PurposeDue to land resource scarcity, sustainable urban development in high-density cities has long been challenging. As such, many cities are formulating plans to “dig deep”, resulting in more citizens working and/or staying underground for longer periods of time. However, owing to the particularities of underground space, the factors involved in the creation of a healthy environment are different from those involved in aboveground developments. This study thus aims to investigate the influences of various underground environment factors on users' health through a holistic approach.Design/methodology/approachTo achieve this aim, 12 underground sites and 12 corresponding aboveground sites are selected for a large-scale questionnaire survey, resulting in 651 survey samples. The survey covers post-occupancy evaluation of health (physical and psychosocial), underground environmental quality (visual, thermal, acoustic comfort, indoor air quality and ventilation), space design and greenery. Independent-sample T-test, Pearson correlation, multiple regression modelling and structural equation modelling are used to investigate whether significant differences exist between health of underground and aboveground users, and to develop an underground environment-health model for unveiling the significant associations between underground environment factors and users' health. To cross validate the results, an objective field measurement study is further conducted on six underground sites. The objective measurement results are used to cross validate the survey results.FindingsThe questionnaire results provide the following evidence: (1) health of underground users is significantly poorer than that of their aboveground counterparts; (2) underground development users' health is significantly affected by space design, greenery and environmental quality in terms of thermal comfort, indoor air quality, ventilation and acoustic comfort but not visual comfort; and (3) amongst the various identified factors, space design has the strongest predicting effects on human health. The field study echoes the survey findings and further unveils the relationships between different environmental factors and human health.Originality/valueThe results shed light on the importance of distinguishing between underground developments and aboveground ones in various guidelines and standards, especially those related to space management.