example, depression and insomnia share a link: depression is a common cause of insomnia and insomnia can also lead to depression.111

An experimental study of ten elderly individuals and fourteen young adults examined the association of sleep and disturbed mood.115 Participants completed a survey on their mood states after nights of normal sleep and nights of disturbed sleep. Results found that lack of sleep was significantly associated with poorer mood, especially in the young adults.115

Endocrine System

Hormone imbalance. Studies have shown that sleep and lack of sleep can impact body functions by creating hormone imbalances including glucose metabolism dysfunction and elevated risk of obesity and diabetes.116

In a study examining the effects of chronic sleep loss, eleven healthy adult men were subjected to six consecutive days of four or less hours of sleep and had their hormone and metabolism levels measured in the baseline condition, sleep-debt condition (periods of lack of sleep), and sleep-recovery condition.117 The study showed that among those in the sleep-debt condition, glucose and insulin effectiveness decreased by 30% compared to those in sleep-recovery. There was also a decrement in thyrotropic function of the HPA axis, as well as disturbances in the levels of cortisol found circulating in the blood. The changes seen in these hormonal levels during sleep debt reflect the hormonal changes seen during aging, potentially predisposing those with chronic sleep loss to higher risk of diabetes, hypertension, and impaired cardiac, cognitive, and kidney function.117

Obesity. Increased risk of obesity has been linked to sleep deprivation.118 One reason for this is an imbalance of ghrelin and leptin, hormones that induce feelings of hunger and fullness.114

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Immune System

Decreased immune response. The NHLBI states that sleep has an effect on immune function.114 Insufficient sleep decreases immune responses, making individuals more susceptible to pathogens.114 Other studies also note those who sleep less are at higher risk of diminished immune function.119

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Reproductive System

Fertility. Puberty and fertility are influenced by sleep.114 In a study examining reproductive system function and sleep apnea in five men, participants were measured for luteinizing hormone and testosterone, two hormones required for reproductive health in men, before and after a nine-month treatment for sleep apnea. Hormone production in these men was dysfunctional before treatment, and partially corrected after the treatment.120

Cardiovascular System

Cardiovascular disease. Sleep is involved in maintaining heart health by healing heart tissues and blood vessels. Those with decreased sleep have a higher risk of cardiovascular diseases such as hypertension and stroke.114 A study of 30,397 adults collected information on sleep duration and cardiovascular disease through in-person interviews.121 The study showed that those with less than five hours of sleep at night had 2.2 times the risk of cardiovascular disease compared to those with seven hours, while those with more than nine hours of sleep had 1.57 times the risk of cardiovascular disease compared to those with seven hours.121

Comfort and Focus

Safety. People who have chronic lack of sleep can experience decreased productivity, lower performance, and microsleep at inappropriate times, increasing the risk of potentially fatal accidents and errors.114 122

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Focus and performance. Healthy sleep habits can play a role in decreasing and preventing stress. In a study on sleep and stress, those who received consistently sufficient sleep had a decrease in psychological strain and an increase in self-regulation, two factors used to measure stress.123 Researchers asked 96 American undergraduate students with no reported sleep disorders to log their hours of sleep and variation of hours over the course of a week to determine the amounts of consistent sufficient sleep they received. Participants were also told to complete the Sleep Hygiene Index and the Negative Event Scale to determine the frequency of stressors. Strain was measured by the Perceived Stress Scale and was used as the primary outcome and determinant of stress. Self-regulatory performance was measured by a handgrip task and used to determine sustained exertion, impulse control, and concentration. This study showed that those who received more consistent sleep had less strain and better self-regulation compared to those who received less consistent sleep.123

In a study on the effects of sleep on learning, six young adults were told to perform a recently learned task after a period of normal sleep or after a period of sleep deprivation, with sleep disrupted either during rapid-eye movement (REM) sleep or slow wave sleep cycles.124 Disruption of the REM sleep cycle was associated with lower performance or no improvement when undertaking the task.124


1. Healthy Sleep Habits

The CDC recommends improving sleep hygiene by going to bed and waking up at the same time each day, avoiding large meals before bedtime, and sleeping in a comfortable and gadget-free environment.110 125 In order to promote a shift toward these healthy sleep behaviors, Healthy People 2020 recommends sleep education programs that transcend socio-demographic disparities and are implemented in a variety of settings, including the workplace.109 Sleep hygiene has also emerged as a priority in academic communities where accreditation organization have begun to implement stricter policies and schedules that aim to improve sleep health among medical students as a method to enhance patient safety.15

The benefits associated with healthy sleep habits are widely documented, including improved cardiovascular health and immune function,111 and improvements in learning, performance, and safety.111

2. Physical Activity Promotion

The National Heart, Lung and Blood Institute (NHLBI) recommends spending time outdoors and being physically active to improve sleeping habits.114 In a meta-analysis of 38 studies on the effects of physical activity on sleep, exercise in daylight or bright light that focused on duration rather than intensity was shown to produce small increases in overall sleep time and longer periods of deep sleep.126 127 Two intervention studies showed that physical activity programs led to better sleep quality in poor sleepers, and the researchers also speculated that exposure to bright light during exercise might further increase sleep quality.127 More specific health outcomes associated with physical activity and sleep are outlined in the Fitness WELLography™.

3. Built Environment Design for Healthy Sleep

Design strategies that address acoustic and thermal comfort, healthy dietary behaviors, physical activity, and lighting are all associated with healthy sleep habits. More specific health outcomes and solutions are presented in the Acoustic Comfort, Thermal Comfort, Nourishment, Fitness, and Light WELLographies™.

2. Affect and Mood

Transient affective states and persistent emotional states (mood) are integral in the discussion of mental health and encompass how the mind perceives and responds to external stimuli.9 25 26 These states can have varying impacts on the mind and body by arousing additional emotions or feelings and through secretion of specific hormones that elicit a physiological response.10 Our psychological state and its’ effects on the body and behavior are generally temporary (feature of affective states), however, a prolonged state (feature of mood) can cause longer lasting physiological reactions that can either benefit or harm human health.11 128

As discussed in the Mind and the Human Body section, affect and mood are often discussed together. Affect describes the transient expression of internal experiences. Positive affect is associated with emotions such as joy, interest, or alertness, whereas negative affect is associated with emotions such as anger, guilt, fear, or sadness.9 These psychological states are intricately representative of the interactions between people and places (social and physical environments).9

Negative affect has been associated with poor health outcomes thought to be precipitated by impaired immune function (specifically inflammation).11 12 High negative affect is also included among the myriad of symptoms and psychological states associated with depression.29

Positive affect, although receiving less attention in the literature, has been associated with several positive physiological indicators including reduced activity of the neuroendocrine, inflammatory, and cardiovascular systems.12 128 Positive affect may directly improve health through several pathways, including healthy behaviors and activity of the autonomic, endocrine, immune system, and cardiovascular systems, and indirectly, through the stress response.10 Additional research suggests that positive affect is associated with reduced risk of cardiovascular disease, improved resistance to infection and physical illness, prolonged survival, and improved psychosocial factors such as social connectivity, perceived support from social circles, and optimism.129 130

Mood is related to internalized experiences and emotions in response to the environment and is a combination of both positive and negative affect over a prolonged period.25 26 The context, intensity, and duration of different mood states can play a role in physiological health and well-being. It is estimated that among adults in the U.S. there is a 21% lifetime prevalence of mood disorders, classified as the presence of major depressive disorder (clinical depression), dysthymic disorder, or bipolar disorder.131 Women are at a greater risk of having a mood disorder than men, and the average age of onset in those who have a mood disorder in the U.S. is 30 years old.131 Children are also affected by mood disorders, and there is a 14% prevalence of mood disorders among those between the ages of 13 and 18 years.132

Mood disorders such as depression can increase the risk of chronic diseases such as cardiovascular disease,134 135 cerebrovascular disease,136 137 and diabetes.135 138 139 Another consequence of disturbed mood is disordered motivation, which may pose additional health threats and is a key feature of depression.29 140

Of all mood disorders, major depression (also known as clinical depression) is one of the most common, affecting about 16 million adults in the U.S. and accounting for 8.3% of all years lived with a disability.133

Health Effects

Immune System

Immunosuppression. Prolonged negative affect states can increase the risk of mild immunosuppression due to increased glucocorticoid secretion.58 Glucocorticoids inhibit the proliferative ability of T-cells, thereby decreasing the function of the immune system.141

A meta-analysis of 24 studies on the effects of depression (a class of mood disorders) on pro-inflammatory cytokines involved in healthy immune function showed that individuals with depression had significantly higher concentrations of cytokines TNF-alpha and IL-6, which cause an inflammatory response and can affect brain function.142

Cardiovascular System

Heart disease. According to the Heart and Vascular Institute at Johns Hopkins University, otherwise healthy individuals with depression (marked by both high negative affect and disordered mood)29 have a higher incidence of heart disease than the general population.143 Furthermore, a meta-analysis of cohort studies from 1966 to 2000 found depression to be a predictor of coronary heart disease.144 Depression has also been associated with several of the major cardiac risk factors, including hypertension and diabetes. However, it is believed that depression either precedes or occurs independently of other cardiac risk factors, making it an independent predictor of heart disease.145

A review of studies investigating the effects of worry and generalized anxiety disorder on cardiovascular health and coronary heart disease found an association between worry and the development of coronary heart disease.146

Heart rate. A cohort study of 89 elderly coronary heart disease patients with and without depression investigated the association between depression and detrimental changes in autonomic nervous system activity. Patients with depression had a significantly higher risk for elevated heart rate compared to non-depressed patients.147

Plasma fibrinogen. A cohort study was conducted to show the effect of happiness (associated with positive affective states) on cardiovascular activity in adults, finding that those with low levels of self-reported happiness had elevated biomarkers predictive of future heart disease.128

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Nervous System

Brain damage. There has been evidence to show that the sustained increase in glucocorticoid level caused by depression is linked to damage of the hippocampus and frontal cortex in the brain, which can cause problems with declarative memory.58


1. Nature Incorporation

Several empirical studies have found that natural environments can have a positive impact on health by increasing positive affect, lowering psychophysiological arousal, cognitive fatigue, and stress, and improving the ability to perform tasks that require concentration.18 78 81 82 83 84 85

Connections with nature including direct access to the outdoors or window views of natural elements or through exposure to natural elements indoors are associated with various health benefits including reduced blood pressure and heart rate, improved attention, improved mood and overall happiness,90 reduced job related stress, improvements in overall health status, and higher job satisfaction.89 A study that compared psychophysiological stress recovery and directed attention restoration in natural and urban field settings found that natural settings lowered diastolic blood pressure, increased positive affect, decreased anger, and improved performance on an attention test.86 Among employees, window views of nature are associated with lower stress levels, higher health status, and higher job satisfaction across an array of workplace settings compared to employees who lack windows or have other built environment views.89 It has also been found that exposure to natural artwork has similar effects to actual nature views. In a patient population, positive emotional responses were associated with artwork that depicted nature scenery, while more abstract art was perceived as emotionally challenging and was consistently disliked by patients.89

Non-visual exposure to nature can also be used as a strategy to incorporate restorative elements into the built environment. Exposure to elements that represent nature, including smells or sounds, are associated with reduce blood pressure and stress hormones, improved cognitive performance and perceived improvements in mental health and tranquility.90

2. Design Interventions

Various aspects of the ways in which a space is designed, including the physical elements and layout, along with aesthetic features, have the potential to impact human health and wellness. In a randomized control trial of 152 adults on store design and consumer mood and behavior, participants with higher satisfaction (which was used as a proxy for mood) were those that walked through a store that was newly renovated compared to those that walked through a non-renovated store.148 The renovated store incorporated features suggested to alter one’s mood such as more and brighter colors, a well-structured walking route, wider entryways, and more natural light compared to the non-renovated store, which was painted to make the ceilings look lower.148

In a review of the ways that healthcare geographers can contribute to hospital design, researchers found that building layout, from radial designs to single and double corridors, can impact mood.149

Researchers also theorize that specific elements of design can elicit symbolic associations that in turn can produce positive or negative feelings. Color is one such example, such as the association between the white color of a doctor’s coat and purity and honesty. Names are another, the name “Starship,” given to a children’s hospital in Auckland, New Zealand, evokes a sense of adventure akin to Star Trek in order to provide assurance to young patients.149

According to the International Living Future Institute (ILFI), incorporating beauty into the design of a space can contribute to uplifted human spirit.150 Adding artwork into a space can also be used to create a calming environment, which can also improve mood.150

3. Spatial Adjustment

Design strategies that incorporate space and furniture flexibility can also increase a sense of control (also known as Locus of Control) over the space, which can in turn impact psychological well-being. A study of 70 residents of an elder care home found that subjective well-being was greater after two shared communal spaces were refurbished to extend the possibilities of controlled interaction by providing more gradation of spaces and furniture that could be easily rearranged to accommodate different levels of privacy.64

Control of the immediate physical environment through personalization of one’s workspace was shown to enhance well-being in a study of 338 workers at 20 companies across a variety of industries.14 Other studies have also noted the benefits on well-being of spatial personalization among patients living with dementia.72

4. Opportunities for Input

Architectural programming that aims to understand the values and goals of building occupants and the community at large is essential in creating a high-quality spaces.65 A participatory design process and user-centered design approach can lead to spaces that better serve occupant needs and increase overall satisfaction with the environment.66

Allowing individuals to offer suggestions and comments regarding their surroundings can influence mood.67 One study looked at how the users of a hospital, from patients to staff, would react to the opportunity to provide input into the space’s design.67 Three similar nursing units were selected to participate: in one unit, users were allowed to provide primarily open-ended feedback on minor renovations, while the other units were given no such opportunity. The results of the study showed that those in the units who could offer their input had the biggest changes in mood and morale and perceived quality of care.67

5. Workplace Equity

In a two-year prospective cohort study examining the relationship between workplace justice and depression, researchers followed over 4,000 non-depressed Danish public employees and measured their self-reported depressive symptoms, and perceptions of procedural and relational justice.151 Results showed that those with lower levels of perceived workplace justice were at higher risk for developing depression.151

6. Altruism Programming

A systematic review of studies on altruistic behavior and health, found that compassion and charitable activities are associated with greater happiness, well-being, and longevity.152 Specifically, one study in this review, a cross-sectional study of 2,016 church-going U.S. adults, found a positive association between helping others and better mental health.152

In addition, a study exploring volunteering among older adults found that those who volunteered had higher rates of satisfaction and lower levels of self-reported the negative emotions associated with depression and anxiety compared to those who did not.153

7. Stress Management Programs

The CDC recommends that workplaces include stress management classes or seminars as a part of their employee wellness programs.102

A randomized control trial looked at the effects of a stress management program, the Inner Quality Management Program, on 38 employees with hypertension.154 The 16-hour program taught participants techniques to decrease stress through the use of emotion refocusing and emotional restructuring. Those who participated in the program had increases in positive outlook, peacefulness, and workplace satisfaction and decreases in stress, depression, and global psychological distress, in addition to better blood pressure.154

8. Healthcare Provision

A randomized controlled trial of 12,229 adults in the state of Oregon examined the effects of the availability of insurance on mental and physical health.155 In 2008, the state was undergoing a limited expansion of Medicaid, but because demand exceeded the allotted enrollments, residents were assigned coverage under a lottery system.

Approximately half of the subjects had received coverage, while the rest had not. Two years after the allotment, the researchers found that those who were selected for Medicaid had a 9% decrease in risk for depression compared to those who were not selected into the program.155 Another study looking at the relationship between depression and health insurance coverage among individuals in China found a link between depression risk and whether or not an individual had health insurance.156 Even after controlling for confounding variables, depressive symptoms more severe among individuals without any form of health insurance.156

9. Physical Activity

The U.S. Department of Health and Human Services (HHS) recommends that adults undertake at least 75 minutes of vigorous-intensity physical activity or 150 minutes of moderate-intensity physical activity each week.157 The relationship between regular physical activity and mental health has been well-documented in the literature. For example, in a review of randomized control studies, physical activity was associated with a decreased risk of developing depression.127 In this review, experimental studies of aerobic and resistance activities report that these activities decrease symptoms of depression.127 Physical activity has also been shown to be moderately effective as a treatment strategy for anxiety and depression 158 and may be as effective as psychotherapy interventions.127

However, the association between physical activity and psychological well-being may be dictated by intensity. One study found a dose-response pattern in men: those who participated in physical activities that burned more than 2,500 calories a week had a greater decrease in risk for depression compared to those who burned fewer calories.159

3. Chronic Stress

Stress can be defined most simply as a response to demands placed on the body by internal and external conditions or circumstances.160 Some stress can be considered positive, as it causes the body to release catecholamine hormones that help individuals effectively respond to changing environmental demands.160 However, when persistent, stress can negatively impact psychological and physical well-being. “Stress” is a term often used to describe states of worry and feelings of being overwhelmed.161 When persistent, stressful states can have extreme health consequences including increased risk of depression, cardiovascular disease, diabetes, and upper respiratory infection among other adverse health outcomes.162

Historically, the stress response was an evolutionary advantage that allowed organisms to evade danger.

Today, modern life stressors contribute to the same physiological flight or fight responses our ancestors experienced but persist beyond what the body can adapt to.160 163

According to a 2015 report from the American Psychological Association, financial, professional, familial, and personal health related concerns are the leading sources of stress affecting Americans.164 High stress levels disproportionately affect parents, younger generations, and individuals from lower-income households.164 More specifically, parents with high fiscal stress engage in coping strategies, such as drinking alcohol or smoking, at higher rates than parents with low financially-related stress, with similar trends in coping strategies being found among millennials.164 While reports indicate that overall stress levels have been on a decline since 2007, they are still higher than what is considered healthy,164 and thus pose significant health risks.

Health Effects

Cardiovascular System

Cardiovascular diseases. A systematic review and meta-analysis of fourteen prospective cohort studies, providing a sample size of over 83,000 workers, found the excess risk of congenital heart defect (CHD) caused by job-related stress to be about 50%.165 A second review noted that prospective research conducted among healthy populations consistently shows a link between stress and cardiovascular disease morbidity and mortality.166

Respiratory System

Common cold. In a study of 276 healthy adult volunteers, exposure to major stressful life events was associated with elevated odds of developing a cold following rhinovirus exposure (OR = 1.99), a finding consistent with the prior literature. Researchers posited that chronic stress causes a detriment to the sensitivity of immune cells that regulate the inflammatory response, which heightens the risk of respiratory events.162

Asthma. A recent review examining the relationship between stress and asthmatic events found evidence of elevated immune system activity in response to asthma triggers and that this amplified response is found in the context of common chronic stress scenarios such as low socioeconomic status.167

Infection. A review examining the literature on stress and asthmatic events and symptoms among healthy adults found that chronic stressful experiences are associated with increased risk of respiratory illness.167 Researchers linked stress to elevated disease risk through an excessive inflammatory response.167

Endocrine System

Obesity. In an analysis of 14 cohort studies, researchers noted that across the majority of independent studies collected in their review that there was no significant relationship between stress and body fat; however, after pooling independent study results in a meta-analysis, researchers found a significant, positive association between body fat and stress.168 A five-year longitudinal study looking at BMI and stress among 5,118 participants found that psychosocial stress (including both perceived stress and reports of stressful life events) was positively associated with weight gain but not weight loss.169 Among study participants, those with high levels of perceived stress at baseline experienced a 0.20 kg/m greater mean change in BMI compared with those with low stress, and individuals who experienced two or three or more stressful life events had a 0.13 kg/m and 0.26 kg/m greater increase in BMI compared with those who experienced none.169

Comfort and Focus

Sleep disorders. In a study of 1,300 middle-aged men and women, stress was more strongly associated with sleep duration than BMI, with evidence present of a synergistic effect of BMI and stress on sleep duration.170 Another study of 760 Australian nurses working at a large metropolitan hospital found that chronic stress and psychological strains induced by a high work pace affects sleep quality and impair recovery between shifts, a combination that is predictive of serious maladaptive stress and fatigue related outcomes among nurses.171

Depression. If improperly managed or ignored overtime, chronic stress can lead to serious mental health consequences, including anxiety and depression.172 Stressful life events are linked to both symptoms of depression and major depressive disorder, with past findings indicating that 50%-80% of individuals who are depressed have experienced a major stressful life event compared to only 20%-30% of non-depressed individuals.166 Researchers also note that these stressful events are associated with an attenuated response to treatment and longer, more intense symptoms of depression.166


1. Stress Management Programs

The CDC recommends that workplaces include stress management classes or seminars as a part of employee wellness programs.102

A past randomized control trial looked at the effects of a 16-hour stress management program on 38 employees with hypertension.154 Participants were taught techniques to decrease stress through the use of emotion refocusing and emotional restructuring. Those who participated in the program had increases in positive outlook, peacefulness, and workplace satisfaction, decreases in stress, depression, and global psychological distress, and improved blood pressure.154

A review of seven randomized trials and three cohort studies notes a variety of potentially useful strategies for implementing a successful stress management program.173 Approaches using exercise, music, and relaxation training were shown to be “potentially effective,” while programs that focused on social support were “possibly effective.” Researchers, however, were hesitant to expand their conclusions in this review due to the small sample sizes across studies reviewed in the literature.173

2. Physical Activity Promotion

The U.S. Department of Health and Human Services (HHS) recommends that adults undertake at least 75 minutes of vigorous-intensity physical activity or 150 minutes of moderate-intensity physical activity weekly for health benefits.157 Exercise is also a key component for stress reduction and prevention. Regular physical activity is associated with release of stress-reducing neurotransmitters (endorphins), relaxation, and reductions in symptoms commonly associated with depression or anxiety; collectively, these benefits help ease daily stress levels.174

Social Conditions

The term “psychosocial” refers to an individual’s psychological relationships with their social environment. Among many other drivers, social factors, including the degree of social interactions, a sense of connectedness to social and/or cultural groups, and attachment to places and organizations play an important role in mental health outcomes.

Much attention has been given to the role of social conditions in wellness. At the individual level, social conditions such as the structure of a network, receipt of support, and the quality and quantity of meaningful social interactions and relationships have been identified as important predictors of health,175 including mortality, even when adjusted for other biomedical risks.176 Beyond the level of the individual, social capital is a social condition that applies most readily to groups and has been associated with well-being. Social capital at this broader scale encompasses the social processes between many individuals that bind networks and make cooperative action a reality.177

1. Social Environment

Components of the social environment, including support and capital, are thought to impact health and wellness through a variety of pathways. Social support is defined as a social network’s capacity to provide psychological and physical resources to its members. Of interest are the specific resources provided by healthy social networks that impact an individual’s ability to cope with stress.175 Positive social relationships are thought of as critical psychosocial buffers for the many risk factors associated with poor mental health outcomes including depression.178 Another key component of the social environment is social capital, which includes elements of social relationships (e.g., concrete social network ties), as well as a resource or benefit component at either the individual or collective level (e.g., trust).179 Social capital encompasses several constructs, including the flow of information, reciprocity, collective action, and broader social identities.180 Much of the research regarding social capital and health outcomes has focused on social capital as a mediator between socio-economic disadvantage and health, including mental health outcomes.179 Collectively, these social conditions of the environment are promising targets for built environment interventions.

The built environment can play a role in assisting or deterring the formation and maintenance of strong social ties.

For example, overcrowded, dangerous, and poorly served neighborhoods without safe public spaces for play and social gathering tend to discourage social interaction among children and adults.181 182

Safe, walkable neighborhoods and well-maintained buildings with multiple shared services, amenities, and gathering places help in promoting the formation of strong social ties and may also encourage physical activity and 181lower reports of depression and alcohol abuse.183 Characteristics of an individual’s environment are also associated with social capital. Among these characteristics is collective efficacy, which relates to an individual’s ability to control or mitigate the effects of stressful life events within a community as they occur.184

Health Effects

Overall Health

Mortality. In a review of the literature, a meta-analysis of 148 studies found a 50% increase in survival in those with strong social relationships compared to those with poor social relationships.185 These study findings held after adjustment for demographic and clinical factors.185

Nervous System

Stress response. Researchers have sought to identify the psychological mechanisms at play in the relationship between social behaviors and overall well-being, positing that the association is likely acting through the same neural circuits that are important for mental well-being (SNS and HPA axes).186 Thus, poor social connectivity may elicit a threatening physiological response and, when prolonged, can have similar adverse health outcomes as other environmental stressors.186

Depression. In a study of 4,000 individuals living in New York City, low collective efficacy (construct of social capital) was associated with major depression.184 Specifically, researchers observed a 6.2% lower prevalence of depression among older adults in the high versus low collective efficacy neighborhoods, with similar results observed among adults in younger age groups.184

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Other studies show that social ties such as perceived presence of a caring peer or sense of connectivity to one’s neighborhood are negatively associated with depression and stress symptoms.178

Cardiovascular System

Cardiovascular diseases. A literature review on the effects of social ties on health found an association between social connectivity and cardiovascular health across three studies.187 People with greater social integration had a lower risk of coronary heart disease and myocardial infarction. However, the paper pointed out a number of inconsistencies, with some of studies not showing any association (thought to be due to high-risk relationships and problems with family exacerbated by social integration) and other studies showing an association only for those married and/or not living alone. Nonetheless, there is strong evidence that social integration is associated with better post-myocardial infarction or stroke prognoses.187

In another review, social isolation and loneliness, indicative of poor social relationships, was associated with 50% excess risk of coronary heart disease.188 A recent review looking at the relationship between social relationships, health, and longevity found that social isolation in older age has a more powerful effect on hypertension than clinical risk factors such as diabetes.189

Immune System

Diminished immune function. A literature review on the effects of social ties on health notes that at least three studies show that those with greater social isolation and non-supportive social interaction have an increased risk for decreased immune function, measured by a decrease in antibodies seen in single adults compared to married adults.187 Three other studies in this review showed similar effects in individuals among those caring for a spouse with Alzheimer’s disease.187 Recent reviews have also noted the association between problematic social relationships, diminished immune function, and subsequent inflammatory processes.188

Endocrine System

Hormone imbalance. A cohort study of adults showed that elderly men with greater social integration (measured by reported social ties) had lower levels of stress hormones (lower norepinephrine, epinephrine, and cortisol).187 A comprehensive review of the literature published between 1970 and 1998 found that negative social interactions are marked by elevations in stress hormones in the body.190


1. Altruism

Psychologists posit that volunteering fulfills numerous social functions: it provides a way for people to express their values, can provide career-related experiences, strengthens social relationships, and may provides a way for individuals to overcome personal problems such as guilt.191 Furthermore, the Mental Health Foundation states that helping others increases social support by increasing feelings of belonging while decreasing feelings of isolation and loneliness.192 For example, past research shows that older adults who volunteer experience less depressive symptomatology, lower utilization of health services, and greater overall life satisfaction.193

Organizations can take a varying approach to volunteering and altruism. Organization can elect to participate in organization-wide volunteer programs or offer employees opportunities to engage in ways that are meaningful to them.

2. Organizational Attachment

Early research defines organizational attachment as commitment to the goals and values of an organization and/or to a role within that organization.194 It has since evolved to include the psychological bond between employer and employee. Of note, it is distinct from the affective sense of commitment to an organization that traditionally includes psychological and behavioral involvement.195 Organizational attachment is thought to be determined by many factors, including demographics, nature of the work and job characteristics, the work environment, social relationships, and level of organizational support.195 196 197 An ongoing area of exploration is the study of the mechanisms through which organizational attachment impacts health and well-being. Some evidence suggests that psychological stability generated by positive social bonds with an organization may help explain health outcomes.200 Other work by experts in the field reminds us that organizational attachment is a complex construct that works through many pathways.201 Notably, some researchers have focused on the degree of psychological support from an organization as an important predictor for various health and job-related outcomes, noting that individuals who feel a great sense of psychological support from their organization have greater attachment to the organization.198 Low organizational attachment can have implications for absenteeism, performance, efficiency, and retention.195 199

Health Effects

Comfort and Focus

Performance. Affective components of organizational attachment involve the psychological and behavioral relationship between employees and employers. These processes impact affective states, which in turn impact job performance.195

In a study incorporating a diverse group of workers, a positive relationship was observed between perceived employer support and job performance. Here, job performance was also associated with feelings of affiliation and loyalty to the organization.202

The literature has also presented several other outcomes associated with lacking psychological support from an organization including increased absenteeism, loss of productivity, and increased costs.198

Stress and affect. Benefits of attachment have also been shown to reduce the degree of stress experienced by executives in the workplace. Fortunately, these positive effects are also found for other individuals who view their organization as a place of security.200 Additionally, a study of 117 university employees found that the interaction between supervisor support and a worker’s organizational attachment orientation (secure, anxious, or avoidant) significantly predicted self-reported intensity of work stress and job satisfaction.203


1. Positive Organizational Culture

Strategies that consider people’s psychological needs provide ample opportunities to foster a positive relationship between employees and their organizations.204 Experts note that strategies that promote organizational attachment require attention to numerous factors that influence this development over time and at different stages in an employee’s career.201

3. Attachment to Place

Drawing from research in environmental psychology, urban planning, and human geography, attachment to place is an emerging area of research due to the evident connections between place attachment, human health and well-being,205 and sustainable community development.206 Psychologically, this experience has been conceptualized in a variety of ways, such as: a sense of place, place dependence, community sentiment, and a sense of community.207 Generally, attachment to place describes the emotional attachment that results from steady growth and accumulation of a place’s sentimental value.205 Place attachment is a complex and multifaceted phenomenon that draws upon various aspects of how individuals bond with places including affect and emotions, knowledge, beliefs, and behaviors.208 Many factors have been shown to impact the degree to which individuals become attached to places, including participation in activities and the presence of significant social relationships.207

Research on this topic has found that people tend to connect with green space, and as our environments become increasingly urban, the availability of green space may be an important leverage point for maintaining place attachment and well-being.205 However, research has also shown that attachment to cities and communities also fosters well-being,209 including social well-being.208

Health Effects

Comfort and Focus

Affect. In a review of the psychological dimension of place attachment, researchers noted substantive evidence that place-attachment involves dimension of affect.210 Both positive and negative affect can be associated with attachment to place. For example, a childhood home might be considered an important place to an individual but elicit negative emotions. However, researchers often note that place-attachment is commonly described in the literature and in research using terms associated with positive affect.210

General mental health. In a survey of 223 residents of two different Dutch neighborhoods, mental health was assessed with a five-question survey. Researchers found that mental health scores were significantly lower in the neighborhood with lower reported green space attachment. Researchers posited that improved contact with green space may improve mental health by mitigating attentional fatigue and stress.205 Additional research shows that individuals who have less green space, are dissatisfied with their access to green spaces, or perceive green and open spaces as far from home are at a greater risk for anxiety, depression, and poor mental health outcomes.211 212 213


1. Nature Incorporation

Green space and other elements of nature incorporation have the potential to facilitate attachment to place due to their restorative nature, opportunities for social and active engagement, and familiarity.214 Environments that promote restoration have the potential to provide relief from fatigue-inducing stressors, and can help moderate the stress, irritability, and overall negative effects that result from cognitive fatigue.13 215

2. Design Interventions

Spaces can impart many health advantages when designed with the needs of the users at the forefront. Spaces that consider the personalities and culture of its users have more potential to foster meaningful connections between a space and its users. By considering how spaces will be used and by whom, designers can create spaces that minimize stress by providing opportunities to seek privacy, collaborate and connect with others, rest and relax, and work.204

3. Opportunities for Input

When occupants have an opportunity to inform the design of the spaces they use, their input may help improve the suitability of such spaces for the activities that take place within them. Effective architectural programming that aims to understand occupants, their values and goals, and the community at large is essential in creating a high-quality design and program.65 In addition, a participatory design process and user-centered design approach can lead to the design of spaces that better serve occupants’ needs, increasing occupants’ satisfaction with their environments.66

Explanations of Solutions

Design Interventions

Artwork, color, architectural design, and light in the indoor environment can be used to elicit different mental states. Artwork has been shown to create a calming environment, which improves occupants’ mood.150 While certain colors are believed to have psychological effects by drawing on memories of the viewer, there is no consensus on which color evokes which mood. Often, the five bright principle colors of red, yellow, green, blue, and purple elicit more positive emotions compared to intermediate hues (mixed colors) and achromatic colors (black, gray, and white).216 Well-structured circulation routes and entryways along with natural light can also be manipulated to impact mental well-being.148

Nature Incorporation

The biophilia hypothesis, introduced by Edward Wilson in 1984, is the idea that humans and nature are connected, thus suggesting that humans have an affinity with the natural world.217 Nature can be incorporated into indoor environments using pictures, sounds, indoor plants, or water features. Some examples of biophilia in the workplace include windows that face nature and increase incoming daylight, interior waterfalls, aquariums, and plant walls.217

Space Adjustment

Spatial adjustment provides an individual with the ability to change the physical indoor environment.14 At the workplace, this can be done by allowing employees to physically adjust their environment to be more comfortable in terms of acoustics, ergonomics, and presence of others, or by giving them the flexibility to move to another part of the workplace that better fits their needs.

Space adjustment also requires workspaces to have different work areas for employees to choose from. Workspace design should include private as well as open areas. Both areas should take visibility and acoustics into account. Private areas should allow for one-on-one conversation without a risk of being overheard, while open spaces should foster conversation.

Opportunities for Input

Occupants should be able to effectively provide input about their environment in a capacity where comments are taken into consideration without negative repercussions. Occupant feedback can be solicited in many ways such as regular occupant surveys or forums.


Altruistic acts are generally done through charitable activities or by volunteering at the individual, community, or organizational level. There are many ways to promote altruism in the workplace, such as creating a code of conduct that encourages employee involvement in charitable activities. Another way is to provide examples of altruistic individuals for employees to model, particularly those who were or are company leaders or societal exemplars.218 Workplaces can also partner with community organizations to provide opportunities for employees to volunteer and make donations.

Business Travel Policies

Business travel policies encourage healthy habits and protect employee health while traveling. In a symposium hosted by the World Bank on business travel, stress, and health, occupational health and travel medicine specialists from influential universities and hospitals advised methods to decrease business travel stress. Their suggestions included setting and enforcing limits on the amount of travel, efficiently managing travel schedules to minimize last minute trips, limiting international trips, providing days off to compensate for frequent trips and weekend work, and allowing calls home at the company’s expense.219

Based on the most common complaints of business travelers, companies should adopt travel policies that prevent inconvenient travel times, poor hotel quality and location, last minute and weekend travel, excessively long trips and layovers, and unhealthy eating.220

Distribution of Educational Materials

Educational materials such as reading material, online or offline programs, and other resources should be provided on health and well-being in locations accessible to all occupants and at varying literacy levels. This can also be done by having a physical or online library in the workspace, made available to all occupants, or by providing occupants access to other sources of information. Posters, flyers, leaflets, and other materials can also be distributed in the workplace on educational topics.

Healthcare Provision

Workplace health care policies and employee wellness programs that provide access to comprehensive care and opportunities and that address multiple health issues in diverse ways are necessary to influence the health of employees inside and outside of the work environment. The CDC states, “workplace health programs are not add-on benefits but basic investments in human capital, similar to training, mentoring, and other employee development programs.”102

Healthy Sleep Habits

Healthy sleep policies encourage a healthy amount of deep and consistent sleep. Allowing employees a space and time to nap at work, allowing breaks to decrease fatigue, and limiting late night work are examples of policies encouraging healthy sleep. Another method to promote healthy sleep is to set caps on consecutive hours of work, such as limiting scheduled work to 12 hours to give employees at least 11 consecutive hours of rest every 24 hours. Employers can also provide employees with education about sleep health and with screenings for sleep disorders.221

Stress Management Programs

Stress management programs provide services to help people learn healthy ways to manage and reduce stress. These services can include confidential counseling to employees, providing a specialist who can increase awareness of stress, and monitoring measures meant to reduce stress.

Technology-Supported Components

Technology-supported components are used to aid people in healthy living efforts. Examples of this type of support are self-monitoring devices such as fitness detectors and pedometers. Electronic programs that support coaching can also be used to help keep track of physical activity and biometric measures.

One example of a wellness-promoting technology that is rising in popularity among workplaces is wearable activity trackers. It is estimated that in the next couple of years, thirteen million wireless wearable trackers will be incorporated into employee wellness programs. These trackers are predominantly used to increase physical activity and maintain or decrease weight. Before integrating these wearable trackers into workplace wellness programs, employers are advised to consult with HIPAA and the ADA for compliance.222

Workplace Equity

Workplace equity policies enforce or encourage fair and equal treatment of all occupants. This can be achieved through transparent employee evaluations. Workplace equity can encompass equal opportunity to be recognized for achievements, fair promotions, fair appeals, and transparency of pay.223

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A systematic review of 18 studies documenting the effects of aromatic chemicals on mood, physiology, and behavior was conducted in order to gain a better understanding of the relationship between olfaction and human health.39 Researchers tested the pharmacological (response of the nervous and endocrine systems) and psychological hypothesis (emotional learning, perception, beliefs, and expectations), which predominate the mechanistic theories for the psychodynamic and physiological effects of odors on the human body. Results of the studies under examination showed that odor appears to significantly affect mood, cognition, behavior, and physiology through the psychological pathway proposed.39

In a study of 175 males with a median age of 24 living in Pune, India, researchers found that 58% of residents from “high-density homes” reported lacking a sense of privacy compared to only 35% from “medium-density homes” and 31% in “low-density homes.”47 Analyses indicated that density of the home (categorized as < 1.6, 1.6-3.25 and > 3.25 persons per room) was negatively correlated with reported social support (r = -0.39) and positively associated with psychological symptoms (r = -0.21), such as anxiety. Researchers note that the inverse association with social support may help explain some of the indirect effects of crowding and privacy on mental health, as poor social support has been independently associated with poor health outcomes.47

In a study on directional choice in a virtual environment, researchers found that wider and brighter paths were more likely to be chosen except when conflicting signage was present at path selection decision points, consisting of signs pointing in the opposite direction of brighter and wider corridors.77 In such instances, participants in the study were more likely to comply with the signage.77

A study of 112 normotensive students randomly exposed participants to various experimental conditions including 1 of 2 environmental conditions (natural or urban) cross with 1 of 2 task conditions (task, no-task).86 Each environmental condition was composed of 2 phases. The natural condition included a view with trees and a walk in a nature reserve. The urban condition included a room without views and walking in an urban area comprised of office and retail spaces. Participants used an ambulatory blood pressure monitor and were asked about pre- and post-test emotions including affect, fear, anger, and attention. Results showed that exposure to natural environments fostered better blood pressure attenuation than urban views.86

A study of 7,547 pregnant women found that access to green space was associated with an 18-23% reduction in reported depressive symptoms compared to women who had less access (measured by the distance between a participant’s home and green space).87 Researchers also noted that this positive effect was particularly strong for disadvantaged women.87

In a small study of 12 female nurses using qualitative and quantitative data collection methods, the participants identified that spaces with physical access to the outdoors were more likely to be “rated” as restorative than spaces with window views, indoor plants, and/or artwork dispersed throughout the space.88 Additionally, this study highlights the importance of the location and proximity of restorative spaces to the work area, which may dictate an individual’s perception of restorative potential. Researchers noted that improvements in restorative quality of a space may have a positive impact on satisfaction, job stress and job performance.88

In an observational study researchers tested 408 adult type-2 diabetes patients for health literacy using the Test of Functional Health Literacy in Adults (s-TOFHLA) and glycemic control using hemoglobin A1c levels.94 Based on these measures, patients with inadequate health literacy scores (16 or less out of 36) had 2.03 times the adjusted odds ratio of poor glycemic control and 2.33 times the adjusted odds ratio of retinopathy, a diabetes-related complication that may result in blindness, compared to those with adequate health literacy.97 However, other studies note that the relationship between health literacy and diabetes control requires further exploration due to inconsistency in the literature.94

175 asthmatic adults (83% women) enrolled in an observational cohort study (n = 224) qualified for a sub-study investigating the impact of health literacy (measured with the Test of Functional Health Literacy in Adults) and asthma outcomes over a two-year follow-up period.101 In addition to worse physical function (p = .0007) and excess emergency department use (p = .03) asthma-related quality of life was also affected by poor health literacy (p = .009).101

A prospective study, with the participation of 6,107 elderly adults, compared BMI and sleep duration, measured by actigraphs and clinical visits.118 Those with less sleep were at higher risk of obesity, with adults who slept under five hours a night having 2.5 kg/m2 (men) and 1.8 kg/m2 higher (women) average BMIs than those who slept seven to eight hours a night.118

In a controlled trial of 42 healthy men, immune markers were measured before and after a period of sleep deprivation.119 After a night of no sleep, the number and activity of natural killer cells and lymphokine-activated killer cells (cells necessary for proper immune function) decreased and interleukin-2 production was suppressed. These changes suggest that those who sleep less are at higher risk for decreased immune function.119

A study of 895 nurses measured the association between sleep and drowsy driving episodes.122 After adjustment, those who had difficulty remaining awake at work (odds ratio of 2.93), worked at night (odds ratio of 2.74), had long work hours (odds ratio of 1.53), or low sleep duration (odds ratio of 0.93) were more likely to experience a drowsy driving episode.122

In a sample of 216 adults, positive affect was measured by asking participants to rate their happiness over the past five minutes on a scale from 1 to 5 over the course of a day.128 The results showed those with the lowest happiness ratings had a 3.72 increased odds of plasma fibrinogen, a predictor of future coronary heart disease, compared to those with the highest happiness levels.128

In a sample of 4,000 adults 18 years or older, researchers investigated the association between neighborhood collective efficacy and major depression (184). After adjusting for demographic and socioeconomic characteristics, recent life events that could contribute to depression and perceived collective efficacy researchers found a strong association between neighborhood collective efficacy and major depression. Models estimated a 6.2% (95% confidence interval: 0.1, 17.5) lower prevalence of depression if all older adults (65 years and older) had lived in high versus low collective efficacy neighborhoods. Similar results were suggested among younger adults; however, the confidence interval crossed the null (184) .

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