Therapeutic Environment Design for Hospitalised Children: A Systematic Review with Implications for Resource-Constrained Settings in the Arab Context

Therapeutic environment design is an important dimension of paediatric healthcare, with physical conditions associated with children’s stress, comfort, well-being and behaviour during hospitalisation. Yet evidence remains concentrated in high-income Western countries, with limited research in Arab settings. This review examines these relationships and how the evidence can inform resource-constrained paediatric healthcare, with particular consideration of Syria within the wider Arab context. Following PRISMA 2020, Scopus and Web of Science were searched for studies published in 2000–2025. Twenty-five publications were included: 23 empirical studies with MMAT 2018 appraisal records and two reviews providing context. Four themes were identified: sensory and atmospheric environment; nature and biophilic design; spatial configuration, layout and privacy; and child-centred experiential and family-supportive design. Daylight was linked to satisfaction, blue and green walls were preferred to white, and poor acoustics and limited thermal control were sources of dissatisfaction. Nature-access studies reported mood, distress and satisfaction outcomes. Spatial legibility, privacy and parent accommodation were relevant to orientation and well-being. Positive distraction was associated with calmer behaviour, and families valued home-like accommodation. Evidence mainly comprised associations, preferences and perceptions. Only three Arab-context studies were identified, and none was from Syria. The review draws on international evidence and the limited research from Arab contexts to develop design considerations for architects, hospital administrators and policymakers in resource-constrained paediatric healthcare settings.

Therapeutic environment, Paediatric healthcare design, Evidence-based design

1. Abulawi, R. A. (2023). The conceptual design themes of artwork in the public spaces of children's hospital. Civil Engineering and Architecture, 11(5), 2413–2434. https://doi.org/10.13189/cea.2023.110513 [Google Scholar] [Crossref]

2. Adams, A., Theodore, D., Goldenberg, E., McLaren, C., & McKeever, P. (2010). Kids in the atrium: Comparing architectural intentions and children's experiences in a pediatric hospital lobby. Social Science & Medicine, 70(5), 658–667. https://doi.org/10.1016/j.socscimed.2009.10.049 [Google Scholar] [Crossref]

3. Alhsainat, A., & Günçe, K. (2024). Healing environment in pediatric cancer centers by utilizing positive distractions. Behavioral Sciences, 14(11), Article 1010. https://doi.org/10.3390/bs14111010 [Google Scholar] [Crossref]

4. Babbu, A. H., & Haque, M. (2021). Effects of the physical environment of pediatric healthcare settings on health outcomes of patient & family and staff. International Transaction Journal of Engineering, Management, & Applied Sciences & Technologies, 12(12), Article 12A12I. https://doi.org/10.14456/ITJEMAST.2021.240 [Google Scholar] [Crossref]

5. Canakcioglu, N. G., & Unlu, A. (2025). Exploring cognitive and syntactic dimensions in a healthcare environment affecting the spatial perceptions of paediatric inpatients. Open House International, 50(2), 302–323. https://doi.org/10.1108/OHI-12-2023-0285 [Google Scholar] [Crossref]

6. Demetriou, E. A., Boulton, K. A., Bowden, M. R., & Guastella, A. J. (2024). Adjustment and homesickness in hospitalised children: A systematic review. Clinical Psychology Review, 110, Article 102431. https://doi.org/10.1016/j.cpr.2024.102431 [Google Scholar] [Crossref]

7. Dyekjær, C. D., & Dreyer, P. (2019). The family house—A safe haven: A qualitative study of families' experiences staying in a hospital family house during their children's hospitalisation. Journal of Clinical Nursing, 28(11–12), 2276–2284. https://doi.org/10.1111/jocn.14827 [Google Scholar] [Crossref]

8. Goel, S., Mihandoust, S., Joseph, A., Markowitz, J., Gonzales, A., & Browning, M. (2024). Design of pediatric outpatient procedure environments: A pilot study to understand the perceptions of patients and their parents. HERD: Health Environments Research & Design Journal, 17(2), 183–199. https://doi.org/10.1177/1937586723122039 [Google Scholar] [Crossref]

9. Gola, M., Francalanza, P. C., Galloni, G., Pagella, B., & Capolongo, S. (2016). Architectures for paediatric palliative care: How to improve quality of life and environmental well-being. Annali dell'Istituto Superiore di Sanità, 52(1), 48–55. https://doi.org/10.4415/ANN_16_01_10 [Google Scholar] [Crossref]

10. Hong, Q. N., Fàbregues, S., Bartlett, G., Boardman, F., Cargo, M., Dagenais, P., Gagnon, M.-P., Griffiths, F., Nicolau, B., O'Cathain, A., Rousseau, M.-C., Vedel, I., & Pluye, P. (2018). The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers. Education for Information, 34(4), 285–291. https://doi.org/10.3233/EFI-180221 [Google Scholar] [Crossref]

11. Kaplan, R., & Kaplan, S. (1989). The experience of nature: A psychological perspective. Cambridge University Press. [Google Scholar] [Crossref]

12. Kotzer, A. M., Zacharakis, S. K., Raynolds, M., & Buenning, F. (2011). Evaluation of the built environment: Staff and family satisfaction pre- and post-occupancy of the Children's Hospital. HERD: Health Environments Research & Design Journal, 4(4), 60–78. https://doi.org/10.1177/193758671100400405 [Google Scholar] [Crossref]

13. Litkouhi, S., Geramipour, M., & Litkouhi, S. (2012). The effect of gender, age, and nationality on the personal space preferences in children's hospitals among Iranian and German children and adolescents. Iranian Red Crescent Medical Journal, 14(8), 460–465. [Google Scholar] [Crossref]

14. Norouzi, N., Martinez, A., & Rico, Z. (2023). Architectural design qualities of an adolescent psychiatric hospital to benefit patients and staff. HERD: Health Environments Research & Design Journal, 16(4), 103–117. https://doi.org/10.1177/19375867231180907 [Google Scholar] [Crossref]

15. Ouzzani, M., Hammady, H., Fedorowicz, Z., & Elmagarmid, A. (2016). Rayyan—A web and mobile app for systematic reviews. Systematic Reviews, 5, Article 210. https://doi.org/10.1186/s13643-016-0384-4 [Google Scholar] [Crossref]

16. Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., . . . Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, Article n71. https://doi.org/10.1136/bmj.n71 [Google Scholar] [Crossref]

17. Park, J. G. (2009). Color perception in pediatric patient room design: Healthy children vs. pediatric patients. HERD: Health Environments Research & Design Journal, 2(3), 6–28. https://doi.org/10.1177/193758670900200302 [Google Scholar] [Crossref]

18. Park, J. G., & Park, C. (2013). Color perception in pediatric patient room design: American versus Korean pediatric patients. HERD: Health Environments Research & Design Journal, 6(4), 10–26. https://doi.org/10.1177/193758671300600402 [Google Scholar] [Crossref]

19. Pasha, S. (2013). Barriers to garden visitation in children's hospitals. HERD: Health Environments Research & Design Journal, 6(4), 76–96. https://doi.org/10.1177/193758671300600405 [Google Scholar] [Crossref]

20. Pati, D., & Nanda, U. (2011). Influence of positive distractions on children in two clinic waiting areas. HERD: Health Environments Research & Design Journal, 4(3), 124–140. https://doi.org/10.1177/193758671100400310 [Google Scholar] [Crossref]

21. Pattabi, A., Nazarene, A., Varghese, S., Hassan, S. M., Nashwan, A. J., Patil, S. K., & Singh, K. (2024). Assessing child satisfaction and expectations for developing a child-friendly environment at the pediatric department in a general hospital in Qatar. Frontiers in Pediatrics, 12, Article 1279033. https://doi.org/10.3389/fped.2024.1279033 [Google Scholar] [Crossref]

22. Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., Britten, N., Roen, K., & Duffy, S. (2006). Guidance on the conduct of narrative synthesis in systematic reviews: A product from the ESRC Methods Programme (Version 1). Lancaster University. https://doi.org/10.13140/2.1.1018.4643 [Google Scholar] [Crossref]

23. Qi, Y., Yan, Y., Lau, S. S., & Tao, Y. (2021). Evidence-based design for waiting space environment of pediatric clinics—Three hospitals in Shenzhen as case studies. International Journal of Environmental Research and Public Health, 18(22), Article 11804. https://doi.org/10.3390/ijerph182211804 [Google Scholar] [Crossref]

24. Sarı Öztürk, Ç., & Merter, Ö. S. (2024). Challenges and facilitators in child-friendly healthcare from the perspective of pediatric emergency nurses: A qualitative study. Journal of Pediatric Nursing, 78, e180–e186. https://doi.org/10.1016/j.pedn.2024.07.004 [Google Scholar] [Crossref]

25. Sherman, S. A., Varni, J. W., Ulrich, R. S., & Malcarne, V. L. (2005). Post-occupancy evaluation of healing gardens in a pediatric cancer center. Landscape and Urban Planning, 73(2–3), 167–183. https://doi.org/10.1016/j.landurbplan.2004.11.013 [Google Scholar] [Crossref]

26. Sherman-Bien, S. A., Malcarne, V. L., Roesch, S., Varni, J. W., & Katz, E. R. (2011). Quantifying the relationship among hospital design, satisfaction, and psychosocial functioning in a pediatric hematology-oncology inpatient unit. HERD: Health Environments Research & Design Journal, 4(4), 34–59. https://doi.org/10.1177/193758671100400404 [Google Scholar] [Crossref]

27. Ulrich, R. S. (1983). Aesthetic and affective response to natural environment. In I. Altman & J. F. Wohlwill (Eds.), Behavior and the natural environment (pp. 85–125). Springer. https://doi.org/10.1007/978-1-4613-3539-9_4 [Google Scholar] [Crossref]

28. Ulrich, R. S. (2000). Evidence based environmental design for improving medical outcomes. In Healing by design: Building for health care in the 21st century (pp. 3.1–3.10). McGill University Health Centre. [Google Scholar] [Crossref]

29. UNICEF. (2025, January 23). Paving the road to a hopeful and inclusive future in Syria, free from violence and hardship [Press release]. https://www.unicef.org/syria/press-releases/paving-road-hopeful-and-inclusive-future-syria-free-violence-and-hardship [Google Scholar] [Crossref]

30. Varni, J. W., Burwinkle, T. M., Dickinson, P., Sherman, S. A., Dixon, P., Ervice, J. A., Leyden, P. A., & Sadler, B. L. (2004). Evaluation of the built environment at a children's convalescent hospital: Development of the Pediatric Quality of Life Inventory™ parent and staff satisfaction measures for pediatric health care facilities. Journal of Developmental & Behavioral Pediatrics, 25(1), 10–20. https://doi.org/10.1097/00004703-200402000-00002 [Google Scholar] [Crossref]

31. Verderber, S., Gray, S., Suresh-Kumar, S., Kercz, D., & Parshuram, C. (2021). Intensive care unit built environments: A comprehensive literature review (2005–2020). HERD: Health Environments Research & Design Journal, 14(4), 368–415. https://doi.org/10.1177/19375867211009273 [Google Scholar] [Crossref]

32. Vollmer, T. C., & Koppen, G. (2021). The parent–child patient unit (PCPU): Evidence-based patient room design and parental distress in pediatric cancer centers. International Journal of Environmental Research and Public Health, 18(19), Article 9993. https://doi.org/10.3390/ijerph18199993 [Google Scholar] [Crossref]

33. Whitehouse, S., Varni, J. W., Seid, M., Cooper-Marcus, C., Ensberg, M. J., Jacobs, J. R., & Mehlenbeck, R. S. (2001). Evaluating a children's hospital garden environment: Utilization and consumer satisfaction. Journal of Environmental Psychology, 21(3), 301–314. https://doi.org/10.1006/jevp.2001.0224 [Google Scholar] [Crossref]

34. Woo, J.-C., & Lin, Y.-L. (2016). Kids' perceptions toward children's ward healing environments: A case study of Taiwan University Children's Hospital. Journal of Healthcare Engineering, 2016, Article 8184653. https://doi.org/10.1155/2016/8184653 [Google Scholar] [Crossref]

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