30th INTERNATIONAL SEMINAR FOR PUBLIC HEALTH GROUP (PHG)

OF THE UNION OF INTERNATIONAL ARCHITECTES (UIA) AT KUALA

LUMPUR CONVENTION CENTRE -
29TH NOVEMBER 2010 – 1ST DECEMBER 2010

SAFE HEALTHCARE FACILITIES FOR CHILDREN AND

ADOLESCENTS

F.Vavili1 and A.Kyrkou2

1. Dr. Architect, Professor, Postal address: Alexandrou Michailidi 1,

54640, Thessaloniki, Greece
2. Architect, Postal Address: Nikitara 5str, 55236, Thessaloniki, Greece

ABSTRACT

A hospital stay is often a traumatic event for everybody due to the loss of
one’s points of reference, reduced autonomy and separation from one’s
relations and familiar environment. A more vulnerable group are children
and adolescents (up to 19 years old), who are still developing perception of
body, time and future and who find it difficult to perceive recovery after their
present discomfort. Safety and security for a child’s well-being in this case
are major issues. A safe and secure hospital environment would offer care,
protection and respect of the child’s body and mind as well as friendly
atmosphere and understandable orientation.
Purpose: This paper estimates the great importance of children’s hospitals
and children’s wards. It shows aspects for creating better healing
environments in children’s health care facilities and also illustrates the
current architectural trends of children’s healing environments.
Methods: This study uses the latest and most contemporary examples of
health facilities for children and adolescents from different geographical
locations. Elementary factors of design are analyzed and specified
according to literature review.
Results: Children’s healthcare facilities can promote the healing process,
reduce stress, eliminate their fears, have positive effects on them and
create a harmless hospital experience, under certain circumstances. Design
details can have an impact on the quality and value of care. Efficient and
flexible design offers more comfort; it can intrigue a child’s imagination and
creativity and offer a more secure environment.
Conclusions: Architecture, design, aesthetics and technology can be a
substantial contribution to safer and more secure healthcare environments

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for children and adolescents. Interior and exterior factors of the healthcare
environments can provide safety and security on a child’s psychology and
its well-being.

Keywords: children’s health care, safe health care

Introduction

A hospital stay is often associated with negative thoughts and

feelings due to “the absence of a familiar setting, the insecurity of the future,
the fear of unknown medical tests or surgery, the pain, the restriction of
social and everyday life that automatically affect the patient” (Vavili,
Manolidou, 2009). Thus, the hospitalization process is inevitably a source of
stress for an individual. When it comes to children’s hospitalization, the
feelings of insecurity, fear and uncertainty, are even stronger, more
complicated and very crucial for their well-being. Children are a unique
group, that are still developing perception of body, time and future and who
find it difficult to perceive recovery after their present discomfort. As Coull A.
points out “Kids are vulnerable due to their developmental age.
Hospitalisation is a defining experience for a child” (Coull, 2009). Their
physical, psychological and mental safety is an extremely important issue in
the hospital environment. According to literature, if children are “given
support, or live in a stable environment, they are not as likely to suffer
debilitating effects from fear” (Rutter, 1981). Children’s healing environment
is a significant parameter in their hospitalization process and can positively
affect their recovery. Regarding children’s healthcare facilities architecture,
quality design and thoughtful planning can approach safety, security and
thus the elimination of their fears, which are substantial for their health.

The Importance of Healing Environment in Children’s Hospitals

The years of childhood and adolescence (according to WHO it is

the period of life between conception and nineteen years of age), are a
“particularly sensitive phase of life for the adoption of healthy lifestyles and
the acquisition of coping mechanisms that could be of help in adulthood and
old age” (Simonelli, Majer, José Caldés Pinilla, 2007). During that period of
their life, their experiences (physical and mental) and many environmental
factors can play a vital role in shaping a child’s character. A hospital visit for
a child can sometimes be a rather upsetting or even frightening experience,
depending on the quality of the healthcare facility and the given medical
care. “Childhood fears can cause undue anxiety, distress, and impairment
in everyday living. Fears can interfere with children's daily activities. They
may prevent children from doing things they enjoy” (Muris, Steerneman,
Merckelbach, Meesters, 1996). In any case though, the role of the pediatric

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hospitals is essential, because after all “children are our investment in
tomorrow’s society”.
The hospital environment is at some time the main micro-system of
the child and represents an extremely interesting context from the point of
view of the health promotion for children and adolescents while in hospital.
“Hospitalisation has the potential to transform an episode, frequently
experienced as traumatic with psychological effects, into a worthwhile
process with a lifelong opportunity for personal learning, growth and
development” (Simonelli, Majer, José Caldés Pinilla, 2007). The
environment plays such an active role during the healing process, it
reduces the patients’ anxiety and fears, supporting their needs or even
giving them back the chance to keep the contacts with their family and
friends; As Filippazzi G. stresses about the healing environment: “…it is
important for all patients, no matter how old they are, but it is particularly
important for children, who often fear their stay in hospital may be forever”
(Filippazzi, 2009). A safe, secure and stress-free hospital environment
would offer care, protection and respect of the child’s body and mind as well
as friendly atmosphere and understandable orientation; thus it would
promote healing.
Regarding the healthcare environment architecture, design, art,
technology and ecology combined all together, can create the exceptional
circumstances for a child’s healing process and promote its well-being. As a
Greek architect, that creates spaces for children, points out: “…Architecture
for children should adapt to the child’s needs and scale, it is all about the
child’s perception of space and the way it can experience it. Spaces made
for children should exceed the tiresome experiences of everyday life and
consist of motivating factors that can awake the child’s imagination and
creativity” (Paraskeva, 2009). When it comes to the bond between a child
and the environment, children can “…remember places and sensations
more than they remember persons, because they react more than adults to
the environment, colors, sounds, lights, smells, objects and movements.
This is more so for children in hospital. Therefore they must feel at ease
from their admission to hospital” (Filippazzi, 2009). Through the
appropriate design and suitable details, a welcome atmosphere can be
composed in which all five senses can be stimulated and make the child
feel more comfortable.

Basic Design Elements in Children’s Hospitals

At the begging of the 21st century, healthy living (meaning health,

fitness and taking care of one’s body) is among the main concerns of our
society. The architectural work of hospitals, clinics, day hospitals or any
other type of healthcare facility has always been a complicated task; even
more nowadays that functionality is required to adapt to the new computer
systems and sophisticated medical equipment must be combined with an
aesthetics that is pleasant for patients, visitors and medical staff. All of the
above has to be united in a modern, pleasant and welcome building that will
offer safe and secure medical care and support a healthier way of living.

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 Children’s healthcare facilities are even more complicated from
adult hospitals, due to the children’s unique needs and their fragile
psychological balance. Ideally a children’s hospital should “…give a sense
of discovery and detail, it should stimulate the senses, it should encourage
movement, it should have the elements of whimsy, humor and variety”
(Cleper-Borkovi, 2009). In architectural terms, modern healthcare facilities
for children use the basic elements of design (such as exterior design,
façades, natural environment, scale, colors, materials, light and shadows,
movement and orientation) in an innovative and creative way along with the
newest technological findings. “…To design a children’s hospital is to listen
to the many voices of children, …, to their parents, to the staff, as well as to
hear the advice of the environmental psychologist, the color specialist, the
play and the music therapist, the pediatrician, the nurse, the intensivist, the
social worker…” (Cleper-Borkovi, 2009).
As mentioned before there are certain needs that the children have
which first of all are a challenge for every architect and secondly have an
impact on the design and thus make the children’s healthcare facilities differ
from all the others. According to James Robertson’s essay (1958)
“…hospitalization constitutes a trauma for a child, …, the separation of
young patients from their parents during hospitalization provokes grave
mental suffering” (Filippazzi, 2009). As Newman C. also stresses:
“…Children are highly depended upon adults for comfort, guidance, and
support”; therefore during their hospitalization they need “…the presence of
caring and attentive caregivers as well as their own parents” (Newman,
2009). In that case, some of the great challenges that rise are in relevance
with the space in the patient’s private room, or ways to create positive
distractions that can take the mind (both the child’s and the parent’s) away
from the pain or the stress. (Fig.1) The private room should be a pain-free
space that the child and its family members can feel comfortable and
support the child’s emotional needs. Furthermore, another very important
factor that has an impact on the children’s healthcare design is the special
needs, habits and preferences that each one of the seven age groups
during childhood and adolescence has. Starting from “…foetus, neonate,
infant, preschool, secondary school, transition to adulthood” (Mazuch,
2009), each stage has each own special characteristics, and each own
scale and ergonometric features; therefore the healthcare environment has
to adapt in order to provide safety and security to everyone.

Figure 1: Positive Distractions.

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 In order to clarify the different characteristics of design elements in
children’s healthcare facilities, it is preferred to separate them in categories;
and further on study them through specific examples of contemporary
architecture from around the world. Some of the most important elements of
design are:
i) the exterior
ii) the interior (e.g. lobby – reception and patient rooms)
iii) the relationship of the building with the natural environment
iv) the lighting (both natural and artificial)
v) the colors and the materials used
vi) the scale
The front view of a building or complex should create a unique
visual impact to the viewer; after all it is the first impression. The outcomes
of contemporary architectural trends in hospital buildings aren’t the massive
buildings of the past that invaded their surroundings. The exterior of a
children’s healthcare facility is of great importance. (Fig.2) “What children
experience at the front door of a hospital, will color the impression of their
entire stay” (Mead, 2005). A children’s hospital should be “simple and easily
understood from the exterior” (Mead, 2005). Colorful facades, design details
and scale, can be used to offer calmness and tranquility to the visitors and
the workers.

Figure 2: Exterior.
The smooth transition from an exterior space to an interior and the
opposite is crucial in the design of healthcare facilities because it can affect
both patients and visitors. Spatial organization of healthcare facilities relies
on the continuity of spaces. The main entrance of a hospital building is
always a prominent space, “…lobbies are the heart of a hospital welcoming
all who came there and making an indelible and uplifting first impression”
(Plappert, Gabel, Clements, 2005) it is a fact that the first impression of a
lobby is decisive for the patient’s feeling of well-being. Moreover, the
qualities in a patient’s room should propose tranquility and security in order
to promote healing. (Fig.3) A child’s room should have positive distractions
that can awaken the senses in order to send the pain away and offer to the
child a safe experience. Thus the design must “…respond to all the child’s
needs, those of the body, mind and soul” (McElroy-Anshen, Allen, 2009).

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Figure 3: Patient’s Room
The bond between nature and well-being is not something new. It is
known since the primitives societies existed. In fact, in ancient Greece, the
healthcare facilities were known as “Asklepieia”, and they were large
complexes, located in stunning natural settings, secluded from other
habitations. Their concept was based on today’s holistic models;
Surrounding the patients with nature, music and art “…in order to restore
harmony and promote healing” (Chez, Pelletier, Jonas, 2004). Local climate
and building orientation specify the main guidelines of the design. The right
position to the sunny side and to the main direction of the wind is of great
importance for the patient’s healing process. One of the basic criteria of an
effective healing environment is also direct contact with nature. “As
Nightingale stated “…It is a curious thing to observe how almost all patients
lie or make their way towards an open window…” (as cited in Skretkowicz,
1992, p. 115), and even more fascinating that children so easily identified
(when given the opportunity to do so) the spaces and places that are
universally recognized as conducive to the healing process” (McLaren,
2009). Well designed exterior spaces like small parks, healing gardens,
atriums and other open air spaces are likely to encourage social
interactions. A hospital’s park can be considered as a relaxing and amusing
place for patients, as well as a place open to public that can play an
essential role. Its purpose is to eliminate or reduce pain and isolation
feelings. (Fig.4) After all, “movement is extremely important for a child
because it means he/she uses to explore the world around him to in order
to learn” (Filippazzi, 2009). A healing garden can stimulate a child’s senses
and it is a safe way to offer moments of exploration, play and freedom.
Also, “garden views from patient’s rooms, a physical therapy session
outside, a meal shared outdoors are all opportunities for families to pull
together in the healing process” (Pangrazio, Saba, 2005).

Figure 4: Hospital Garden.

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 Lighting is an extremely powerful element in design; whether it is
natural or artificial it can utterly change the tone and the perception of a
space and it can also develop the circulation layout. Studies have shown
that interior artificial lighting can also address spatial orientation by working
along with the transitions of natural light. But light, is also an effective
parameter for the patient as a powerful regulator of the body and its daily
functions. (Fig.5) The quality of lighting in hospitals can positively affect the
emotional and medical state of a patient; it can also support well being and
stimulate recovery (Antonakaki, 2009). In any case, light is the reason that
gives all the visual results; “every object we see is the result of light energy
– either light emitted by the object or light reflected from it. Without light,
color would not exist” (Mazuch, 2009).

Figure 5: Lighting.
The selection of materials and colors of the interior is always
related to the use of the space and the people who will be using it.
Architects who design and plan healthcare facilities know that “healing
qualities depend on the choice of materials and colours” (Eggen, 2009).
The proper choice can create an effective impact on the patient or the
visitor. “Colors should offer warmth and variety without shouting or
offending. Textures should be varied, inviting children to touch and learn
about materials” (Mead, 2005). But colors and materials have to reinforce
the functionality of the space and always support the patients; more
specifically, in the neonates’ department bight light colors should be
avoided since a child at birth is sensitive to light (Mazuch, 2009), on the
other hand playful colors and soft carpets on the floor add a welcoming note
in the pediatric concourse. (Fig.6)

Figure 6: Materials and Colors.

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 Scale in the children’s healthcare facilities is a rather important
element of design. As mentioned before the design must respond to all the
child’s needs and they should be adaptable for all the childhood’s and
adolescence’s variations. For example low windows that can offer inviting
views or trees without climbing on a chair or being picked up by an adult
prevent children from feeling “imprisoned” in their hospital room (Filippazzi,
2009). When the environment of the children is in their scale they feel more
secure, because they can explore and thus learn and control an unknown
and strange environment to them. Also, “It is very important to introduce
elements scaled to children of different ages and cultures, offering positive
distractions” (Plappert, Gabel, Clements, 2005).

Children’s Hospitals in Greece

As stressed above, the role of children’s hospitals is extremely

significant for a child’s well-being. Currently, in Greece, there are
unfortunately some very important issues to be solved in this area. More
specifically, one of the biggest problems is the small number of children’s
hospitals and their uneven allocation throughout the country. Thus children
don’t have equal opportunities for health. The analogy between population
and the geographic locations of children’s hospitals is uneven. According to
the Greek population census of 2001 and the arrival of immigrants through
the last decade there is a growing need for the development of children’s
medical care throughout the country.
Greece is divided in seven health peripheries in total, according to
their regional and geographical locations.(Fig.7) There are five public
children’s hospitals on the whole (including a new built oncology hospital for

Figure 7: Greece’s Health Peripheries.

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children), all located near the capital of Athens. The rest of the country’s
children are serviced by the children’s wards at general hospitals have
(though not all of them).
The arrangement and the quality of paediatric hospitals lacks of
homogeneity throughout the country and thus rearranging and updating the
schedule of accommodation is an urgent task. There is an obvious need for
a modern and functional children’s hospital in the northern part of Greece in
order to restore the balance and create equal opportunities for health.
Regarding the history of this children’s hospital in the North part of Greece
there has been a conversation among doctors’ and architects of
Thessaloniki.
Thessaloniki is the capital of the region of Macedonia, and it is
Greece's second major economic, industrial, commercial and political
centre, and a major transportation hub for the rest of south-eastern Europe,
it has 1.084001 citizens. It was about 2001-2002 that the idea of a new
children’s hospital is a priority for the needs of the city and the northern part
of Greece in general. These conversations were gradually translated
through the Regional Health Authority of central Macedonia into a very
promising architectural project. In 2006 the minister of Health at that time
formally proposed the creation of two new hospitals in the city of
Thessaloniki: a children’s hospital and an oncological hospital (Bouka,
2007). (Fig.8)

Figure 8: Thessaloniki.
According to the proposal, the new children’s hospital would be
located at Thessaloniki in the suburbs (Mikra), near the city airport. It would
have about 400 beds, for children up to 14 years old and its total cost would
be 324.000.000,00€ (about 452,433,484.37 USD). It was supposed to be
sited in a big building complex of 84.000 sq. m. with nearby facilities and in
full collaboration with the new oncological hospital (Bouka, 2007).
Unfortunately though, due to mistaken political choices, problematic
bureaucracy and of course the economy crisis, this grandiose plan never
came true; but the needs of Northern Greece for an up to date children’s
hospital still exist.

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 The architects and the medical professionals of Thessaloniki must
come up with a new plan for a children’s hospital; one that is simultaneously
functional, economic and tailored for Greece’s potentials and needs. So the
extravagant, costly proposals of the past must be re-examined. This new
children’s hospital doesn’t have to be huge, it could have less beds than
400 based on the initial proposal, and from an economic point of view it
could share some facilities for specialized medical examinations with other
modern hospitals that already exist in the city, it could also share the costs
of catering and other peripheral facilities; But on the other hand it would
offer a safe, cosy and fresh hospital environment for the children. Therefore
the real question here is more about the correct location for this children’s
hospital.
In Thessaloniki there are 14 public hospitals (www.nosokomia.gr).
An interesting region for this new proposal is just out side the city center, by
the city’s ring road; where two of the most up to date hospitals of
Thessaloniki are located. The “Papageorgiou General Hospital” built in
1997 and given to public use in 2000, which has 750 beds and covers
75.000 sq. m. and “424 Army General Hospital” built in 2001 and given to
public use in 2007, which has 354 beds and covers 105.000 sq. m. (Fig.9)

Figure 9: Papageorgiou General Hospital and 424 Army General Hospital

(from left to right).
Close to these two healthcare facilities there is an appealing
location for placing the new children’s hospital; (Fig.10) This area used to
be a former military shooting field which is currently without any use at all
(www.rthess.gr). Near by the two existing hospitals there are also some
hotels for out of town patients’ relatives. So, creating a new children’s
hospital there would be absolutely functional and satisfy multiple needs.
Public transportation from the city centre for this location will be soon solved
as the plans of the metro station will get there.

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Figure 10: Area of Future Proposal.
Another, very appealing and costless proposal for a new children’s
hospital in Thessaloniki can come by rearranging the existing hospitals
which are located in the city centre. In Thessaloniki downtown there are in
total four public general hospitals (Agios Demitrios, G.Genimatas, AHEPA
and Limodon). Agios Demitrios General Hospital is established in a
stunning neoclassical building, surrounded by a large courtyard, possibly
designed by architect V.Poselli. (Fig. 11)

Figure 11: Agios Demitrios Hospital.

Limodon Hospital is rather small for its departments’ capacity and its
numerous patients. The second plan suggests that all activities of Agios
Demitrios General Hospital should be moved to G.Genimatas General
Hospital because of their proximity (they are very close to each other) and
the unique neoclassical building should be given another use. Also
G.Genimatas General Hospital should stop being a Teaching Hospital
because it is near by to AHEPA Teaching Hospital in the university campus.
Limodon hospital (specializes on infectious diseases) should be shut down.
The pediatrics’ department, the pediatrics’ surgery department and the
vascular surgery department should be removed from the above hospitals
and be relocated to the newly built 424 Army General Hospital. Instead,
Army General Hospital should become a Regional Teaching Hospital.

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Within it an advanced traumatologic center, which is utterly needed in the
region, should be developed (Kalergis, 2010). (Fig.12)

Figure 12: Thessaloniki City Centre.

To sum up, Greece’s number of children hospitals is very small and
their allocation is uneven. Due to the economy crisis, Greece is presently in
a very difficult financial state, thus making a new hospital from the begging
is an uncatchable dream. There are ways that can reduce the costs of a
new building such as sharing some facilities and rethinking the scale and
the capacity of the proposal. Therefore, with correct planning and proper
estimations there are solutions that are financially viable and will satisfy the
needs of children. Then in terms of safety and for better and healthier living,
children all over Greece can have access to a secure and specialized
hospital environment and please their physical, psychological and mental
needs during their hospitalization process without any further impacts.

Conclusion

Summarizing, the increasing need for health services is a fact.

Thus, hospital design is a major chapter in current architectural trends.
Children’s healthcare facilities are very unique, complicated and necessary.
They are a challenge for every architect due to the multiplicity of their tasks.
A specialized healthcare facility for children can offer more thoroughly safe
medical care to this unique group of patients. Contemporary children’s
hospitals are based on the best interest of a hospitalized child; certain
principles and criteria are applied on the specific issue of safety and health
promotion for children and adolescents in and by hospitals. Architecture,

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technology, psychology and ecology are all involved in the healing
environment of today’s healthcare facilities. Specialists from different
epistemological fields are cooperating in order to eliminate the children’s
fears of hospital visits and turn that into a safe and useful experience.
Design details have an impact on the quality and value of care. Efficient and
flexible design provides more comfort for patients and their family members.
In contemporary architecture, there are many examples that offer safety
and security during the children’s hospitalization process.

References

Antonakaki, T. (2009) Aspects of Healing Environments. Thessaloniki: ZITI

Publications.

Bouka, N. (2007) http://www.ygeianet.gr/ap/keimeno.php?id=3300

[Accessed: 2010, September 10], translation in English by Kyrkou A.

Chez, R., Pelletier, K., Jonas, W. (2004) Toward Optimal Healing

Environments in Health Care, Second American Samueli Symposium.
A Supplement to the Journal of Alternative and Complementary
Medicine, Vol. 10, Supplement I.

Cleper-Borkovi, F. (2009) The Culture For The Future Of Healthcare

Architecture, Proceedings of 28th International Public Health Seminar.
Firenze: Alinea editrice.

Coull, A. (2009) The Culture For The Future Of Healthcare Architecture,

Proceedings of 28th International Public Health Seminar. Firenze:
Alinea editrice.

Eggen, H. (2009) Aspects of Healing Environments. Thessaloniki: ZITI

Publications.

Filippazzi, G. (2009) The Culture For The Future Of Healthcare

Architecture, Proceedings of 28th International Public Health Seminar.
Firenze: Alinea editrice.

http://www.nosokomia.gr/web/index.php?option=com_content&task=view&i
d=16&Itemid=32 [Accessed: 2010, September 14], translation in
English by Kyrkou A.

http://www.rthess.gr/articles_det.asp?artid=178 [Accessed: 2010, October

2], translation in English by Kyrkou A.

Dr. K.Kalergis (2010), associate professor, Proposal by planning team

chaired by Dr. K.Kalergis.

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Mazuch, R. (2009) The Culture For The Future Of Healthcare Architecture,
Proceedings of 28th International Public Health Seminar. Firenze:
Alinea editrice.

McElroy-Anshen + Allen, J. (2009) The Culture For The Future Of

Healthcare Architecture, Proceedings of 28th International Public
Health Seminar. Firenze: Alinea editrice.

McLaren, C. (2009) Analyzing qualitative data about hospitalized children:

Reflections on bodily expressions. The Qualitative Report. Retrieved
from http://www.nova.edu/ssss/QR/QR14-1/mclaren.pdf

Mead, W. (2005) Designing the World’s Best Hospitals. Australia: images

publishing.

Muris, P., Steerneman, P., Merckelbach, H., Meesters, C. (1996): The role
of parental fearfulness and modelling in children's fear. Behaviour
Research and Therapy, Vol. 34, issue 3, pp. 265-268.

Newman, C. (2009) The Culture For The Future Of Healthcare Architecture,

Proceedings of 28th International Public Health Seminar. Firenze:
Alinea editrice.

Pangrazio, J., Saba, J. (2005) Designing the World’s Best Hospitals.

Australia: images publishing.

Paraskeva, P. (2009) Creative Spaces for Children. Athens: 1st Pan-

Hellenic Conference of Art and Environmental Art Education,
Foundation of Secondary Degree for Education and Evgenidio
Institution.

Plappert, J., Gabel, L., Clements, D. (2005). Designing the World’s Best
Hospitals. Australia: images publishing.

Rutter, M. (1981) The city and the child. American Journal of

Orthopsychiatry, Vol. 51, issue 4, pp. 610-625.

Simonelli, F., Majer, K., José Caldés Pinilla, M. (2007) Health Promotion for
Children and Adolescents in and by Hospitals, Background
Document. Florence: Meyer University Children’s Hospital.

Vavili, F., Manolidou, A., (2009) Health Facilities and Stress, Arts and
Health Facilities. Thessaloniki: ZITI Publications.

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