Development and Initial Validation of Healing and Therapeutic Design Indices and Scale for Measuring Health of Sub-Healthy Tourist Populations in Hot Spring Tourism

Abstract

The built environment, technology, human health and well-being, and sustainable development are closely related, and human-centered therapeutic design in environmental, architectural, spatial, and landscape domains demonstrates human health promotion potential. This study examines health promotion design measurement indices and develops a scale for sub-healthy tourists in a hot spring tourism destination. Recent research mainly emphasized the development and utilization of hot spring resources and their economic benefits. It rarely provided a systematic discussion on the health-promoting impact of environmental design and evaluation criteria. Thus, this study employs the literature review method and the Delphi expert method to construct an index system and measurement scale that comprises 20 evaluation indices of physical, mental, and social health. Moreover, this study conducts a questionnaire survey to measure the physical, mental, and social health of sub-healthy tourists and non-sub-healthy tourists (observation and control groups) and the sub-healthy tourists before and after their visit to the hot spring tourism destination (pre-test group and post-test group). The scale demonstrates satisfactory reliability and validity, and the health–healing design measurement indices for the sub-healthy tourists consist of three subscales: physical, mental, and social health. The evaluation index system and measurement scale can comprehensively and effectively measure the effects of healing and therapeutic design (HTD) and can be used as reliable tools for sub-healthy tourists in hot spring tourism.

1. Introduction

In this post-pandemic era, a significant shift can be seen in people’s views about health, and physical, mental, and social sustainability have gradually become important standards for assessing wellness and quality of life. Tourism activities and experiences, which can induce a sense of well-being, can also meet people’s demand for quality-of-life enhancement. Enhancing people’s health, quality of life, and well-being is the primary goal of tourism destination development [1].

According to the World Health Organization, health is not only the absence of disease or infirmity but also a state of harmony of physical, mental, and social adaptation [2]. By contrast, sub-health is a state of the human body between health and disease, which manifests as reduced vitality and functional and adaptive capacity over a certain period [3]. The sub-health state has become a threat to people’s health, but tourism has been found to alleviate sub-health conditions and facilitate rehabilitation to a certain extent [4]. Therefore, effective interventions are necessary to improve the health status of sub-healthy people, and healing and therapeutic design (HTD) has become an important issue in health promotion. Healing and therapeutic design (HTD) is a concept that concentrates on promoting an individual’s physiological state, psychological needs, and social and emotional experiences by creating a comfortable environment [5]. This design approach emphasizes promoting health and wellness functions through environmental design to comprehensively improve an individual’s quality of life. Specifically, it focuses on the layout and function of the physical space and takes into account people’s emotional needs and psychological states, as well as how environmental factors affect their recovery [6]. The Attention Restoration Theory (ART) provides important theoretical support for the framework of HTD. Elements and characteristics of the environment can be designed specifically to help restore individual attention and improve the overall health condition. Physically, the healing environment draws attention, immerses the individual, and provides a sufficient sense of space. Mentally, a designed, comfortable environment can relieve individuals from the stress of daily life. Socially, the environment is aligned with the individual’s social needs and goals, thereby enhancing the individual’s cultural integration and life satisfaction [7]. Therefore, HTD can be mainly divided into three dimensions: physiological, psychological, and social; for instance, Seasonal Affective Disorder (SAD) tourists who take vacations to the Hainan Islands to escape the cold climate in winter can effectively improve their Quality of Life (QOL) and receive physical, mental and social therapy [8]. Nonetheless, in recent years, the vast majority of studies on recreation and health tourism have addressed the development and utilization of tourism resources or the promotion of tourism satisfaction but have neglected the health impact of the environmental design of tourism destinations. Hot spring tourism has gradually garnered attention from academia and the industry owing to its unique combination of environmental healing and therapeutic functions, natural rehabilitation value, and multifunctional activity spaces, which have become important for tourists to improve their health and pursue pleasure [9]. Hot spring resorts are considered an ideal destination for sub-healthy groups because they integrate healing environments and health-promoting functions. The minerals in hot spring waters, the thermal healing effect, and the quiet environment can improve tourists’ physical functions and overall health through psychological release and social interaction [10]. By changing the temperature and humidity and the activity environment, the environmental design of hot spring tourist resorts can alleviate tourists’ physical and mental discomfort and positively influence their behavioral activation system and positive emotions and thus improve their health [11], especially their emotional health [12]. The built environment, technology, and human sustainability are closely associated with health and well-being, and human-centered HTD can contribute to achieving sustainable environmental, architectural, spatial, and landscape development goals [13]. HTD as an intervention can help improve people’s health and be positively applied to the arts, architecture, landscapes, spaces, and the environment [14]. The uniqueness of the environmental design of hot spring tourist resorts, such as their environmental design and layout, landscape esthetics, spatial openness, and integration of natural elements, can promote physical and mental relaxation and restoration and thus reinforce their distinctive value as a rehabilitation destination [15]. How hot spring tourism destinations can exert a healing effect on sub-healthy people through scientific and environmental design should be investigated from the perspective of environmental science and architecture. Moreover, optimization strategies based on HTD concepts for environmental and architectural design should be proposed to provide effective healing interventions to sub-healthy people and implications for hot spring tourism destination planning.

Recent advancements in environmental psychology, therapeutic design, and global health tourism emphasize the critical role of therapeutic environmental design in promoting well-being. Studies, such as those by Salingaros (2025), highlight the importance of empathetic and health-promoting architectural façades, emphasizing the psychological benefits of AI-driven design [16]. Similarly, Zhang (2024) links sensory elements, such as lighting, color schemes, and natural landscapes, to emotional responses, advocating for emotion-centered design methodologies to enhance overall quality of life [17]. In elderly care, Li et al. (2025) emphasize the integration of therapeutic design and sustainability, demonstrating its impact on well-being in day care centers [18]. Natural environments, as explored by White et al. (2019) and Marcus and Sachs (2013), consistently improve health outcomes by fostering attention restoration and psychological recovery through features like water elements, greenery, and open spaces [19,20]. Meta-analyses on forest bathing (Siah et al., 2023; Takayama et al., 2020) further validate the combination of natural elements in therapeutic spaces, enhancing mental health [21,22]. These findings align with the growing emphasis on health tourism for sub-healthy populations, as discussed by Smith and Puczkó (2014) [23]. More specifically, when it comes to hot spring therapies, existing research such as Zhang et al. (2016) and Zhang et al. (2019) demonstrates the effectiveness of hot spring therapies in improving blood pressure, psychological states, and sleep quality, leveraging tools like the Pittsburgh Sleep Quality Index (PSQI) to measure these outcomes [24,25]. Furthermore, research by Feng (2023) highlights the significance of perceived value and its influence on satisfaction and revisit intention, utilizing scales such as the Perceived Value Scale [26]. Additionally, studies by Xi et al. (2021) and Liu et al. (2017) highlight the importance of place attachment and perceived restorativeness in promoting psychological recovery, utilizing the Place Attachment Scale and the Perceived Restorativeness Scale (PRS) [27,28]. While these findings provide valuable insights, a gap remains in developing and validating targeted design indicators for sub-health populations in hot spring tourism. Accordingly, as illustrated in Figure 1, the proposed conceptual model for evaluating the effects of Healing and Therapeutic Design (HTD) at hot spring tourism destinations integrates design elements, mechanisms, and health outcomes to systematically examine the pathways through which therapeutic environments promote well-being. Drawing on Attention Restoration Theory (ART) and therapeutic landscape principles, the model highlights the critical role of natural elements (e.g., water features and greenery), architectural elements (e.g., lighting, textures, and spatial layouts), and integrated facilities (e.g., hot pools and meditation rooms) in activating sensory engagement, stress reduction, emotional regulation, and social interaction [19,20]. These pathways significantly enhance physical health (e.g., improved energy, reduced discomfort), mental health (e.g., cognitive clarity, emotional resilience), and social health (e.g., interpersonal communication, work efficiency) [16,17,18]. By integrating these validated tools and addressing physical, mental, and social dimensions, future research can advance the theoretical and practical frameworks for restorative environmental design in health tourism.

This study raises the following questions: Will the environmental design of a hot spring resort exert a rehabilitative effect on tourists in a sub-health state? How can a hot spring resort environment be used as an effective nonmedical intervention to exert a rehabilitative effect on the physical, mental, and social health of tourists with sub-health conditions? How can we further define rehabilitation design evaluation indices and develop corresponding measurement tools for tourists’ health status?

The cases in this study are derived from academic literature, industry standards, and design awards, with a focus on aspects that exhibit the integration of multiple design elements and their physical, mental, and social impacts on tourists. Guangdong Province in China is hot and humid throughout the year, making it an ideal location for vacation resorts with superior hot spring qualifications. This study selects the Bishuiwan Hot Spring Resort in Guangzhou City, Guangdong Province, China, as a case study. Since Bishuiwan Hot Spring Resort opened in 2002, its integration of traditional and modern wellness practices has established it as a hot spring tourism industry leader. Its unique combination of therapeutic environmental features, comprehensive infrastructure, and long-standing reputation in the industry ensures it is a scientifically and practically significant case to examine the environmental design effect of hot spring destinations. This study addresses hot spring destinations to investigate their role in facilitating health recovery among sub-healthy tourists and to develop a comprehensive index system and measurement scale for HTD. This study involves several steps. First, this study designs an evaluation scale for sub-healthy tourists by conducting a literature review and using the Delphi expert survey method. Second, this study comprehensively assesses the validity of the developed index system and measurement scale based on the statistical analysis of the questionnaire survey and the change in the average value. This study attempts to explore the changes in the health indicators of sub-healthy tourists after they are exposed to the environmental design of the hot spring tourism destination. In addition, this study designs an HTD evaluation index system and measurement scale for tourists’ health. This study contributes to the scientific foundation of hot spring tourism resource development and environmental design to facilitate the transformation of hot spring resorts from resource-oriented to health-oriented destinations and enhance tourists’ well-being and quality of life.

2. Literature Review

2.1. Tourism and Wellness

Previous research has focused on tourists’ health, quality of life, and well-being [29]. Empirical studies confirmed that a favorable climate and environment (e.g., forests, seashores, sunshine, hot springs, and so on) could reduce the likelihood of humans suffering from common diseases and promote tourists’ health by lowering their blood pressure, diminishing sympathetic neural activity, and improving their neurological functioning [30,31,32]. In addition, safe, relaxing, and enjoyable tourism vacation activities can alleviate tourists’ sub-health states or symptoms, such as organic fatigue, stress perception, and sleep disorders, to a certain extent and thus contribute to their psychological health [33]. Moreover, tourism vacation activities can strengthen relationships between tourists and their families, friends, and communities, as well as social communication and connections, to benefit the tourists’ social health [34].

In recent years, scholars have explored the effects of tourism on tourists’ well-being, primarily in the three aspects of their physical, mental, and social health. By engaging in tourism and leisure activities, tourists can experience pleasure, relaxation, and flow; relieve their physiological, psychological, and social stress; and improve their quality of life and physical and mental health [35]. Tourism landscapes can bring tourists close to nature and exert different effects, such as rehabilitating the health of cancer patients to a certain extent [36]. Meanwhile, vacation and excursion activities can enhance the health and quality of life of tourists and the resident population. For instance, Wei et al. formulated a theoretical criterion for assessing the thermal comfort of the environment and concluded that thermal comfort can influence residents’ quality of life [37]. Ye et al. argued that outdoor activity spaces can substantially affect human health by influencing the human body’s thermal comfort [38]. From another perspective, different vacation tourism types, such as medical tourism [39], spa tourism [40], forest tourism [41], rural tourism [42], and climbing tourism [43], were found to exert different positive effects on people’s physical, mental, and social health. Among them, hot spring tourism can be a nonintervention therapeutic alternative to enable tourists to cope effectively with their sub-health and specific pathologies. In this post-pandemic era, researchers gradually emphasize human health conditions and use tourism wellness and health activities as important health interventions to stimulate positive tourism experiences and tourist health rehabilitation [44,45,46,47,48]. However, most studies concentrated on tourists’ health tourism experience, and trim work has been performed on developing HTD evaluation index systems and scales.

2.2. Hot Spring Tourism Environmental Design

Hot springs have become an important destination for sub-healthy people in perennially hot and humid areas because of their specific therapeutic functions. Reference [40] suggested that unique heat sources in hot springs can treat people’s ailments and improve their health. However, the health effects of hot spring tourism environments on tourists have been overlooked, and existing research centers primarily focus on assessing resource development and economic performance and tourists’ experience and decision-making motivation. Moreover, previous studies failed to consider how hot spring environments affect health status rehabilitation [9,49,50,51,52]. For instance, Zhu and Lan [49] probed into the optimal planning of natural hot spring tourism routes in coastal city models and scenarios. Chen et al. [50] explored the service factors of hot spring vacations for tourists’ health. Meanwhile, Ding [51] investigated how the sustainable attributes of hot spring tourism can affect tourists’ selection intention, and Clark-Kennedy and Cohen [9] revealed the motivational factors of hot spring tourism. Lin [52] indicated how gastronomic experiences and mental health can be vital in hot spring tourists’ revisit intention. However, few studies on hot spring tourist destinations focused on systematically evaluating their impact on tourists’ health. Furthermore, a comprehensive evaluation index system, particularly for sub-healthy populations, has yet to be established. This study attempts to fill this research gap. The positive role of environmental HTD in improving mental and physical health has been widely acknowledged. Environmental psychology research demonstrated that natural environments with green spaces, open bodies of water, and natural light can lessen tourists’ psychological stress and contribute to their health rehabilitation [53]. According to restorative environment theory, natural environments promise psychological recovery by attracting an individual’s attention, generating pleasure, and reducing fatigue [54]. The concept of HTD has garnered considerable attention because it can improve individuals’ physical and mental health by optimizing the functionality and esthetics of architectural spaces [55]. HTD has been widely used in hospitals, nursing resorts, hot springs, and gardens, but investigations into its application in environmental design, especially in hot spring tourist destinations, remain superficial.

This study selects the Bishuiwan Hot Spring Resort in Guangzhou City, Guangdong Province, as the research setting and uses the literature review, Delphi expert survey, and questionnaire survey methods to develop and construct systematically an indicator system and measurement scale for the health of sub-healthy tourists in a hot spring tourism destination. This study sheds light on the health–healing mechanism of hot spring resorts and provides HTD solutions for sub-healthy tourist populations, which contributes to the sustainable development of health tourism destinations in this post-pandemic era.

3. Research Methods

This study employed a holistic approach to conduct qualitative and quantitative investigations, that is, a literature review, a Delphi expert survey, and a questionnaire survey. First, this study developed inclusion and exclusion criteria for tourists with sub-health symptoms based on previous studies and the sub-health rating scale (SHMS V. 1.0). Second, this study conducted two rounds of Delphi expert consultations to screen and identify the scale indices to develop a questionnaire for the evaluation of the health status rehabilitation of sub-healthy tourists. Third, based on the developed scale, this study designed a pre-test and post-test questionnaire for the tourists who engaged in hot spring tourism. This study measured the health-related indicators of a sub-healthy tourist population and a non-sub-healthy tourist population (observation group and control group) and the sub-healthy tourist group before and after their visit to the hot spring resort (pre-test and post-test of the observation group) in three dimensions, namely, their physical, mental, and social health. Fourth, this study statistically analyzed the paired t-test results to test the effects of hot spring intervention.

By referring to the SHMS V. 1.0 [56], this study developed the following inclusion criteria for the sub-healthy tourist group: tourists with physical sub-health (physical symptoms, organ functions, body motor functions, and energy), mental sub-health (positive emotions, psychological symptoms, and cognitive functions), and social sub-health (social adaptation, social resources, and social support) and tourists who can perform sub-health self-assessments. The calculated scores were divided into 1, 2, 3, 4, and 5, representing “very poor,” “relatively poor,” “average,” “good,” and “very good,”, respectively, with high scores indicating good health and less obvious sub-health and scores less than or equal to 25 representing a sub-health status.

This study involved the development of a scale for the rehabilitation indicators of the sub-health tourists in the hot spring tourism destination. In addition, this study used qualitative methods, that is, the literature review and Delphi expert survey methods, and selected the Mood Disorder Questionnaire [57], the Hamilton Depression Scale [58], and a Likert scale [59] as the rating tools. This study applied the Delphi method to adjust the selection and assignment of the HTD effect evaluation indicators to form a preselection table (

Table 1. Preselection table of HTD evaluation index system for sub-healthy tourists.

Construct	Factor	Design Basis
Physical health	Sleep length Energy Sexual desire Talkativeness Concentration Body pain Accelerated associations Fluttering of ideas Amount of exercise Frequency of going out	Chinese Medical Association of Psychiatry [60], Yang et al. [61], Wang [62], Rohan et al. [63]
Mental health	Emotional intensity Pleasure from activities Creativity Mood affected by circadian rhythm Exaggerated self-evaluation	Zhang [64], Dupuis and Smale [65], Berman et al. [66], Hartig [67]
Social health	Recklessness Irritability Socialization frequency Work efficiency Social competence	Sherri [68] and Zhai et al. [69]

).

According to the principles of representativeness, authority, and wide coverage, the Delphi method was used to conduct two rounds of expert consultations with 18 experts from universities, leisure and tourism institutions, design, and medical institutions. The selection of experts was guided by the criteria of academic and professional background, research and practical experience, and institutional diversity to ensure their qualifications and relevance to the study.

Table 2. Profile of expert members.

Expert	Gender	Education	Years of Experience	Background
1	M	Doctoral degree	15	Human geography
2	M	Doctoral degree	16	Sustainable tourism
3	F	Doctoral degree	18	Health and wellness tourism
4	F	Master’s degree	12	Urban and rural planning
5	M	Doctoral degree	30	Public health
6	M	Doctoral degree	21	Nutrition science
7	M	Doctoral degree	25	Psychiatry
8	F	Master’s degree	20	Traditional Chinese medicine and health preservation
9	F	Master’s degree	10	Sustainable tourism
10	M	Doctoral degree	15	Architectural design
11	M	Doctoral degree	26	Human geography
12	M	Master’s degree	12	Landscape architecture
13	F	Master’s degree	11	Sports science and physical education
14	F	Doctoral degree	10	Traditional Chinese medicine rehabilitation
15	M	Doctoral degree	18	Psychology
16	F	Doctoral degree	16	Health and physical education
17	F	Master’s degree	15	Environmental design
18	M	Doctoral degree	24	Leisure management

lists the demographics of the members. The experts were invited to assess the significance of the indicators for all levels of the model by using the questionnaire for the first round of expert consultations and allowing for anonymity of the responses, which was preliminarily formulated after the interviews with the experts and a discussion with the research team. The second round of expert consultations questionnaire was developed based on the experts’ opinions and inclusion criteria for the indicators. After two rounds of consultations, this study developed a scale with 20 items, which is shown in

Table 3. Analysis results of two rounds of Delphi expert consultations.

System Layer	Indicator Layer	First Round			System Layer	Indicator Layer	Second Round
		Mean	IQR	Stability			Mean	IQR	Stability
Physical health	Sleep length	4.16	1.00	87.8%	Physical health	Drowsiness	4.45	1.00	88.6%
	Energy	4.35	1.00	87.8%		Energy	4.48	1.00	88.6%
	Sexual desire	4.10	1.00	85.5%		Sexual desire	4.29	1.00	86.5%
	Talkativeness	4.25	1.00	82.6%		Willingness to communicate	4.31	1.00	88.6%
	Concentration	4.20	1.00	85.5%		Concentration	4.52	1.00	86.5%
	Body pain	4.10	1.00	82.9%		Physical discomfort	4.26	1.00	82.6%
	Accelerated associations	4.04	1.00	85.5%		Accelerated associations	3.98	1.00	86.5%
	Fluttering of ideas	3.88	1.00	72.5%		Flow of breath	4.06	1.00	82.6%
	Amount of exercise	4.26	1.00	85.5%		Amount of exercise	4.30	1.00	85.5%
	Frequency of going out	4.07	1.00	81.0%		Willingness to go out	4.32	1.00	81.0%
Mental health	Emotional intensity	4.24	1.00	85.5%	Mental health	Emotional intensity	4.39	1.00	85.5%
	Pleasure from activities	4.19	1.00	85.5%		Pleasure from activities	4.54	1.00	86.5%
	Creativity	4.49	1.00	76.2%		Active thinking	4.58	1.00	86.6%
	Mood affected by circadian rhythm	4.51	1.00	89.6%		Mood affected by circadian rhythm	4.71	1.00	90.7%
	Exaggerated self-evaluation	4.29	1.00	76.4%		Self-conceit	4.31	1.00	86.5%
Social health	Recklessness	4.22	1.00	72.4%	Social health	Ability to restrain	4.63	1.00	82.4%
	Irritability	4.16	1.00	70.6%		Excitement	4.30	1.00	82.4%
	Socialization frequency	4.22	1.00	82.6%		Increased socialization	3.83	1.00	82.6%
	Work efficiency	4.36	1.00	85.5%		Work efficiency	4.61	1.00	86.5%
	Social competence	3.95	1.00	82.6%		Interpersonal sensitivity	4.50	1.00	86.5%

. The inclusion criteria for the indicators were a consensus of over 70%, a mean score ≥ 4.00, an IQR ≤ 1, and a stability > 80%.

In the first round of expert consultations, of the ten physical health indicators, nine had a consensus of more than 70%, an IQR ≤ 1, and a stability > 80%; therefore, the nine indicators were included, and the remaining indicator was excluded or modified. Of the five mental health indicators, five had a consensus of more than 70%, an IQR ≤ 1, and a stability > 80%; thus, the five indicators were included, and none were excluded. Four of the five social health indicators had a consensus of more than 70%, an IQR ≤ 1, and a stability > 80%; hence, the four indicators were included, and the remaining indicators were excluded.

The experts who participated in the assessment were from two research fields, namely, tourism and medicine; thus, they may demonstrate some divergence in their judgment. Hence, the indicators with a relative significance score of 4 or below were excluded from the analysis. According to the experts, the expression of some of the indicators should be revised slightly (Table 3). For example, among the physical health indicators, the term “sleep length” may be ambiguous; thus, it should be changed to “drowsiness.” Moreover, the term “talkativeness” is unsuitable for describing the respondents’ physical state and should be revised to “willingness to communicate.” “Body pain” should be revised to “physical discomfort,” “fluttering of ideas” is similar to “accelerated associations” and thus should be combined as “accelerated associations,” and “frequency of going out” is not suitable for measuring the physical state of the respondents and should be revised to “willingness to go out.” In addition, the experts suggested adding the “flow of breath” indicator. Among the mental health indicators, “creativity” did not apply to the randomly selected respondents and was revised to “active thinking.” Furthermore, the experts suggested that “exaggerated self-evaluation” be replaced with “self-conceit.” Regarding the social health indices, many of the experts suggested replacing “recklessness” with “ability to restrain” and “irritability” with “excitement.” The terms “socialization frequency” and “social competence” are closely related; thus, experts suggest combining them to refer to “increased socialization.” The experts also suggested adding the “interpersonal sensitivity” indicator. The questionnaire excluded the tourist groups with underlying medical conditions such as diabetes, hypertension, and heart disease.

A second round of Delphi expert consultations was conducted for the revised indicator system. All the indicators met the requirements and demonstrated excellent stability based on the criteria of a consensus over 70%, a mean score ≥ 4.00, an IQR ≤ 1, and a stability > 80%. Thus, all the indicators were retained. To observe the significance of each indicator rationally, this study calculated the “significance,” “accessibility,” “familiarity,” “theoretical analysis,” “practical experience,” “peer knowledge,” and “personal intuition” for each indicator, as displayed in

Table 4. Mean values of indicators.

Construct	Index	Significance	Accessibility	Familiarity	Theoretical Analysis	Practical Experience	Peer Knowledge	Personal Intuition
Physical health	Drowsiness	4.17	3.94	3.72	3.44	3.44	3.33	3.83
	Energy	3.94	3.61	3.94	5.50	3.22	3.33	3.50
	Sexual desire	3.89	3.61	3.94	3.28	3.50	3.72	3.56
	Willingness to communicate	3.89	3.83	3.83	3.72	3.39	3.78	4.00
	Concentration	3.94	3.94	3.61	3.61	3.67	3.28	4.06
	Physical discomfort	3.72	3.61	3.83	3.56	3.78	3.17	3.83
	Accelerated associations	4.00	3.72	3.56	3.39	3.67	3.33	3.44
	Flow of breath	3.50	3.17	3.61	3.28	3.44	3.33	3.83
	Amount of exercise	3.94	3.83	3.89	3.56	3.61	3.61	4.06
	Willingness to go out	3.61	3.50	3.67	3.28	3.83	3.78	3.67
Mental health	Emotional intensity	3.94	3.61	4.00	3.72	3.83	3.67	3.61
	Pleasure from activities	4.11	3.61	4.17	3.61	3.44	3.50	3.61
	Active thinking	4.39	3.94	4.17	3.94	4.06	3.78	3.67
	Mood affected by circadian rhythm	4.17	3.94	4.06	4.06	4.06	3.94	3.83
	Self-conceit	4.28	4.17	4.06	3.17	3.50	3.50	4.00
Social health	Ability to restrain	4.00	3.83	3.89	3.28	3.61	3.72	3.94
	Excitement	3.89	3.67	3.67	3.67	3.44	3.67	3.89
	Increased socialization	3.78	3.94	3.78	3.39	3.67	3.72	4.00
	Work efficiency	4.06	3.83	3.94	3.33	4.00	3.83	4.11
	Interpersonal sensitivity	3.89	3.67	3.50	3.44	3.44	2.89	3.72

.

4. Findings

A total of 18 prestigious experts from related fields scored each item individually to determine the mean value. After soliciting the experts’ ratings and feedback, this study established standard values for each self-assessment item and obtained comprehensive evaluation results by summarizing the scoring table. This study retained the 18 members of the expert panel after the second round of scoring, who could form relatively consistent opinions. Based on the principles and requirements of the Delphi method, a third round of independent scoring was unnecessary. The scoring results from the second round were adopted as the comprehensive weight of each dimension, the weight of the physical, mental, and social health dimensions provided by the expert panel. Subsequently, the corresponding questionnaire scale was developed.

This study used the back-translation and mutual translation methods for the questionnaires to ensure that they were semantically transparent. Specifically, members of the research team worked back-to-back, with one researcher reporting the Chinese version of the questionnaires, one translating the questionnaires back to English, and another translating the questionnaires back to Chinese to check them against the original Chinese versions. After repeated proofreading, the research team checked the questionnaires for accuracy and developed a highly scientific and objective evaluation system and measurement questionnaire for health status recovery. The scale was divided into four parts: basic personal information, the inclusion criteria, the pre-test, and the post-test. The same set of questionnaires was used for the pre-test and post-test to measure the self-assessment scores of the physical, mental, and social health indices of the tourists with sub-health conditions before and after they visited Bishuiwan Hot Spring Resort in Guangzhou City to participate in vacation activities (

Table 5. Self-assessment scale of indicators for evaluating HTD effect on tourists’ health.

Construct	Index	Overall Score (100 Points)
Physical health	Drowsiness	50 points
	Energy
	Sexual desire
	Willingness to communicate
	Concentration
	Physical discomfort
	Accelerated associations
	Flow of breath
	Amount of exercise
	Willingness to go out
Mental health	Emotional intensity	25 points
	Pleasure from activities
	Active thinking
	Mood affected by circadian rhythm
	Self-conceit
Social health	Ability to restrain	25 points
	Excitement
	Increased socialization
	Work efficiency
	Interpersonal sensitivity

). The pre-test and post-test questionnaires consisted of ten physical health self-assessment items (ten questions) for a total of 50 points; five mental health self-assessment items (five questions) for a total of 25 points; and five social health self-assessment items (five questions) for a total of 25 points. The questionnaires consisted of 20 questions for the three health dimensions. Each item was a factor, and each factor was scored on a five-point scale, with a total score of 100 points for the pre-test and post-test, in which 1 represents “extreme enhancement,” 2 represents “enhancement,” 3 represents “no change,” 4 represents “becoming weakened,” and 5 represents “becoming very weak.” This study developed a theoretical health recovery evaluation model for the sub-healthy tourists in the hot spring destination (Figure 2). The larger the total score value, the higher the sub-health level and the poorer the health of the tourists. Tourists with a total score of 20 points or lower are regarded as having no sub-health conditions; that is, they are the healthy group. As this research is centered on healing and therapeutic design for sub-healthy populations in hot spring tourism, individuals who do not fall into the sub-healthy category lie beyond the scope of this study and are therefore excluded from the present analysis.

4.1. Empirical Test

This study recruited six volunteers to implement the study and set up a sampling site at the Bishuiwan Hot Spring Resort in Guangzhou City, Guangdong Province. The tourists who answered the pre-test were screened and divided into the sub-healthy tourist population and the non-sub-healthy tourist population (observation group and control group). The questionnaire excluded tourist groups with underlying medical conditions, such as diabetes, hypertension, and heart disease, as well as those who spent less than three days on vacation at Bishuiwan Hot Spring Resort. The sub-healthy tourist group was instructed to answer the questionnaire before and after they visited the hot spring resort (observation group pre-test and post-test). A total of 221 questionnaires were distributed, and 215 valid questionnaires were obtained, with a validity rate of 97.3%. All participants provided the electronic version of informed consent. All study procedures were approved by the Ethics Committee of Shenzhen University (protocol registration no. PN-2024-00175).

4.2. Data Analysis

As shown in

Table 6. Demographic information of the sample.

	Frequency		Percentage
Gender	Male	102	47.4%
	Female	113	52.6%
Age	Under 18	5	2.3%
	18 to 25	44	20.5%
	26 to 30	65	30.2%
	31 to 40	42	19.5%
	41 to 50	30	14.0%
	51 to 60	22	10.2%
	Over 60	7	3.3%
Education	Junior high school and below	12	5.6%
	High school/technical secondary school	18	8.4%
	Junior college	40	18.6%
	Undergraduate degree	84	39.1%
	Postgraduate degree or above	61	28.4%

, the demographic composition of the study sample reveals a nearly balanced gender distribution, with 47.4% male and 52.6% female participants. The majority of respondents were aged 26 to 30 (30.2%), followed by those aged 18 to 25 (20.5%) and 31 to 40 (19.5%). In terms of education, the most significant proportion of participants held an undergraduate degree (39.1%), while 28.4% had a postgraduate degree or higher, and 18.6% completed junior college. Only a small percentage had education levels of high school or below (14.0%).

A multiple regression analysis was conducted using SPSS 26.0 (IBM Corp., Armonk, NY, USA) to examine the effects of demographic factors (age, gender, and education level) on post-overall health among tourists. Regression coefficients were used to evaluate the direction and magnitude of the relationships. Significance was determined by p-values relative to the 0.05 threshold, and multicollinearity was assessed using VIF statistics. As shown in

Table 7. Regression analysis of demographic variables on post-overall health.

Coefficient a
Model	Unstandardized coefficient		Standardized coefficient	t	Significance	Collinearity statistics
	B	Standard error	Beta			Tolerance	VIF
(Constant value)	64.373	4.068		15.825	0.000
Age	0.062	0.471	0.009	0.132	0.895	0.929	1.077
Gender	3.610	1.334	0.187	2.706	0.007	0.955	1.047
Education	−0.382	0.596	−0.044	−0.641	0.522	0.954	1.048

^a dependent variable: post-overall health.

, gender had a significant positive effect on overall health (B = 3.610, p = 0.007), whereas neither age (B = 0.062, p = 0.895) nor education level (B = −0.382, p = 0.522) showed a significant association. All VIF values were below 10 (range: 1.047–1.077), indicating no multicollinearity among predictors. Results indicated gender is the only demographic variable exerting a significant positive effect on post-overall health among tourists, and females have better post-vacation health outcomes. This may be attributable to gender-related differences in health perception, coping strategies, or engagement with wellness-oriented activities during the hot spring vacation. In contrast, the absence of significant effects for age and education level implies that these factors do not substantially influence post-vacation health evaluations in this sample, possibly due to homogeneous health perceptions across age groups or the limited role of educational attainment in shaping short-term health experiences during hot spring vacation.

The 215 effective questionnaires were tested.

Table 8. Results of reliability tests.

Construct		α Value
Physical health	Pre-test	0.766
	Post-test	0.752
Mental health	Pre-test	0.814
	Post-test	0.815
Social health	Pre-test	0.841
	Post-test	0.852
Overall scale	Pre-test	0.835
	Post-test	0.786

shows that the alpha value of the overall pre-test and post-test scales and the three core dimensions exceeded 0.6 (Wu, 2025) [70]. Table 8 reveals that the deletion alpha of a particular item (alpha value) showed a different degree of reduction through the validity test of the variable. The results showed that the α coefficient of the pre-test and post-test scales (total scale) was 0.835 and 0.786, respectively, and the α coefficient of the three subscales was more than 0.7, which indicated that the HTD effect evaluation scale for the sub-healthy tourist population demonstrated excellent internal consistency reliability. In addition, in

Table 9. Results of validity tests.

KMO Value		Pre-Test	Post-Test
		0.881	0.871
Bartlett’s test of sphericity	Chi-squared approximation	2514.474	2232.539
	df	190	190
	Sig.	0.000	0.000

, the KMO value of the pre-test and post-test variables was 0.881 and 0.871, respectively; the significance of Bartlett’s test of sphericity was 0.000, which was less than 1%; and the chi-squared approximation was 2514.474 and 2232.539, which indicated that the overall scale demonstrated good convergent validity. Therefore, the scale exhibited high reliability and validity. Furthermore, the questionnaire developed for the indicator measurement to determine the changes in the health status of the sub-healthy tourists in the hot spring tourism destination demonstrated good applicability and stability. Thus, it can be adopted and utilized repeatedly as a reliable tool for measuring HTD rehabilitation effects in hot spring tourism destinations in the three aspects of physical, mental, and social health.

The paired t-test was conducted using SPSS 26.0 statistical software, and a p-value < 0.05 was considered statistically significant. The results of the paired t-tests, as shown in

Table 10. Comparison of HTD effect scores before and after hot spring tourism vacation.

Construct	Index
		Pre	Post	t-Value	p-Value
Physical health	Drowsiness	1.48 ± 0.587	3.09 ± 0.912	−24.794	<0.001
	Energy	2.03 ± 0.794	3.24 ± 0.0745	−14.944	<0.001
	Sexual desire	2.54 ± 0.795	3.72 ± 0.753	−16.292	<0.001
	Willingness to communicate	2.16 ± 0.978	3.27 ± 0.882	−10.524	<0.001
	Concentration	2.20 ± 1.055	3.27 ± 0.918	−9.512	<0.001
	Physical discomfort	2.10 ± 0.739	3.62 ± 0.726	−21.162	<0.001
	Accelerated associations	1.91 ± 0.843	3.52 ± 0.825	−18.526	<0.001
	Flow of breath	2.20 ± 1.033	3.31 ± 0.865	−10.011	<0.001
	Amount of exercise	2.40 ± 1.018	3.47 ± 0.911	−9.750	<0.001
	Willingness to go out	2.39 ± 1.026	3.44 ± 0.904	−9.922	<0.001
Mental health	Emotional intensity	2.11 ± 1.151	3.27 ± 0.938	−9.564	<0.001
	Pleasure from activities	2.10 ± 1.199	3.28 ± 0.985	−9.392	<0.001
	Active thinking	2.03 ± 1.016	3.34 ± 0.903	−11.721	<0.001
	Mood affected by circadian rhythm	1.74 ± 0.782	3.52 ± 0.808	−22.104	<0.001
	Self-conceit	1.81 ± 0.787	3.57 ± 0.834	−25.715	<0.001
Social health	Ability to restrain	1.76 ± 0.782	3.53 ± 0.825	−25.893	<0.001
	Excitement	1.87 ± 0.731	3.49 ± 0.808	−21.913	<0.001
	Increased socialization	2.29 ± 0.981	3.38 ± 1.015	−10.869	<0.001
	Work efficiency	2.56 ± 1.113	3.65 ± 1.133	−9.162	<0.001
	Interpersonal sensitivity	2.28 ± 1.003	3.69 ± 1.055	−12.707	<0.001

, demonstrate decreases in the self-assessed sub-health score and significant improvements in the health indicators of tourists after their hot spring tourism vacation. The data provide persuasive evidence of the positive effects of healing and therapeutic design (HTD) interventions in hot spring destinations on tourists’ physical, mental, and social health. The physical health subscale revealed substantial improvements in all measured indicators. Notably, the mean score of drowsiness improved from 1.48 ± 0.587 before the vacation to 3.09 ± 0.912 after the vacation, indicating a significant reduction in feelings of fatigue (t = −24.794, p < 0.001). The mean score for energy increased from 2.03 ± 0.794 to 3.24 ± 0.745, representing a notable boost in energy levels (t = −14.944, p < 0.001). Scores of sexual desire were increased from 2.54 ± 0.795 to 3.72 ± 0.753, reflecting improved physical vitality and well-being (t = −16.292, p < 0.001). Other indicators, such as concentration, physical discomfort, and amount of exercise, also exhibited significant gains, as all p-values were below the 0.001 threshold. The mental health subscale also reported substantial improvements across all indicators. Scores of emotional intensity increased from 2.11 ± 1.15 to 3.27 ± 0.94, indicating heightened emotional regulation and intensity (t = −9.564, p < 0.001). Scores of pleasure from activities were improved from 2.10 ± 1.199 to 3.28 ± 0.985, suggesting enhanced enjoyment from engaging in activities (t = −9.392, p < 0.001). Scores of active thinking rose from 2.03 ± 1.016 to 3.34 ± 0.903, reflecting improved cognitive engagement and mental clarity (t = −11.721, p < 0.001). Significant effects were also observed for mood affected by circadian rhythm and self-conceit, with large t-values and p-values below 0.001, further supporting the efficacy of HTD interventions. The social health subscale revealed improvements in interpersonal and social functioning. Scores of ability to restrain significantly improved from 1.76 ± 0.782 to 3.53 ± 0.825, suggesting enhanced self-control and emotional regulation (t = −25.893, p < 0.001). As for increased socialization, scores rose from 2.29 ± 0.981 to 3.38 ± 1.015, indicating enhanced social interactions and willingness to engage with others (t = −10.869, p < 0.001). Scores of work efficiency improved substantially from 2.56 ± 1.113 to 3.65 ± 1.133, reflecting better focus and productivity (t = −9.162, p < 0.001). All social health indicators showed significant improvements, suggesting that the HTD environment fosters positive interpersonal and social outcomes.

Figure 3 illustrated the significant improvements in health outcomes across the three domains. The post-test scores of physical health were markedly higher than the pre-test scores, highlighting the physical restorative effects of HTD. An apparent increase in post-test scores of mental health reflected enhanced emotional well-being and cognitive engagement. The most significant improvement was observed in the social health domain, emphasizing the role of HTD in fostering social interaction and interpersonal skills.

Thus, the results analyzed strongly support that hot spring tourism, as a form of healing and therapeutic design, has significant positive effects on tourists’ physical, mental, and social health. The consistent improvements across all subscales, coupled with statistically significant t-values, demonstrated the efficacy of HTD interventions in promoting overall well-being.

5. Discussion

5.1. Conclusions

Studies on the impact of health tourism have increased gradually. However, few studies comprehensively examined the design of rehabilitation evaluation indicators for tourists’ health in hot spring tourism destinations. This study investigates specific HTD quantitative indicators in a hot spring tourism destination that can influence tourists’ health and quality of life. Specifically, this study conducts qualitative and quantitative investigations into the designed indicator evaluation system and HTD theoretical model. This study uses the Delphi method to address the selection and revision of the measurement indicators. The indicator evaluation system consists of three subscales, namely, physical, mental, and social health, with a total of 20 indicators. The physical health indicators are drowsiness, energy, sexual desire, willingness to communicate, concentration, physical discomfort, accelerated associations, flow of breath, amount of exercise, and willingness to go out; the mental health indicators are emotional intensity, pleasure from activities, active thinking, mood affected by circadian rhythm, and self-conceit; and the social health indicators are ability to restrain, excitement, increased socialization, work efficiency, and interpersonal sensitivity. This study finds that mental adjustment, physical rehabilitation, and social behavior optimization can improve tourists’ health. Furthermore, this study designs a questionnaire for empirical verification, and the outcomes reveal that the developed measurement scale demonstrates robust and accurate reliability and validity. The empirical data offer strong support for the beneficial impacts of healing and therapeutic design (HTD) interventions in hot spring destinations on the physical, mental, and social well-being of tourists. Among the demographic factors examined, gender emerged as the sole variable demonstrating a statistically significant positive association with overall post-health. Thus, the scale can be regarded as a reliable tool for measuring the effects of environmental HTD on sub-healthy tourists in hot spring tourism destinations.

The findings of this study align with and extend existing literature on the relationship between environmental design and health outcomes, particularly in the context of healing and therapeutic spaces. We illustrate the psychological benefits of empathetic and sensory responsive design highlighted by Salingaros (2025) [16] and Zhang (2024) [17], the restorative value of nature-based interventions emphasized by White et al. (2019) [19] and Takayama et al. (2020) [22], and the social dimensions of health tourism underlined by Smith and Puczkó (2014) [23]. Specifically, Salingaros (2025) emphasizes the role of façade design and window placements in fostering psychological well-being [16], while Zhang (2024) investigates the link between architectural design and sensory–emotional dynamics [17]. Both studies emphasize the importance of design in promoting mental and emotional health, which aligns with this study’s findings on the significant improvements in mental health indicators among sub-healthy tourists following exposure to Healing and Therapeutic Design (HTD) interventions. Additionally, Li et al. (2025) explore restorative design in elderly care environments, demonstrating how environmental modifications can enhance well-being, a concept reflected in this study’s focus on the multidimensional health benefits of hot spring tourism destinations [18]. Moreover, the results of this study complement broader research on the health impacts of natural environments. White et al. (2019) [19] and White et al. (2010) [71] emphasize the restorative and affective benefits of spending time in natural spaces, particularly in “blue spaces” (e.g., water-based environments). Similarly, Siah et al. (2023) [21] and Takayama et al. (2020) [22] provide systematic evidence of the mental health benefits of forest bathing, underscoring the therapeutic potential of immersive natural experiences [21,22]. Based on the ART, this paper explains the restorative function of environmental design for the health of tourists in hot spring resorts. It reveals the comprehensive improvement of their physical, mental, and social needs by HTD [7]. Compared with the indicators of Lin and Liu [72], the indicators for assessing the health rehabilitation of the hot spring tourists in this study are more refined and specific, owing to the addition of social health indicators such as ability to restrain, excitement, increased socialization, work efficiency, and interpersonal sensitivity. Compared with Liu and Cui [73], this study includes physical health indicators such as physical discomfort, accelerated associations, flow of breath, and amount of exercise. Meanwhile, compared with the scales and questionnaires of Roecklein et al. [59], Berman et al. [66], Hartig [67], Sherri [68], and Zhai et al. [69], the scales and questionnaires developed in this study are more generalizable to sub-healthy tourist populations.

5.2. Theoretical Implications

This study designs an index system and a scale for HTD intervention indices for sub-healthy tourists in a hot spring tourism destination. The applicability and credibility of the scale are tested by conducting pre-test and post-test questionnaire surveys on sub-healthy tourists and non-sub-healthy tourists. The constructed evaluation indices can define the tourists’ health from the quality of life perspective and enrich research on HTD in hot spring tourism. This study makes several innovative contributions.

First, this study operationalizes the abstract principles of Attention Restoration Theory and therapeutic landscape frameworks into a measurable model (Figure 1), clarifying the mechanisms through which HTD elements, offers a systematic lens for analyzing the pathways linking environmental design to health rehabilitation. Second, by selecting sub-healthy tourists as research subjects, this study fills the gap in hot spring tourism research regarding the healthcare needs of sub-healthy individuals. Third, by developing a systematic HTD evaluation method for sub-healthy tourists in a hot spring tourism destination, this study offers practical insights into environmental factors, such as temperatures, humidity, and layout, and provides a solid framework for health tourism planning in the post-pandemic era. The findings emphasize the interconnectedness of physical, mental, and social health, aligning with overall health theories. The most significant improvements in social health highlight the critical role of social interaction and engagement within HTD environments, extending theoretical insights into the social dimensions of health tourism. Last, this study designs an HTD indicator questionnaire for sub-healthy tourists, which can be employed as an effective tool for measuring the healing effect of hot spring tourism destinations. The significant post-test improvements provide theoretical support for the role of HTD in alleviating sub-healthy conditions, offering a novel perspective on health tourism interventions.

5.3. Practical Implications

Hot spring tourism is a form of tourism that integrates health and ecology. Thus, designs that combine the demands of sub-healthy people should be emphasized. Moreover, tourism products that consider health, emotional and social values should be developed to realize the function of the HTD of hot spring tourism destinations. Evaluating the designed index system can shed light on hot spring resort recreation and tourism development, such as the physical health indices of sleep, exercise, and flow of breath. The designed index system can comprehensively consider multiple mental and social health factors, such as emotional intensity, active thinking, mood affected by circadian rhythm, work efficiency, and increased socialization. This study shows that the HTD index system for sub-healthy tourists in a hot spring vacation destination can evaluate the conditions necessary to plan and design hot spring tourism products to a certain extent. An HTD evaluation system for hot spring tourism can be created from the three aspects of physical, mental, and social health by focusing on natural and human resources that reflect the three aspects’ natural and humanistic advantages and combining them with health and wellness designs. Hot spring tourism destinations should be optimized to provide tourists with a high-quality healthcare experience through customized and humanized services to provide pleasure, induce a sense of unimpeded experience, and promote health rehabilitation.

5.4. Limits and Future Research

Despite these advancements, several future research directions emerge. First, this study focuses on HTD indicators affecting tourists’ health. Macroenvironmental factors, such as landscape esthetics, the greening rate, spatial layout, water quality, temperature, air quality, the sound environment, light design, movement planning, psychological counseling, and privacy preservation, should be integrated into future studies to investigate therapeutic designs for mass tourists. Second, this study does not consider the demographic characteristics and physical health of the respondents; thus, future studies could explore the applicability of HTD interventions across diverse demographic groups, such as individuals with chronic illnesses or varying cultural backgrounds, and examine how demographic characteristics could affect tourists’ physical, mental, and social health by segmenting the target population. Third, longitudinal studies are needed to investigate the long-term effects of HTD interventions on health outcomes, as this study primarily captures short-term improvements. Future research could expand the sample size, incorporate longitudinal designs, and explore multi-site comparisons to enhance generalizability and develop context-specific benchmarks for effect sizes in health-related research. Future studies can adopt new technologies and analytical methods, such as big data, wearable brain electroencephalograms, and other physical instruments and tools, to conduct additional analyses, including neural network analyses, and advance the field. Last, expanding the scope to include other types of natural environments, such as forests or coastal areas, could provide a comparative framework for understanding the relative benefits of different therapeutic settings.