Evidence-based design is driving best practices in the U.S., but can we expect similar outcomes when research conducted here is applied abroad?  This is an important question to start answering given the large number of healthcare projects around the world being designed by American firms. 

The Middle East is a region with particular interest in this discussion because of the current volume of projects in design and construction. The region’s cultures differ from the West in fundamental ways, yet Western models of healthcare planning and design are being embraced and replicated with little adaptation.  

One example is in the concept of time. America has a monochronic concept of time in which we do one things in an orderly fashion and schedules are highly valued. However, people in polychronic cultures, such as the Arabic Middle East, tend to do multiple things at once and change plans often, valuing relationships over maintaining a strict schedule.  

One implication of this difference in healthcare design can be seen in our focus on reducing wait times to improve patient satisfaction. While long waits are seen as having a negative impact on patient stress in America, they may not have the same negative impact in a polychronic culture.

Adapting EBD principles overseas

Many hospitals projects in the Middle East, especially in Saudi Arabia and Qatar, have implemented Western evidence-based design (EBD) strategies, like providing access to views of nature and family zones in patient rooms. However, relatively few of these facilities are operational and even fewer have undergone the full EBD process to measure outcomes. 

As more projects begin to follow EBD principles, there needs to be a greater understanding of which EBD strategies are culturally specific and which can be generalized across cultures by replicating major EBD studies in other cultures and following up with the rigorous pre- and post-occupancy evaluations. Until this is done, we can invest in general cultural research and hypothesize where there are likely to be similarities and differences to guide design decisions.

For example, providing access to daylight is not a straight-forward strategy where more is better.  In parts of the Middle East, the intense sun is viewed as something to be avoided.  Therefore, the design strategy should be to filter daylight through a screen to illuminate a space and make it more comfortable and appropriate for the region. 

Cultural research is a key part of evidence-based design that should ideally begin before programming.  This method can include primary research, such as observation, interviews, and surveys, and/or secondary research in the form of literature reviews and analysis of previous primary research. 

Primary cultural research requires considerable time and expense, and travel is often restricted, while secondary research is a far easier undertaking for designers and architects working abroad. Those who do spend extended time in the Middle East are also great sources of primary knowledge to be extracted and shared.

Accounting for cultural differences

Although many clients request a hospital design based on Western standards, many of our planning metrics must be adjusted to support the needs of the specific population. 

For example, when planning clinic waiting areas for facilities in the Middle East, expect patients to be accompanied by more than one family member, since medical decisions are often family decisions. 

Designers should plan for seating to be arranged in clusters that families can claim and try to make them all the “best seat in the house.” This can be accomplished by creating a layout where every cluster has a positive distraction, such as a view to a courtyard garden, rather than a layout where only one or two clusters have a view.

These cultural considerations also mean that larger waiting areas should be programmed, with a greater number of seats per patient and more space allocated per seat.

Future research

In the scientific world, the more a study is replicated in different settings, the more we can rely on its findings.  With all of the international design work underway by large firms with research capabilities, it’s time to start replicating the classic evidence-based design studies, such as the effects of daylight on patient stress, satisfaction, and length of stay.   

The collective evidence-based design knowledge needs to expand globally in a way that acknowledges the differences that distinguish cultures and the commonalities that unite them.

Bonny Slater

Bonny Slater is an associate and senior interior project designer in Perkins+Will’s Washington, D.C. office.  She can be reached at bonny.slater@perkinswill.com.


For more on international design, check out:

Part one: Designing Abroad: How Sustainability Is Making An Impact In The Middle East

Part Two: Designing Abroad: Planning For A Global Marketplace