Towards a Synergistic Design Framework for Health-Promoting Schools in Hot and Humid Climates: A Systematic Review

Abstract

Children and adolescents in hot and humid climates face increasing health risks due to climate change. Although the concept of Health-Promoting Schools (HPSs) is widely recognized, a systematic framework that integrates climate adaptability, child-specific needs, and multidimensional environmental design is still lacking. To address this gap, this study conducted a systematic literature review of 89 publications with three objectives: (1) synthesize research from the past decade on the impact of school physical environments on the health and academic performance of children and adolescents; (2) develop an evidence-based synergistic design framework with a categorized indicator system; and (3) integrate qualitative and quantitative evidence on how these indicators influence different health dimensions. The resulting framework emphasizes multidimensional, synergistic optimization and provides climate-responsive design strategies tailored to educational settings in hot and humid regions. By offering a theory-to-practice pathway, the framework complements existing healthy building guidelines for K–12 schools and supports designers and policymakers in creating environments that enhance thermal resilience, cognitive performance, and holistic child development.

1. Introduction

1.1. Background

Children and adolescents’ health is a global concern. Schools as the primary setting for children and adolescents’ daily study and activities, are increasingly recognized as important places for promoting health, development and well-being [1]. According to the Harvard School of Public Health, by the completion of secondary education, a student will have accumulated more than 15,000 h of exposure to school indoor environments. The K–12 period represents a crucial stage for students’ physical, social, and emotional development [2]. The World Health Organization (WHO) recognizes that the sustainable development of children and adolescents is fundamental to achieving the United Nations Sustainable Development Goals (SDGs) [3]. Accordingly, it urges countries to implement policies and strategies that protect and enhance the health and well-being of young populations.

In recent years, however, global climate change has posed unprecedented threats to human society in terms of scale, speed, and intensity. One of its most prominent consequences is the increasing frequency of extreme weather events, including heat waves, particularly in hot and humid regions. These heat waves have substantially elevated health risks for vulnerable populations, including older adults, children, and adolescents. The U.S. Environmental Protection Agency (EPA) has reported that exposure to extreme heat can impair children’s learning and cognitive performance, disrupt sleep, and negatively affect mental health. It can also compromise kidney, liver, and respiratory functions, leading to an estimated annual reduction of 4% to 7% in academic achievement [4].

As the world’s second most populous country, China has approximately 231.6 million children and adolescents aged 6–19, and the promotion of youth health and well-being has long been regarded as a national priority. The Healthy China Initiative (2019–2030), particularly the “Health Promotion in Primary and Secondary Schools” component, mandates integrated strategies to enhance students’ physical and psychological health, foster healthy behaviors, and promote positive lifestyles in pursuit of comprehensive health outcomes. In this context, governments, institutions, and academic communities are increasingly calling for greater attention to the intersection of climate change and youth health. Crucially, the effective implementation of related policies—such as the development of health-promoting schools—requires practical, evidence-based design strategies and guidelines that can be directly applied by planners and designers.

1.2. Towards a Health-Promoting School Approach (HPS)

The World Health Organization (WHO) introduced the Health-Promoting School (HPS) approach in 1995. This framework emphasizes that schools are not merely venues for academic instruction but also critical settings for fostering students’ physical, mental, and social well-being. Despite widespread recognition of its importance, the sustainable and systematic implementation of the HPS approach has not yet been achieved globally over the past 25 years [3]. In response to this challenge, the World Health Organization (WHO), in collaboration with the United Nations Educational, Scientific and Cultural Organization (UNESCO), launched a global standard for health-promoting schools in 2021, titled Making Every School a Health-Promoting School: Implementation Guidelines [3]. This framework establishes eight global standards and thirteen implementation areas (Figure 1). It emphasizes that action plans for health-promoting school development should be adapted to national contexts and aligned with country-specific priorities, while remaining guided by the overarching principles outlined in the Global Standards and Implementation Guidance.

1.3. Research Gaps

Recent international and regional healthy building rating systems, schemes, and frameworks—such as the WELL Building Standard [5] and Fitwel [6]—provide design-oriented guidance for the implementation of healthy buildings (

Table 1. Basic information on the international mainstream healthy building rating systems.

	Standard	Version	Year of Launched	Concepts/Categories
1	WELL Building Standard	V2	2020	10 Concepts: Air; Water; Nourishment; Light; Movement; Thermal Comfort; Sound; Materials; Mind; Community
2	Fitwel	V3	2024	7 Categories: Community health; Morbidity and absenteeism; Social equity for vulnerable populations; Instills feelings of wellbeing; Enhances access to healthy foods; Promotes occupant safety; Increases physical activity

). Although certain indicators or credits within these systems can be applied to healthy school construction, such generic standards often fail to adequately address climate-specific challenges as well as the distinct physiological, psychological, and behavioral needs of child and adolescent populations within school environments. Moreover, although research on healthy buildings has expanded substantially in recent years, existing review studies tend to focus on isolated health outcomes or individual environmental factors. This fragmented perspective limits the adoption of a holistic and multidimensional approach and hinders the integration of diverse health dimensions into a cohesive, school-oriented design framework.

1.4. Research Objectives

Based on the above reviews, this study aims to develop a theoretical–analytical framework and corresponding design guidelines for health-promoting schools in hot and humid climate regions. The study objectives are (1) provide an overview of the literature from the past ten years (2016–2025) addressing the impacts of the school physical environment on the health and performance of children and adolescents in both pre- and post-pandemic contexts; (2) an evidence-based, synergistic design framework for health-promoting schools, including a structured set of indicators that influence children’s and adolescents’ health and performance; and (3) synthesize qualitative and quantitative evidence to elucidate how these indicators affect children and adolescents across different health dimensions.

2. Methodology

2.1. Materials and Methods

The first step of the methodology involved developing a preliminary framework and identifying key aspects through the integration of the WHO Health-Promoting School (HPS) framework with two healthy building standards. Subsequently, a systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Statement; the review protocol was not registered. Article screening, review, and initial categorization were performed independently by the first author. In cases where articles were difficult to classify due to complexity or insufficient information, all four authors jointly discussed the studies to reach a consensus. To identify publications and design strategies relevant to hot and humid climate regions, a three-step screening process was adopted. First, relevant literature was retrieved using a predefined search string. Second, abstracts, keywords, and titles were examined to determine whether the studies focused on hot and humid climates. Third, full-text articles were reviewed to identify key findings and to confirm eligibility for inclusion in the review. Finally, eligible empirical evidence was synthesized and categorized according to the key aspects of the proposed framework, leading to the extraction of climate-responsive design strategies for health-promoting schools.

2.2. Primary Framework and Features Identification

Three global standards of the WHO Health-Promoting School (HPS) framework that are directly related to the school built environment were incorporated into the development of the primary framework: the social–emotional environment, the physical environment, and health services. The remaining five standards, which primarily concern government policy and other non–built-environment aspects, were beyond the scope of this study and therefore not included. Partial concepts from the latest versions of two mainstream international healthy building standards—WELL V2 and Fitwel V3 were adopted as core components of the primary framework, owing to their strong emphasis on evidence-based design strategies that promote health and well-being. Based on the definitions and strategic structures of these selected standards, the original categories were consolidated and refined. In alignment with the objectives and scope of this study, eight distinct typologies were identified: Safety, Air, Light, Community, Thermal Comfort, Acoustics and Soundscape, Mind, Spatial design and movement, and Education. Figure 2 illustrates the relationships among Fitwel, WELL, the proposed Health-Promoting School Design Framework (HPSDF), and the WHO HPS framework.

2.3. Publications Search Procedure

The initial literature search identified 10,714 articles from the ScienceDirect (Elsevier) database [7], using Boolean search strings. Two search strategies were employed: #1 (“school design” OR “school environment”) AND (student OR child OR kids OR adolescen*) AND (health OR wellbeing OR performance); and #2 (“school design” OR “school environment”) AND (“hot-humid climate” OR “thermal comfort” OR heat). The search targeted English-language publications published between 2016 and 2025, encompassing both pre- and post–COVID-19 pandemic periods. This search strategy was designed to capture studies at the intersection of educational facility design, climatic context, and key health- and performance-related outcomes. The search was conducted on 7 December 2025. Titles, abstracts, and keywords were screened during the preliminary identification of relevant studies. Peer-reviewed original research articles and review papers published in academic journals were included. The review protocol was not registered, and the authors declared no competing interests.

2.4. Inclusion and Exclusion Criteria

The inclusion criteria for study selection were defined as follows (Figure 3): (1) peer-reviewed review articles and original research articles, with empirical studies including experimental measurements, randomized controlled trials (RCTs), or large-scale surveys; (2) studies targeting children (5–9 years) and/or adolescents (10–19 years) enrolled in K–12 schools; and (3) studies providing qualitative and/or quantitative evidence on the impacts of school design strategies or school environmental factors on students’ physical health, psychological well-being, and cognitive or academic performance. Records that were not related to the school environment or that belonged to other domains despite sharing similar search terms were excluded. All retrieved articles were manually screened by the authors to eliminate studies irrelevant to the scope of this review. To determine whether the identified literature and corresponding climate-responsive design strategies were applicable to schools in hot and humid climate regions, a three-step assessment process was employed. First, studies focusing specifically on tropical and subtropical regions were identified by examining their titles, abstracts, and keywords. Second, for studies conducted in non-tropical or non-subtropical regions but addressing climate change response strategies, full-text screening was performed to assess whether the proposed strategies could be applied to school settings in hot and humid climates. Based on this evaluation, studies were either included or excluded from the review. Following this screening process, a total of 89 records were included in the final review (Table S3).

2.5. Method for Quantifying and Synthesizing Health Impact Evidence

To systematically quantify and synthesize the multifaceted health impacts of school design strategies identified in this review, an evidence-fragment methodology was adopted [7]. The procedure comprised three key steps. First, each empirically supported design strategy or intervention reported in the 89 included publications was treated as a single unit of analysis, referred to as an evidence fragment. A single publication could contribute multiple evidence fragments if it examined several distinct strategies or reported different health outcomes for the same intervention (Section 3.2). This approach enabled a fine-grained mapping of the available evidence. Second, the health impacts associated with each evidence fragment were coded. Each fragment was classified according to the health impact domains defined in the proposed framework. A single fragment could be coded as having positive effects in one or multiple health domains, depending on the reported findings. Third, quantitative synthesis and percentage-based analysis were conducted at the level of the Indicator Group. For each group, the total number of associated evidence fragments (N) was calculated. The number of fragments reporting positive, negative, or mixed health impacts within each Indicator Group was then counted. The strength and consistency of evidence for a given health impact were expressed as a percentage, calculated as follows:

$$\mathrm{P}\mathrm{e}\mathrm{r}\mathrm{c}\mathrm{e}\mathrm{n}\mathrm{t}\mathrm{a}\mathrm{g}\mathrm{e}\mathrm{ }={\displaystyle \frac{NumberoffragmentssupportingaspecifichealthimpactwithinanIndicatorGroup}{TotalNforthecategory}}\times \mathrm{ }100\%$$

(1)

The percentages provide a clear visual overview of the distribution of evidence. For instance, a value of 100% for Physical Health indicates that all evidence fragments associated with a given design strategy group reported benefits for physical health. Notably, the sum of percentages across health domains within a single row may exceed 100%, as individual evidence fragments can document synergistic effects across multiple health dimensions. This quantitative synthesis directly informs the analysis of synergistic health impacts by identifying which design interventions are most consistently associated with multiple health benefits and where the evidence base is most robust (Section 4.1).

3. Results and Analysis

3.1. Research Trends

CiteSpace 6.2 was employed to generate and analyze a keyword co-occurrence timeline visualization based on 9288 screened records (Figure 4). This bibliometric analysis reveals the evolutionary trajectory of research themes within the domains of campus environments and students’ health and academic performance. The resulting knowledge map comprises 11 major clusters, labeled from #0 to #10 and ordered by cluster size, thereby visually illustrating the relative research activity levels and temporal lifecycles of different thematic areas.

This bibliometric analysis highlights the development and evolution of research themes in campus environments and students’ health and academic performance. The resulting knowledge map identifies 11 major clusters, labeled #0 to #10 and ranked by cluster size, providing a visual representation of the relative activity and temporal progression of each thematic area.

The co-occurrence analysis of keywords reveals the clustering characteristics and research focus within the domain of campus environments and student health. Keywords with higher co-occurrence frequency and centrality indicate greater academic attention and stronger connections with other keywords. As shown in Figure 5, these keywords form 11 major thematic clusters, labeled Cluster #0 to Cluster #10.

Clusters #0, #3, and #7 are labeled children, adolescent, and adolescence, respectively. Positioned at the core of the map, these clusters represent central subjects spanning the entire research timeline, indicating that whether early studies emphasized physical development or recent research focuses on psychological resilience, students remain the primary population of interest. Clusters #1, #2, and #8—school health promotion, academic achievement, and academic performance—are closely interconnected, reflecting the core theme that campus environments interact complexly with students’ physical health, daily activity, and academic outcomes rather than existing in isolation.

Clusters #5 and #6, labeled school climate and indoor air quality, capture dual dimensions of the physical and psychological environment. Notably, these clusters reflect how broader contextual shifts have reshaped research priorities. Since 2020, following the COVID-19 pandemic, the prominence of Cluster #6 (indoor air quality) has increased markedly. This shift highlights a growing focus on environmental indicators linked to respiratory health—such as ventilation and air quality—as well as on the safety and resilience of campus environments in the context of climate change.

Finally, Clusters #9 and #10, labeled intervention and creativity, signal an expansion of the research paradigm. The transition from evaluating existing environments to proactively designing strategic interventions demonstrates that the academic community is increasingly aiming to reduce students’ psychological stress and enhance creativity and holistic competencies through optimized campus design. This trend reflects a broader goal of constructing modern educational spaces that integrate health, safety, and educational efficiency.

3.2. Records Identified and Analysis

Following the systematic review process, a total of 89 publications met the eligibility criteria and were included for synthesis. To systematically quantify and synthesize the multifaceted health impacts of school design strategies identified in these studies, an evidence-fragment methodology was adopted, adapted from established practices in systematic reviews of complex environmental interventions [7]. This approach enables detailed, transparent, and reproducible analysis, moving beyond simple counts of included studies to reveal the density and consistency of evidence supporting each design recommendation. In this framework, each empirically supported design strategy or intervention reported within the 89 publications was treated as a single unit of analysis, referred to as an “evidence fragment”. A single publication could contribute multiple evidence fragments if it investigated several discrete strategies or reported findings on different health outcomes—such as physical health and academic performance—for the same intervention. This method allowed for a fine-grained mapping of the evidence base. From the included literature, a total of 272 evidence fragments were extracted and categorized across the nine environmental dimensions of the proposed framework. Due to word limitations, the full list of categories, along with their corresponding fragments (evidence-based design strategies), key findings, health impacts (physical health, psychological health, and performance), research methods (quantitative or qualitative), and references are provided in Appendix A.

3.2.1. Quantitative Synthesis and Analysis of Evidence Fragments

The quantitative distribution of 272 evidence fragments highlights both climatic and pedagogical priorities (Figure 6). Thermal Comfort (24.6%) and Air (21.7%) together account for nearly half of all evidence, establishing them as the primary areas for intervention in hot-humid regions. This reflects a substantial focus on bioclimatic and technological solutions, such as adaptive ventilation [7,8] and pollution source control [9]. The Mind category (18.4%) emerges as the third most densely represented dimension, indicating a well-developed body of research linking the school environment to psychological and socio-emotional health. Strategies in this domain emphasize restorative environmental design, including biophilic integration for stress reduction and attention restoration [10], deliberate creation of positive school climates and social support systems [11], and the design of spaces that foster belonging and self-efficacy [12].

The remaining categories, although supported by fewer discrete strategies, demonstrate distinct and complementary characteristics. Community strategies (9.2%) are predominantly participatory and process-oriented, emphasizing co-design and the cultivation of social capital [13]. Education (6.6%) are transformative and experiential, leveraging the environment as a pedagogical tool to foster stewardship and health literacy [14]. Light (6.3%) and Acoustics (3.7%) strategies reflect an evolution from purely performance-based metrics toward human-centric outcomes, emphasizing circadian health and perceptual soundscape quality [15]. Spatial Design strategies (5.5%) are behavioral and ergonomic, promoting physical activity and pedagogical flexibility through thoughtful layout and furniture selection. Finally, Safety strategies (4.0%) integrate physical and psychosocial approaches, addressing both injury prevention and the promotion of emotional security [16,17].

3.2.2. Quantitative and Qualitative Methods

The methodological distribution across the nine environmental design dimensions reveals a clear predominance of quantitative approaches, which constitute approximately two-thirds of the evidence base (66.5%, 181 out of 272 fragments). This reflects a strong research emphasis on measurable environmental parameters and their objective impacts on health and performance. As shown in

Table 2. Distribution of quantitative and qualitative evidence.

Category	Total (No.)	Quantitative Methods (No.)	Qualitative Methods (No.)	Quantitative % of Total	Qualitative % of Total	Quantitative % (Within Category)	Qualitative % (Within Category)
Air (A)	59	53	6	19.49%	2.21%	89.83%	10.17%
Acoustics and Soundscape (AS)	10	8	2	2.94%	0.74%	80.00%	20.00%
Light (L)	17	15	2	5.51%	0.74%	88.24%	11.76%
Thermal Comfort (TC)	67	54	13	19.85%	4.78%	80.60%	19.40%
Spatial Design and Movement (SD)	15	8	7	2.94%	2.57%	53.33%	46.67%
Mind (M)	50	35	15	12.87%	5.51%	70.00%	30.00%
Community (C)	25	8	17	2.94%	6.25%	32.00%	68.00%
Safety (S)	11	0	11	0.00%	4.04%	0.00%	100.00%
Education (E)	18	0	18	0.00%	6.62%	0.00%	100.00%
Total	272	181	91	66.54%	33.46%	-	-

and Figure 7, this quantitative focus is most pronounced in categories addressing core physio-climatic factors: Air (89.8% quantitative), Light (88.2%), and Thermal Comfort (80.6%). Studies in these areas primarily employ instrumental monitoring, environmental simulation, and controlled experiments to determine performance thresholds and align methodological approaches with physiological outcomes and cognitive function, thereby supporting repeatable, indicator-driven design guidelines.

In contrast, qualitative methods dominate in dimensions where socio-emotional and process-oriented factors are central. Safety and Education are entirely supported by qualitative evidence (100%), relying on policy analysis, case studies, participatory observation, and interviews to investigate complex issues related to emotional security, behavior change, and pedagogical integration. Similarly, Community is strongly qualitative (68.0%), emphasizing participatory planning and co-creation of social infrastructure. Spatial Design and Movement (46.7% qualitative) and Mind (30.0% qualitative) also demonstrate substantial qualitative contributions, capturing subjective experiences, user preferences, and social dynamics that mediate the effects of space on well-being.

This methodological distribution highlights the complementary strengths of the evidence. Quantitative data provide rigorous, generalizable benchmarks for optimizing the physical environment, while qualitative insights are essential for understanding implementation processes, socio-emotional mechanisms, and user perceptions critical for creating health-promoting and inclusive school communities. Integrating both methodological strands ensures that the proposed framework is not only grounded in empirical rigor but also responsive to the human and contextual factors necessary for designing truly health-promoting school environments.

3.2.3. Synthesis of Design Strategies by Environmental Dimension

Table 3. Classification of primary spatial focus, building lifecycle stage, group of indicators, indicators, and corresponding health impacts and research methods.

Category	Primary Spatial Focus	Building Lifecycle	Group of Indicators	Indicators	Health Impacts	Research Methods
Air (A)	Classroom, Envelope	P + D	A.1 Ventilation Strategies	Natural/mixed-mode ventilation design, climate-responsive envelopes	Improved air quality, thermal comfort	Simulation, field study
	Classroom, HVAC	R + C/O + M	A.2 Pollution Monitoring and Control	Installing air purifiers, high-efficiency filters, PM2.5/CO2 monitoring, window operation protocols, occupancy management	Respiratory health, cognitive performance, Ongoing health protection, adaptive comfort	Experimental, case study, Monitoring, modeling, surveys
	Classroom, Envelope	P + D/O + M	A.3 Greening and Barriers	Indoor Green Walls (IGWs), green screens and green gates	Removal of Particulate Matter (PM)	Experimental, case study, surveys
Acoustics and Soundscape (AS)	School Boundary, Classroom	P + D/R + C	AS.1 Noise Mitigation Design	Roadside noise barriers, acoustic material selection, space layout for sound	Mental health, cognitive performance	Simulation, field measurement
	Classroom	O + M	AS.2 Soundscape Management	Introducing natural sounds, managing equipment noise	Attention restoration, psychological comfort	Experimental, surveys
Light (L)	Classroom	P + D	L.1 Daylighting and Visual Design	Window optimization, shading design, surface reflectance	Visual health, psychological comfort	Simulation, field study
		R + C	L.2 Non-Visual Light Effects	Circadian-effective LED systems, tunable lighting installation	Sleep quality, mood, cognitive performance	Experimental, simulation
Thermal Comfort (TC)	Building Envelope, Schoolyard	P + D	TC.1 Passive Design Strategies	Building orientation, insulation specification, shading design (sails, trees)	Heat stress reduction, energy efficiency	Simulation, case studies
	Envelope, Outdoor Space	R + C	TC.2 Adaptive Interventions	Adding insulation (e.g., strawbale), installing misting systems, revegetation	Improved thermal comfort, outdoor usability	Experimental, case study
	Classroom, HVAC system	O + M	TC.3 Thermal Control	Temperature setpoint management, fan use, adaptive behavior promotion	Cognitive performance, immediate comfort	Field monitoring, experiments, surveys
Spatial Design and Movement (SD)	Overall Layout	P + D	SD.1 Space Layout and Activity Promotion	Optimizing classroom-playground distance, activity space layout, circulation design	Physical activity, social interaction	Simulation (ABM), observation
	Social/Outdoor Spaces	R + C	SD.2 Child Participatory Design	Co-designing hubs, terraces, flexible furnishings	Sense of belonging, mental well-being	Participatory workshops, interviews
Mind (M)	Views, Interiors	P + D/R + C	M.1 Mental Health-Supportive Environments	Integrating green views, plants, restorative landscapes, colors	Stress reduction, attention restoration	Surveys, psychological measures
	Whole School Climate	O + M	M.2 Psychosocial Support Systems	Fostering supportive climate, teacher/peer support programs	Mental health, academic engagement	Mixed methods, longitudinal studies
Community (C)	Whole School, Social Spaces	O + M	C.1 Participatory Planning and Co-design	Collaborative design workshops, student/parent involvement in decision-making, co-creation of spaces	Empowerment, ownership, alignment with user needs	Whole School, Social Spaces
	Social Hubs, Terraces, Corridors	P + D/R + C	C.2 Social Infrastructure and Connectivity	Creating social hubs, terraces for gathering, managing vertical movement, providing varied space types	Enhanced social interaction, sense of community, belonging	Case studies, observation, POE
	School Climate, Classrooms	O + M	C.3 Social-Emotional Support Systems	Fostering supportive school climate, strengthening school identification, peer/teacher support systems	Mental health, resilience, coping during crises	Mixed methods, longitudinal studies, surveys
Safety (S)	Corridors, Playgrounds, Classrooms (Hotspots)	P + D/R + C	S.1 Physical Safety and Injury Prevention	Analyzing design features (visibility, lighting), optimizing seating, addressing vandalism, identifying hotspots	Prevention of accidents, bullying, and physical harm	Case studies, spatial analysis, observation
	School Clinic/Health Room	O + M	S.2 Health Service Integration and Access	Establishing school-based health centers, integrating immunization/screening, providing general care	Physical and mental health maintenance, health equity, attendance support	Policy analysis, program evaluation, case studies
	Whole School Environment	O + M	S.3 Psycho-Social Safety and Bullying Prevention	Creating positive social climate, reducing peer victimization, promoting supportive adult relationships	Emotional security, mental well-being, reduction in harm	Surveys, intervention studies, mixed methods
Education (E)	Schoolyard, Green Infrastructure	O + M	E.1 Environmental Education and Behavior Guidance	Outdoor classrooms, green wall living labs, storytelling interventions	Environmental awareness, behavior change	Experimental intervention, participatory observation

Noted: P + D = Planning and Design; R + C = Retrofit and Construction; O + M = Operation and Maintaince.

presents the classification of primary spatial focus, building lifecycle stage, groups of indicators, specific indicators, corresponding health impacts, and research methods. The clustering of evidence into distinct indicator groups reflects targeted responses to the unique challenges and opportunities presented by school environments and their young occupants in hot-humid regions.

Thermal Comfort

Thermal comfort is the most extensively studied category, addressing the fundamental stressor of heat. Children who have higher metabolic rates per body mass and less developed thermoregulatory systems than adults, are particularly vulnerable to overheating, which can directly impair cognition and health. TC 1. Passive Design Strategies prioritize architectural interventions over mechanical systems. Key indicators include schoolyard revegetation, sun sails or shading devices, and building orientation. These strategies reduce solar heat absorption and maintain outdoor spaces for physical activity and recess, essential for child development. TC.2 Adaptive Interventions and TC.3 Thermal Control focus on maintaining safe and comfortable operative temperatures. Indicators include temperature setpoints (e.g., 26 °C vs. 32 °C), ventilation strategies, and insulation specifications, particularly critical for retrofitting poorly insulated school buildings.

Air

Children’s developing respiratory systems make them particularly sensitive to pollutants. A1. Ventilation Strategies emphasize natural and mixed-mode ventilation, balancing air exchange with thermal comfort and security. CO₂ monitoring serves as a proxy for occupancy-related bioeffluents, directly linked to drowsiness and cognitive performance. A2. Pollution Monitoring and Control targets school-specific sources, including PM2.5/CO₂ monitoring for traffic or idling buses, and the use of air purifiers when outdoor air quality is insufficient. A3. Greening and Barriers applies vegetation as a functional biofilter, including indoor green walls and perimeter green screens.

Mind

The school environment is a critical setting for socio-emotional development and psychological restoration. M1. Mental Health-Supportive Environments leverage biophilic design and perceptual psychology. Indicators include access to nature, green views, and visual comfort, supporting attention restoration and stress recovery. For adolescents, spaces providing prospect and refuge, such as terraces and quiet hubs, facilitate self-regulation. M2. Psychosocial Support Systems involve fostering a supportive school climate and positive teacher–student relationships, mediated by spatial design that enables informal interactions and a sense of belonging, crucial for adolescent identity formation and mental well-being.

Acoustics and Soundscape

Auditory development and the centrality of verbal instruction make acoustics essential. S1. Noise Control and Soundscape Optimization addresses both sound level and quality. Strategies include mitigating external noise (e.g., traffic) to preserve speech intelligibility and using natural sounds or reverberation management to create a concentration-supportive soundscape.

Light

Lighting supports both visual and non-visual health outcomes. L.1 Daylight and Visual Comfort includes daylight autonomy, glare control, and quality of view, balancing diffuse light for paper-based tasks with glare reduction on whiteboards and screens. L.2 Non-Visual Light Effects address circadian entrainment through circadian-effective lighting and tunable artificial lighting, particularly important for secondary school students with delayed sleep phases.

Spatial Design and Movement

School spaces should support movement, social interaction, and autonomy. SD.1 Space Layout and Activity Promotion transforms incidental movement (between classes, during recess) into meaningful physical activity to combat sedentarism. SD.2 Child Participatory Design engages students in the design process, fostering ownership, agency, and psychological well-being.

Community

The healthy building standards WELL, Fitwel, and the global standards of WHO HPS emphasize that community as a supporting environment, is critical to children and adolescents’ socio-environmental development. Hence, our review synthesizes the evidence into three actionable groups of indicators. C1. Participatory Planning and Co-design engages students in shaping their environment. C2. Social Infrastructure and Connectivity creates dedicated social spaces, such as hubs and terraces, to promote interaction and social bonds. C3. Social-Emotional Support Systems establish policies and practices that foster a supportive whole-school environment, buffering against adversity and promoting mental well-being.

Safety

Safety integrates physical, medical, and psychosocial protection. S.1 Physical Safety and Injury Prevention addresses the immediate built environment, using design to enhance visibility, manage high-traffic areas, and reduce environmental hazards and opportunities for bullying. S.2 Health Service Integration and Access embeds proactive health support within the school, ensuring students have direct, equitable access to screenings, immunizations, and basic care, which is crucial for maintaining daily health and attendance. S.3 Psycho-Social Safety and Bullying Prevention targets the relational environment by fostering positive climates and supportive adult-student relationships, directly addressing the social roots of distress and aggression. This integrated approach ensures safety is not merely the absence of physical danger but the presence of holistic protection and care.

Education

Education is a category within our framework specifically designed for K-12 schools, distinct from the general healthy building standards mentioned above. Indicators of E.1 Environmental Education and Behavior Guidance transform infrastructure into experiential learning tools, such as schoolyard gardens as living labs, outdoor classrooms, and storytelling interventions for thermal adaptation. These strategies integrate health and sustainability into daily school experience.

4. Discussion

This systematic review integrates current evidence to develop a synergistic design framework for health-promoting schools (HPS) in hot-humid climates. The following discussion interprets the key findings, situates the proposed framework within the context of existing research and practice, and highlights its specific contributions and practical implications for designing school environments that promote physical, psychological, and cognitive well-being.

4.1. Synergistic Health Impacts

4.1.1. Mapping of Categories of Design Strategies and Health Impacts

The synthesis of evidence confirms that school design strategies rarely produce isolated effects. Rather, they generate multifaceted impacts across students’ physical, psychological, cognitive, and behavioral health domains (

Table 4. Mapping of health impact domains addressed by the evidence-based strategies.

Health Impact Domain	Associated Strategy Characteristics	Examples of Evidence-Based Design Strategies
Physical Health	Reduced respiratory symptoms, heat stress; increased physical activity; lower obesity risk	Air purification and green barriers; Shading and cooling interventions; Activity-promoting layouts
Psychological Well-being	Reduced stress, anxiety, depressive symptoms; enhanced mood, resilience, subjective well-being	Biophilic design elements; Supportive school climate; Restorative soundscapes
Cognitive and Academic Performance	Improved attention, processing speed, memory, test scores	Optimized thermal comfort; Enhanced IAQ; Access to green views
Social and Behavioral Development	Enhanced pro-social interaction; increased environmental awareness; reduced bullying	Participatory design processes; Nature-based education; Spatial design for safety and visibility

; Figure 8). This highlights the interconnected nature of environmental interventions, where improvements in one dimension—such as thermal comfort or indoor air quality—can simultaneously enhance cognitive performance, psychological well-being, and social behaviors.

The most pronounced synergistic effects are observed in strategies that bridge Thermal Comfort and Air Quality, Green Space/Biophilic Design dimensions. For example, schoolyard revegetation—primarily categorized under Thermal Comfort and Green Spaces—serves as a multi-benefit intervention. It mitigates heat stress through shading (enhancing physical health), captures airborne particulate matter (improving air quality and physical health), dampens traffic and playground noise (supporting psychological calm and cognitive focus), provides restorative visual and sensory connections to nature (boosting psychological health), and functions as an outdoor learning resource (fostering cognitive and developmental growth). Similarly, mixed-mode ventilation systems or strategically designed windows, while targeting Thermal Comfort and Air Quality, also reduce CO₂ concentrations, which is directly associated with improved cognitive performance and reduced drowsiness.

The Spatial Design and Movement dimension demonstrates strong synergy with the Mind dimension. Activity-promoting layouts that reduce distances to playgrounds and improve accessibility increase moderate-to-vigorous physical activity, combating sedentarism and supporting physical health. When co-designed with students to include social hubs and diverse zones, these spaces also foster social interaction, a sense of belonging, and autonomy—key determinants of psychological well-being.

Furthermore, interventions in Acoustics and Soundscape and Light contribute to supportive sensory environments that underpin cognitive and psychological health. Noise mitigation strategies not only protect hearing but also reduce cognitive load and annoyance, freeing mental resources for learning and reducing stress. Access to natural light and views regulates circadian rhythms, improves mood, and reduces visual strain, thereby supporting sustained attention and cognitive performance.

This analysis underscores that a siloed approach to school design may overlook compound benefits and create unintended trade-offs. For instance, sealing a building envelope for energy efficiency may enhance thermal comfort but degrade indoor air quality if not paired with appropriate mechanical ventilation. The synergistic framework explicitly guides designers to identify and optimize these interactions. Strategies such as biophilic design inherently deliver co-benefits across sensory, psychological, and environmental performance metrics. By designing synergy, health-promoting schools can create environments where improvements in thermal resilience, air quality, noise control, and spatial ergonomics converge to multiplicatively support children’s holistic development, academic achievement, and long-term well-being. This evidence-based, integrated perspective provides a robust and efficient pathway to educational settings that are not only safe and comfortable but actively nurture the multifaceted health of their occupants.

4.1.2. The Impact of Indicators of Evidence-Based Design Strategies on Health

Building on the evidence-fragment methodology described in Section 2.4, a quantitative synthesis was conducted to assess the distribution and strength of evidence linking specific evidence-based design strategies to student health outcomes.

Table 5. Impact of indicators of evidence-based design strategies on health. N. denotes the amount of evidence that the percentage reported is based on (one paper can contain multiple pieces of evidence).

Category	Group of Indicators	Impact of Indicators of Evidence-Based Design Strategies on Health			N.
		Negative	Various	Positive
Air	A.1 Ventilation Strategies	0%	0%	48%	25
	A.2 Pollution Monitoring and Control	0%	0%	38.5%	20
	A.3 Greening and Barriers	0%	0%	13.5%	7
Acoustics and Soundscape	AS.1 Noise Mitigation Design	0%	0%	75.0%	6
	AS.2 Soundscape Management	0%	0%	25.0%	2
Light	L.1 Daylighting and Visual Design	0%	0%	94.0%	15
	L.2 Non-Visual Light Effects	0%	0%	6.0%	1
Thermal Comfort	TC.1 Passive Design Strategies	0%	0%	53.2%	33
	TC.2 Adaptive Interventions	0%	0%	19.4%	14
	TC.3 Thermal Control	1.6%	1.6%	21%	15
Spatial Design and Movement	SD.1 Space Layout and Activity Promotion	0%	7.1%	71.4%	11
	SD.2 Child Participatory Design	0%	0%	21.4%	3
Mind	M.1 Mental Health-Supportive Environments	0%	0%	78.6%	33
	M.2 Psychosocial Support Systems	0%	0%	21.4%	9
Community	C.1 Participatory Planning and Co-design	0%	0%	4.8%	1
	C.2 Social Infrastructure and Connectivity	0%	0%	42.8%	9
	C.3 Social-Emotional Support Systems	0%	0%	52.4%	11
Safety	S.1 Physical Safety and Injury Prevention	0%	0%	25%	2
	S.2 Health Service Integration and Access	0%	0%	50%	4
	S.3 Psycho-Social Safety and Bullying Prevention	0%	0%	25%	2
Education	E.1 Environmental Education and Behavior Guidance	0%	23%	77%	13

presents the impact of indicators across the nine environmental categories defined by the framework. The distribution of evidence fragments reveals a clear hierarchy of research focus, reflecting the primary environmental challenges in hot-humid climates. Thermal Comfort (N = 62), Air (N = 52), and Mind (N = 42) together account for over half of all synthesized evidence fragments, establishing them as the most densely researched pillars of the framework. Across most indicator groups, nearly all evidence was coded as having a “Positive” health impact, reinforcing the premise that intentional design of the school physical environment is a critical lever for promoting student health and well-being.

Conversely, categories such as Acoustics and Soundscape (N = 8) and Education (E.1, N = 13) exhibit relatively lower evidence counts, highlighting gaps in the literature. These areas warrant further primary research to expand the evidence base and refine guidance for the design of school environments that support holistic student health.

4.2. Positioning and Contribution Relative to Existing Standards

In this study, we proposed a synthesized framework for health-promoting schools, grounded in mainstream assessment tools and augmented with evidence-based strategies identified through the reviewed literature. The framework is intended to complement and enhance existing green and healthy building standards by offering a targeted perspective for the specific context of K–12 schools in hot-humid regions.

Broad international standards, such as LEED v4.1, provide comprehensive foundations for sustainability, while health-focused tools like WELL v2 and Fitwel v3 translate public health evidence into actionable building design criteria. However, their application to educational facilities often requires additional interpretation to address the unique physiological vulnerabilities, behavioral patterns, and pedagogical needs of children and adolescents. Similarly, climate-adaptive systems such as Singapore’s Green Mark provide valuable guidance on thermal performance, but their general scope across multiple building types limits specificity for optimizing environments tailored to learning and child development.

The proposed framework advances these systems by integrating and refining their principles to create a specialized, actionable guide for educational settings. It combines a climate-responsive technical focus with a pediatric health perspective, structuring evidence into indicators explicitly linked to school spaces (e.g., classrooms, schoolyards) and project lifecycle stages. This specificity is intended to serve as a practical supplement to broader standards, enabling designers and policymakers to translate general healthy building concepts into tailored solutions for K–12 schools in hot-humid climates.

4.3. Implications for Research and Practice

This study advances the operationalization of the health-promoting school (HPS) concept through a detailed environmental design lens, integrating building science, environmental psychology, and educational practice. Practical implications for stakeholders include:

For designers and architects: The framework translates abstract principles into categorized, evidence-based indicators mapped to specific spaces (e.g., classrooms, building envelope, schoolyard) and project phases (planning and design, retrofit, operation). This structured approach supports informed decision-making when balancing competing performance objectives, ensuring that interventions simultaneously enhance physical, psychological, and cognitive outcomes.

For policymakers and school administrators: The framework provides a structured yet adaptable tool for developing localized design guidelines and retrofit priorities, particularly for the extensive existing school building stock in subtropical urban areas. Emphasis on participatory strategies (e.g., SD.2, C.1) offers a practical process for engaging the school community in co-design, fostering ownership, and promoting long-term adherence to health-promoting interventions.

By bridging evidence, design practice, and policy, the framework offers a comprehensive, actionable approach to creating school environments that support holistic health, resilience, and learning outcomes in hot-humid climates.

4.4. Limitations and Future Research

This review acknowledges several limitations in both the source literature and the derived framework. First, the evidence base comprises predominantly quantitative research in the physical domains (e.g., Air, Thermal Comfort, Acoustics, Light) versus qualitative studies in socio-behavioral domains (e.g., Community, Safety, Education). The differing nature of these data sources complicates direct comparisons of “effect strength” across dimensions. Second, many studies are context-specific, often focused on a particular school or city. While these findings provide valuable insights, they require careful adaptation when applied to different cultural, economic, and microclimatic contexts within the broader hot-humid zone. Third, the framework primarily addresses design-phase interventions. Although operational practices, maintenance regimes, and occupant behavior are recognized as critical for realizing intended health benefits, these factors warrant further empirical investigation. Finally, the review did not include a formal risk-of-bias assessment for the included studies, which may affect the interpretation of cumulative evidence strength.

Future research should aim to: (1) Strengthen underrepresented dimensions, particularly Safety, Education, and Community, through rigorous quantitative or mixed-methods studies. (2) Conduct longitudinal studies to assess the sustained impact of synergistic interventions on physical, psychological, and academic outcomes. (3) Examine the interactions between design interventions and operational practices to optimize real-world implementation and efficacy. (4) Adapt and validate the framework across diverse hot-humid contexts to ensure its generalizability and cultural relevance. Addressing these gaps will enhance the robustness, applicability, and practical value of the proposed health-promoting school framework.

5. Conclusions

This systematic review synthesizes a decade of empirical research to propose a novel, synergistic design framework for Health-Promoting Schools (HPS) in hot-humid climates. The framework—encompassing Thermal Comfort, Air, Acoustics and Soundscape, Light, Spatial Design and Movement, Mind, Community, Safety, and Education—moves beyond the parameter-specific focus of conventional building standards by explicitly addressing the interconnected physical, psychological, and cognitive needs of children and adolescents. By providing an actionable, evidence-based toolkit, the framework facilitates the translation of aspirational global HPS guidelines into localized, climate-responsive design and retrofit strategies. Categorizing strategies according to spatial focus and building lifecycle stage, it offers concrete guidance for both new construction and the critical challenge of upgrading existing school stock in high-density subtropical cities. Overall, this structured yet adaptable roadmap empowers designers, policymakers, and educators to collaboratively create school environments that not only respond to the challenges of a warming climate but also actively foster the holistic well-being, resilience, and potential of young occupants.