Introduction

Cities are at the forefront of some of the most pressing health and social challenges of the 21st century (WHO, 2023, 2025). Rapid urbanization, demographic shifts, climate change, and digital transformations are reshaping how health is produced, experienced, and governed in urban settings (Bambra et al., 2020; WHO, 2023). A triple health burden of non-communicable diseases, infectious outbreaks, and violence disproportionately affects vulnerable populations (WHO, 2025). Addressing these multifaceted issues requires moving beyond traditional sectoral approaches toward integrated urban models that can coordinate infrastructure, services, equity, and citizen engagement in a dynamic system (WHO, 2023, 2025). However, despite growing recognition of these needs, existing urban frameworks often remain fragmented or limited in scope (Bambra et al., 2020; WHO, 2025).

Emerging as a pioneering response to urban health challenges, the Healthy Cities movement—spearheaded by the World Health Organization since 1986—has advocated for a holistic urban governance model centered on social determinants of health, cross-sector collaboration, and community empowerment (Hancock and Duhl, 1986; de Leeuw and Simos, 2017). By prioritizing walkable neighborhoods, equitable access to green spaces, affordable housing, and essential services, this framework embeds health equity into urban planning processes, particularly for marginalized groups (WHO, 2025). Despite its emphasis on participatory governance, critics argue that the model struggles to integrate rapidly advancing digital tools—such as IoT-enabled health monitoring or AI-driven resource allocation—into its legacy systems, limiting its responsiveness to contemporary urban complexities (Kitchin, 2014; Angelidou, 2015).

In contrast to the social determinants-focused Healthy Cities model, the Smart City framework leverages digital technologies—such as sensors, the Internet of Things (IoT), big data, and artificial intelligence—to enhance the efficiency, responsiveness, and sustainability of urban systems (Albino et al., 2015; Yigitcanlar et al., 2018). This approach aims to optimize infrastructure across sectors including transportation, energy, security, and healthcare, often through integrated digital platforms and real-time monitoring systems (Khayal and Farid, 2017). This model has facilitated innovation in service delivery and urban management, but actual implementation of participatory elements remains limited despite its increasing emphasis on citizen participation and engagement (Söderström et al., 2014; Joss et al., 2019). Furthermore, debates persist about balancing technological innovation with digital equity, particularly in low-income households (Kolotouchkina et al., 2024). These discussions extend to considerations of digital access, privacy, and equity in smart city implementations (Hollands, 2008; van Zoonen, 2016). Although health considerations are increasingly integrated (Trencher and Karvonen, 2019), holistic approaches addressing both digital infrastructure and social determinants remain rare (Praharaj et al., 2018).

In response to these shortcomings, hybrid models such as Smart Healthy Age-Friendly Environments (SHAFE) and Collaborative Age-Friendly Smart Ecologies (CASE) have emerged to explore the integration of digital technologies into socially inclusive and health-supportive urban design, especially for older populations. The SHAFE model pioneered by the European Innovation Partnership on Active and Healthy Aging, specifically promotes the convergence of smart technologies (e.g., digital health, smart homes) and age-friendly urban features to support aging in place (Marston and van Hoof, 2019). The CASE framework extends this idea by emphasizing collaborative, intergenerational, and community-based approaches to smart aging environments (Torku et al., 2021). These models represent meaningful progress, particularly in advancing user-centered design and highlighting the role of digital tools in health and wellbeing. However, they tend to be demographically narrow (primarily focused on older adults), conceptually siloed, and often lack a systems-level view of how urban health, technology, and governance interact across the life course and at different spatial and institutional scales (WHO, 2007).

Despite their innovations, there remains a need for a comprehensive framework that balances digital innovation with public health values, enables inter-sectoral coordination, and explicitly incorporates health equity and citizen empowerment as central design principles. Sufficient theoretical integration across disciplines is still demanded to guide practical implementation or comparative assessment.

This gap highlights the necessity for a new framework that unites the technological strengths of Smart Cities with the equity-driven ethos of Healthy Cities, while expanding beyond both to include systemic interdependence, capability-building, and participatory urban governance. The Smart Healthy City (SHC) model proposed in this study seeks to fulfill this role. Table 1 provides a comparative overview of Smart City, Healthy City, SHAFE, and Smart Healthy City concepts, highlighting how our proposed framework builds upon and extends these existing models.

Table 1 Comparative Analysis of Smart City, Healthy City, SHAFE, and Smart Healthy City Concepts.
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This study is guided by three research questions:

RQ1: What constitutes the concept of a Smart Healthy City?

RQ2: What are the key concepts integral to achieving the core objectives of a Smart Healthy City?

RQ3: What are the priority concepts within a Smart Healthy City?

To understand and articulate this emerging concept, we adopted an innovative two-stage concept mapping methodology, specifically designed for capturing emerging concepts such as Smart Healthy Cities (SHCs). This approach combines insights from Expert-Focused Group Interviews (E-FGIs) to generate foundational ideas, followed by rigorous analytical techniques and participatory decision making process of formal concept mapping to structure and validate these concepts. The empirical results yielded four interconnected dimensions of SHC, which reflect a multi-dimensional and multi-level view of urban health governance, encompassing both human-centered and technology-driven elements.

To further interpret the logic and interconnections among these clusters, we drew on six theoretical perspectives that collectively provide a comprehensive foundation for understanding SHCs. These perspectives were selected not simply because of their prevalence in literature, but for their strategic value in illuminating different dimensions of the SHC concept and their capacity to bridge traditionally separate domains of urban development and public health. They complement each other in addressing technological, social, environmental, and governance aspects of SHCs.

Socio-ecological Theory (Bronfenbrenner, 1979; McLeroy et al., 1988) provides a multilevel approach to health determinants, showing how urban subsystems interact across different social levels—from individual behaviors to community characteristics to policy environments—particularly relevant for understanding environmental and community aspects of SHCs.

Smart City Theory (Albino et al., 2015; Yigitcanlar et al., 2018) illuminates how digital infrastructure and innovation enhance urban services and quality of life, demonstrating ways in which ICT solutions can monitor health indicators, improve service delivery, and enable data-driven decision-making.

The Health Equity perspective (Marmot and Wilkinson 2006; Gómez et al., 2021) emphasizes equitable access to resources while recognizing how social, economic, and environmental factors shape health outcomes across diverse populations—crucial for addressing social sustainability in SHCs.

Systems Thinking (Meadows, 2008; Webb et al., 2018) offers tools for analyzing urban complexity and interdependencies, conceptualizing cities as complex adaptive systems where health interventions in one domain create ripple effects throughout the urban ecosystem.

The Capabilities Approach (Sen, 1999; Nussbaum, 2011) defines health as the freedom to achieve wellbeing, emphasizing how urban design and technology can expand individual agency and substantive freedoms, supporting the health empowerment dimension of SHCs.

Participatory Urban Planning Theory (Healey, 2005; Buffel et al., 2018) underscores inclusive governance and citizen engagement, recognizing that effective SHC initiatives must incorporate diverse stakeholder voices through collaborative processes.

Together, these perspectives facilitate interdisciplinary integration across urban planning, public health, and technology fields, enhancing both the explanatory power and practical applicability of our SHC framework to diverse urban contexts.

To convey findings from this research, we structured this paper as follows. The Methods section explains the two-stage concept mapping approach, including expert selection and analytical procedures. The Results present the emergent conceptual framework of SHC and the four clusters derived from expert knowledge, how they are linked to achieving health equity, smart connectivity, and system-level resilience, and what priority ideas are. The Discussion interprets these findings using theoretical lenses and evaluates their implications for achieving objectives of SHCs as well as implications related to SHAFE and CASE. The Conclusion offers directions for policy, practice, and future research. By grounding the SHC framework in interdisciplinary theory and critically examining the socio-technical dimensions of urban health governance, this study contributes to ongoing discussions in the humanities and social sciences on how cities shape well-being, citizenship, and inequality in the digital age.

Methods

Study design

This study employed a two-stage concept mapping approach to address the methodological challenges of conceptualizing Smart Healthy Cities (SHCs), an emerging interdisciplinary field lacking clear definition. It was conducted over a three-month period from April 2023 to June 2023. The overall research process is illustrated in Fig. 1.

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The Two-Stage Concept Mapping Procedure.

As a complex, multidisciplinary, emerging concept, SHC requires an integrated approach drawing from various fields (Sugandha et al., 2022). Concept mapping offers advantages for understanding complex topics by systematically structuring inputs and visualizing relationships between concepts, combining qualitative analysis with quantitative verification (Naeem et al., 2023). However, traditional concept mapping approaches face a specific challenge when applied to novel interdisciplinary domains like Smart Healthy Cities: they typically rely on established literature and predefined concepts as their starting points (Trochim, 1989; Kane and Trochim, 2007). For emerging fields where foundational concepts are still being defined, this dependency on existing knowledge creates significant limitations.

Our methodological innovation addresses this challenge through a deliberate separation of statement generation from statement structuring. As Gibbons et al. (1994) argues, emerging complex concepts require specialized approaches that capture collective epistemology across disciplinary boundaries. By first employing Expert Focused Group Interviews to generate rich foundational statements and then using these statements in a formal concept mapping process, our approach overcomes the limitations of traditional single-stage methods.

The six theoretical perspectives guided our methodological choices, including expert selection, data collection approach, statement development, and analytical framework, ensuring comprehensive coverage of the interdisciplinary nature of SHCs.

Participant Selection

For E-FGIs, selection criteria aimed to ensure diverse expertise across SHC domains (Albino et al., 2015; de Leeuw and Simos, 2017), by focusing on our four key interdisciplinary areas essential to SHC development: public health, urban planning, digital innovation, and social sustainability, which are areas identified in recent conceptual studies on the SHC frameworks (Sugandha et al., 2022; Lim et al., 2024).

Thirty-five experts were selected based on their expertise. Participants were university professors, public health officials, digital healthcare entrepreneurs, urban designers, and public institution representatives from the Republic of Korea. Experts from patient advocacy organizations and living labs to incorporate user-centered, community-based perspectives participated as well. Selection was based on academic background, professional experience (minimum 5 years), publication record, or involvement in relevant policy initiatives. Geographically, our participants were from public major metropolitan institutions to community-based organizations in small and medium-sized cities, as well as experts involved in digital healthcare pilot projects in provincial areas. The complete participants list is provided in Table S1 in the Supplementary Materials.

In the subsequent Group Concept Mapping (GCM) stage, we recruited 16 participants, which falls within the recommended range of 10 to 40 participants for such studies (Kane and Trochim, 2007; Rosas and Kane, 2012; Antoniou et al., 2019). This sample size aligns with Burke et al. (2005), who found effective concept mapping with 14-37 participants, while Rosas and Kane (2012) confirmed that purposively selected samples representing diverse expertise can produce high-quality concept maps.

Data Collection and Analysis

All data collection processes were conducted online, except for the pilot session of the GCM.

Stage 1: E-FGIs

Ten semi-closed E-FGIs (two sessions of five) were conducted on Gather.town using Miro, with each session lasting approximately 120 min. The first group of sessions consisted of various unidisciplinary groups, while the second featured multidisciplinary groups with mixed expertise. During these Interviews, we implemented a structured discussion protocol to identify potential core objectives of SHCs, which were later incorporated into the importance rating task.

Key questions to explore the concepts of the SHCs included: ‘How would you define a Smart Healthy City?’ and ‘What are the essential components of a Smart Healthy City?’ Participants were divided into five thematic teams (governance, public health, urban planning, digital innovation, and social policy) and engaged in group discussions facilitated by two experienced moderators each. Participating experts shared insights on how their domains relate to the SHC concept, using Miro to visualize and organize key ideas in real time. All sessions were audio recorded with participants’ consent and fully transcribed.

From the transcriptions, we identified 402 foundational statements including direct quotes and paraphrased concepts. They encompassed principles, components, and other related content of SHCs. These statements were then analyzed using thematic analysis (Braun and Clarke, 2006). Three independent researchers refined these through a systematic process, specifically focusing on statements directly relevant to the conceptualization of SHCs rather than implementation principles or specific components. The six theoretical perspectives were used as filtering criteria to ensure comprehensive theoretical representation. This process yielded 52 statements specifically pertinent to the SHC concept, with excellent inter-rater reliability (Fleiss’ kappa κ = 0.95, 95% CI [0.93, 0.97]).

Stage 2: GCM

Prior to full implementation, a pilot session was conducted on April 28, 2023, with 8 experts meeting in person at a university for approximately 2 h (Son et al., 2023). This pilot session served to validate both research questions and the statements that would be used in the full GCM process. Following feedback and refinement during this session, the research team finalized a set of 57 statements for use in the main GCM exercise.

For the full GCM implementation, 16 participants were engaged in individual sessions lasting 90 minutes each via Zoom. They used Padlet, a collaborative digital platform, to perform two key tasks that form the foundation of concept mapping methodology.

First, participants categorized the statements into conceptual groups based on their perceived relatedness. This clustering process was open-ended, allowing participants to create as many categories as they deemed appropriate to represent meaningful groupings within the SHC framework. Participants could freely move statements between clusters until they were satisfied with their arrangement.

Second, participants rated each statement’s importance using a 5-point Likert scale, provided a quantitative assessment to complement the qualitative clustering. Participants were also asked to evaluate each statement’s specific relevance to three derived SHC objectives. This multi-dimensional rating approach allowed the research team to identify which concepts were considered most crucial across different aspects of the SHC framework.

The individual nature of these sessions ensured that each expert could provide their perspective without being influenced by group dynamics, while the structured approach generated consistent data across participants that could be aggregated for subsequent statistical analysis.

Statistical analysis

We applied multidimensional scaling (MDS) and Hierarchical Cluster Analysis (HCA) (Kane and Trochim, 2007). An individual similarity matrix was constructed based on the results of statement clustering, with statements in the same cluster coded as 0 and those in different clusters as 1. Reverse coding was applied before analysis.

For MDS, we employed a non-metric approach with a two-dimensional solution. HCA was performed using Ward’s method with squared Euclidean distances. The number of clusters was determined through a combination of statistical measures and expert judgment, which will be explained in more detail in the next section. We used SPSS version 27.0 for the analyses.

To compare the importance of concepts across the three key objectives of the SHC, we conducted importance assessment of statements. A ladder graph was generated to analyze aggregate patterns. Three-dimensional go-zone plots were developed to assess importance at the individual statements level (Kane and Trochim, 2007). We used mean values to divide these three-dimensional plots into eight octants. Due to the difficulty in identifying the zones of the statements in the SPSS visualization results, the statement numbers were reviewed using Rhino-Grasshopper 1.0.000. (Fig. S1 in Supplementary Materials).

Interpreting the concept map

The hierarchy and number of clusters were determined based on the final concept map, dendrogram, and similarity clustering outcomes. Additionally, names were assigned to the clusters and the X and Y axes. The MDS, HCA, and similarity clustering results were shared with the participants before this process to ensure informed interpretation.

Although participation in both the statement structuring and map interpretation sessions was mandated (Kane and Trochim, 2007), two participants missed the final session due to unavoidable circumstances. The remaining 14 participants examined the HCA results to determine the number of clusters and the conceptual structure comprising these clusters. This interpretive session was conducted via Zoom and lasted for 90 minutes. During the time, participants freely discussed the analysis results, reached consensus on the conceptualization of a SHC, and derived final implications. The concept map interpretation took a total of two weeks.

Validity and reliability measures

Content validity was ensured through expert review of the statements. Reliability was assessed by calculating the stress value in MDS and thoroughly checking the final concept map.

Ethical considerations and data handling

This study received ethical approval from the Korea University Institutional Review Board (IRB No. KUIRB-2023-0077-01). All participants were provided with detailed information regarding the study’s purpose, procedures, confidentiality, and data usage, and electronic written consent was obtained prior to participation.

For the E-FGIs conducted via Gather.town, audio recordings were made with prior consent and were used solely for transcription and thematic analysis. All identifying information was removed during transcription. Transcribed data were securely stored in an IRB-compliant, encrypted cloud-based repository with access restricted to the research team.

For the GCM process, participation was anonymous, and no recordings were made. All responses were collected through a secure online interface, and no personally identifiable information was stored.

Results

In this section, we present the description of the objectives of the SHCs, followed by our findings in three main areas based on our research questions: Concept Map Analysis, Pattern Matching, and Go-Zone Analysis (Table 2).

Table 2 Summary of Key Findings Based on Research Questions.
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Objectives of the SHCs

The E-FGI process identified three core objectives for SHCs: health equity, smart connectivity, and system-level resilience. Health equity focuses on creating inclusive cities where healthcare resources, services, and opportunities are fairly distributed across all population groups, with particular attention to reducing geographical and socioeconomic health disparities. Smart connectivity represents the strategic integration of information and communication technologies to enhance community resources, optimize urban service delivery, and continuously improve both physical and social environments through digital connections that empower citizens. System-level resilience encompasses the city’s capacity to anticipate, respond to, and recover from various health threats—including climate change, emerging infectious diseases, and mental health challenges—while building preventive approaches that strengthen citizen capabilities and create sustainable, health-promoting environments.

RQ1: concept map analysis

Our analysis revealed four distinct dimensions of SHCs: Healthy Environment Cities, Smart Networking Cities, Socially Sustainable Cities, and Health Empowering Cities. The MDS of the sorted statements produced a stress value of 0.30, indicating a satisfactory model fit between the raw data and the outcomes (Rosas and Kane, 2012). Participants labeled the X-axis from ‘technology’ to ‘human,’ and the Y-axis from ‘individual’ to ‘community,’ creating four distinct quadrants that contextualize each cluster’s focus (Fig. 2).

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Four-cluster Concept Map of a Smart Healthy City.

These clusters exhibited varying sizes and layering, reflecting the complexity and interconnectedness of SHC concepts. The “Healthy Environment Cities” cluster occupied the smallest area but had the most layers (3), situated in the technology and individual quadrant. In contrast, the “Socially Sustainable Cities” cluster covered the largest area with 3 layers, primarily in the human and community quadrant. The “Smart Networking Cities” cluster consisted of 2 layers, positioned in the technology and community quadrant while overlapping the individual side. The “Health Empowering Cities” cluster was a single-layer cluster located in the human and individual quadrant. This distribution suggests a balanced approach to SHCs, encompassing both technological and human-centered aspects across individual and community levels.

Table 3 provides a structured overview of the four Smart Healthy City (SHC) dimensions, along with their definitions, thematic focus, examples of high-rated statements, core SHC objectives, and theoretical connections. A full list of the 57 statements and their cluster assignments is provided in Supplementary Table S2.

Table 3 SHC Dimensions Summary and Comparison.
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The “Healthy Environment Cities” dimension focuses on physical urban infrastructure for health, with the highest-rated statements including “health-promoting urban environment elements” (mean = 4.29) and “easy access to healthcare services” (mean = 4.21). The “Smart Networking Cities” dimension emphasizes digital connectivity for health system transformation, with “going beyond traditional healthcare through smart technologies” received the highest rating (mean=4.50). The “Socially Sustainable Cities” dimension centers on inclusive community wellbeing, with the statement “targeting the health of the entire community” was rated highest (mean=4.50). The “Health Empowering Cities” dimension concentrates on individual and system-level resilience, with the statements “model for disease prevention” and “public health city safe from infectious diseases” received the highest ratings in this dimension (both mean=4.29).

RQ2: pattern matching

The pattern matching analysis showed that each SHC dimension aligns differently with core objectives—with Healthy Environment Cities contributing broadly across all objectives, Smart Networking Cities strongly supporting smart connectivity, Socially Sustainable Cities primarily advancing health equity, and Health Empowering Cities enhancing system-level resilience (Fig. 3). “Healthy Environment Cities” showed similar average importance across all three objectives (mean ratings: 4.1, SD: 0.3), while “Smart Networking Cities” correlated strongly with smart connectivity objectives (mean rating: 4.5, SD: 0.2). “Socially Sustainable Cities” aligned closely with health equity objectives (mean rating: 4.6, SD: 0.3) and “Health Empowering Cities” showed the strongest association with system-level resilience objectives (mean rating: 4.0, SD: 0.2).

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Pattern matching results.

Building on these statistical associations, a more detailed prioritization of key concepts was identified for each SHC objective. To achieve “Health Equity”, the key concepts were prioritized in the following order: Socially Sustainable City (mean importance rating=4.16), Healthy Environment City (3.77), Health Empowering City (3.62), and Smart Networking City (3.50). For “Smart Connectivity”, the priority order was different: Smart Networking City (4.30), Healthy Environment City (3.77), Health Empowering City (3.33), and Socially Sustainable City (3.18). Similarly, for “System-level Resilience,” the prioritization was: Smart Networking City (3.85), Healthy Environment City (3.71), Health Empowering City (3.68), and Socially Sustainable City (3.67). These ratings demonstrate how different SHC dimensions contribute with varying strengths to each core objective.

RQ3: Go-Zone Analysis

The go-zone analysis identified critical high-priority concepts across dimensions, including improved healthcare access, efficient health promotion, smart technology integration, and disease prevention, with a notable absence of Socially Sustainable Cities concepts among the highest-rated statements. (Fig. 4; Table 4).

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Go-zone analysis results.

Table 4 Detailed Statements in Zone 8 and Importance Ratings.
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Statements in zone 8 (upper-left octant) were rated above average in importance for all three SHC aims, making them particularly valuable targets for intervention and policy development. Critical concepts emerging as high priorities across multiple SHC dimensions were identified within specific clusters. Within the “Healthy Environment Cities”, three key priorities emerged: improved access to healthcare services (mean importance: 4.15, SD: 0.70), efficiency in health promotion (mean importance: 3.98, SD: 0.19), and well established basic infrastructure (mean importance: 3.78, SD: 0.14). The “Smart Networking Cities” dimension contributed one high-priority concept: integration and utilization of smart technologies (mean importance: 4.04, SD: 0.40). From the “Health Empowering Cities” dimension, focus on disease prevention (mean importance: 3.95, SD: 0.24) was identified as a critical priority.

These findings highlight key areas for targeted interventions in SHC development, emphasizing the importance of accessible healthcare, efficient health promotion, smart technology integration, and preventive health measures.

Discussion

This study advances our understanding of SHCs by providing a structured framework that integrates smart technologies with health-promoting strategies in urban environments. Our findings offer valuable insights for both theory and practice in urban health promotion and smart city development, with particular relevance to the creation of age-friendly environments.

RQ1: conceptualization of smart healthy cities

Our study reveals that a SHC is structured around four key dimensions: Healthy Environment Cities, Smart Networking Cities, Socially Sustainable Cities, and Health Empowering Cities. This multidimensional conceptualization bridges the gap between traditional smart city approaches emphasizing technological infrastructure (Bibri and Krogstie, 2017) and healthy city concepts focusing on environmental and social determinants of health (Kickbusch, 2010).

Dimension-specific theoretical foundations

The Healthy Environment Cities dimension is primarily grounded in Socio-Ecological Theory (Bronfenbrenner, 1979; McLeroy et al., 1988), which recognizes how physical and built environments fundamentally shape health outcomes through multi-level influences. This connection is evident in the high importance placed on health-promoting urban environment elements (mean=4.29) and efficient health systems (mean=4.15).

The Smart Networking Cities dimension is rooted in Smart City Theory (Bibri and Krogstie, 2017; Allam and Newman, 2018), which conceptualizes how digital technologies and data-driven approaches can enhance urban functionality and quality of life. The exceptionally high rating for “going beyond traditional healthcare through smart technologies” (mean=4.50) directly reflects Smart City Theory’s emphasis on technological innovation as a catalyst for urban transformation.

The Socially Sustainable Cities dimension is explicitly grounded in the Health Equity and Social Determinants of Health perspective (Braveman and Gottlieb, 2014). The strong alignment with health equity is evident in statements targeting community health (mean=4.50) and improving quality of life for vulnerable populations such as people with disabilities (mean=4.07) and the elderly (mean=4.07).

The Health Empowering Cities dimension is distinctly anchored in the Capabilities Approach (Sen, 1999; Nussbaum, 2011), which conceptualizes wellbeing in terms of substantive freedoms and opportunities rather than merely resources or outcomes. Statements emphasizing disease prevention (mean=4.29), public health safety (mean=4.29), and personalized services (mean=4.07) reflect the capabilities perspective’s emphasis on adaptive capacity and individual agency.

Advancing beyond existing urban models

The integration of these theoretical perspectives creates a more comprehensive framework than previous conceptualizations of either smart cities or healthy cities in isolation. Although smart city models have traditionally emphasized technological infrastructure and efficiency (Bibri and Krogstie, 2017), and healthy city approaches have focused on health-promoting environments and social determinants (Kickbusch, 2010), our SHC framework bridges these perspectives while incorporating social equity, socio-ecological system, individual capabilities, and participatory approaches.

This integrated framework offers urban planners and policymakers a roadmap for developing cities that are not only technologically advanced but also health-promoting, socially inclusive, and environmentally sustainable. Our approach aligns with recent calls for more holistic urban development strategies. The Healthy Environment Cities dimension echoes Mueller et al. (2020)’s work on environmental ecological strategies in smart city planning, while the Smart Networking Cities aspect builds upon Allam and Newman (2018)’s emphasis on interconnected digital systems for enhanced urban services.

Notably, our framework gives equal weight to human-centered dimensions often underemphasized in existing smart city models. The Socially Sustainable Cities and Health Empowering Cities dimensions address critiques by scholars like Hollands (2008), who argue for more inclusive and equitable smart city development. This balanced approach helps mitigate concerns about techno-centric urban planning that overlooks social equity and individual well-being.

RQ2: key concepts to achieving core objectives of a SHC

Our pattern matching analysis revealed distinct relationships between SHC dimensions and core objectives. These findings provide valuable insights for understanding how different aspects of SHCs contribute to broader urban health goals and can guide strategic prioritization in SHC development.

The balanced contribution of the Healthy Environment Cities dimension across all three core objectives suggests its foundational importance in the SHC framework. This finding aligns with socio-ecological models that position the physical environment as a crucial determinant of health outcomes that affects all aspects of urban functioning (McLeroy et al., 1988; Northridge, 2003).

The strong correlation between Smart Networking Cities and smart connectivity objectives aligns with current smart city literature (Allam and Newman, 2018). For older adults and other vulnerable populations, this could translate into improved telehealth services, remote monitoring, and smart home technologies that support independent living.

The strong relationship between Socially Sustainable Cities and health equity objectives highlights the critical role of social factors in urban health, a point often overlooked in technocentric smart city models (Vanolo, 2014). This finding underscores the importance of social sustainability in creating truly inclusive SHCs, particularly when considering the needs of older adults and other vulnerable populations.

The association between the Health Empowering Cities dimension and system-level resilience objectives reflects the importance of capability building in creating adaptive urban health systems, consistent with Bai et al. (2018)’s call for resilient city systems.

RQ3: priority concepts and core objectives

Gap between conceptual recognition and practical prioritization

Our Go-Zone analysis reveals an intriguing discrepancy in the perceived importance of Socially Sustainable Cities concepts. While the pattern matching results show strong correlations between Socially Sustainable Cities and SHC objectives, none of the five highest-rated statements in the Zone 8 fall within this cluster.

Participants frequently emphasized the need to support vulnerable populations, promote intergenerational connection, and foster social cohesion. Yet when these concepts were evaluated across all SHC objectives, they received relatively moderate ratings compared to more instrumental or interventionist concepts (e.g., urban infrastructure, digital platforms, disease prevention). This disconnect between acknowledged value and operational priority may stem from the difficulty of quantifying social outcomes, the slower return on investment associated with social interventions, or the lack of institutional mandates that center social inclusion in smart city planning (Hollands, 2008; Söderström et al., 2014).

This absence of highly rated statements from the Socially Sustainable Cities cluster reveals a critical tension in contemporary urban policy: while social sustainability is often conceptually embraced, it is practically deprioritized during decision-making processes. This discrepancy reflects a broader pattern wherein values such as equity, inclusion, and intergenerational wellbeing are rhetorically supported but displaced by technologically visible or economically measurable initiatives (Shelton et al., 2015).

This finding underscores the importance of embedding explicit equity mechanisms within SHC implementation frameworks. Institutional tools like Ontario’s Health Equity Impact Assessment (HEIA) provide concrete examples of how social impact evaluations can be systematically integrated into planning processes (Public Health Ontario, 2020). Such mechanisms, along with participatory governance structures and inclusion benchmarks, help ensure that socially sustainable principles are not overshadowed by techno-centric smart city agendas (Buffel and Phillipson, 2016; Bai et al., 2018). Aligning the practical priorities of smart cities with their normative commitments to inclusion is essential for realizing the full potential of SHCs in addressing long-standing urban health disparities.

Implementation challenges in social sustainability

The observed tension between conceptual recognition and practical implementation of social sustainability from the Go-Zone analysis emphasizes the need for explicit mechanisms to bridge the gap between rhetorical commitment and actionable priorities in SHC development. Several international cases demonstrate successful integration of social sustainability into smart city planning. Amsterdam’s City Makers movement has influenced the smart city agenda by empowering local residents, cooperatives, and grassroots innovators to co-create solutions for social inclusion, housing, and health (Meijer and Bolívar, 2016; de Waal and Dignum, 2017). Barcelona’s DECODE project emphasizes data sovereignty and citizen control over personal information, fostering digital inclusion and trust in public systems (Calzada, 2018; Cardullo and Kitchin, 2019). These initiatives show that community-centered governance can mobilize technology for equity, participation, and empowerment, not just efficiency.

For SHC implementation, these cases underline the importance of institutional mechanisms, such as participatory budgeting, living labs, and co-design platforms, that elevate community voice in digital urban transformation. Embedding social sustainability into the core of smart urban governance ensures that SHCs are not only technologically sophisticated but also socially just and inclusive across generations.

Integrating the SHC framework

The integrated framework is illustrated in Fig. 5.

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A Conceptual Framework for SHCs.

Conceptual positioning of SHC dimensions

To further articulate this conceptual structure, the SHC framework maps its four core dimensions along two interpretive axes: Prevention–Adaptation and Interventions–Outcomes. These axes were deliberately selected to represent fundamental urban health system dynamics. The Prevention–Adaptation axis distinguishes between proactive approaches that anticipate health needs and reactive strategies that respond to emerging challenges. The Interventions–Outcomes axis differentiates between action-oriented processes and their resultant health states. Together, these axes create a conceptual space that allows for systematic positioning of diverse urban health approaches within a unified framework (Northridge, 2003).

Each SHC dimension occupies a distinct quadrant based on its dominant operational logic. Healthy Environment Cities (prevention-outcomes) prioritize urban health elements and infrastructure supporting preventive health; Health Empowering Cities (prevention-interventions) focus on disease prevention models, public health safety, and building health capabilities; Smart Networking Cities (adaptation-interventions) leverage digital technologies to transform healthcare delivery; and Socially Sustainable Cities (adaptation-outcomes) promote community-wide health outcomes, quality of life for vulnerable populations.

While conceptually distinct, these dimensions function as an integrated system rather than isolated components. Dynamic interconnections across dimensions create enabling conditions, reinforcing feedback loops, and balancing mechanisms.

Systems thinking as a lens for dimensional interactions

Systems Thinking approach (Meadows, 2008; Webb et al., 2018) provides a critical theoretical lens for understanding how the SHC dimensions function as interconnected components of a dynamic urban ecosystem. We adopt Meadows’ Complex Adaptive Systems approach to conceptualize SHCs as networks of interdependent elements.

This perspective illuminates synergistic interactions among the four dimensions. Smart Networking Cities’ digital infrastructure enhances Healthy Environment Cities through real-time air quality monitoring systems (Trencher and Karvonen, 2019). Meanwhile, urban design initiatives like Barcelona’s Superblocks demonstrate how interventions on physical environment can reduce pollution while increasing physical activity (Mueller et al., 2020). Similarly, participatory processes within Socially Sustainable Cities create enabling conditions for Health Empowering Cities’ preventive health initiatives.

This systems thinking explains SHCs’ adaptation to complex challenges. During COVID-19, Singapore leveraged Smart Networking infrastructure for digital contact tracing (Lai et al., 2021), while Seoul maintained equity through targeted support for vulnerable populations (Kim, 2022; Jeong and Kim, 2024). These self-organizing responses exemplify the characteristics of complex adaptive systems, requiring integration of digital tools with socially inclusive governance (Webb et al., 2018).

Participatory urban planning as an integrative governance framework

Healey (2005)’s participatory urban planning theory provides an overarching normative framework informing implementation across all SHC dimensions. This perspective emphasizes that effective urban development requires collaborative processes engaging diverse stakeholders and integrating multiple knowledge forms.

Participatory approaches enhance each dimension: residents co-designing health-promoting environments (Healthy Environment Cities); citizen participation in digital governance (Smart Networking Cities); co-creation of inclusive policies with vulnerable groups (Socially Sustainable Cities); and active health management participation (Health Empowering Cities).

This participatory lens complements socio-ecological theory by providing mechanisms for community engagement across multiple levels. It also reinforces the capabilities approach by highlighting how participation builds capacity and agency among urban residents (Nussbaum, 2011). Methodologically, this perspective informed our research design, particularly in structuring expert focus groups to include diverse stakeholders—reflecting Healey’s emphasis on collaborative dialog across traditional boundaries.

Methodological innovations: bridging abstract concepts and applied frameworks

Echoing these participatory principles, we implemented participatory stakeholder inclusion strategies through our E-FGI (the first step), organizing experts into thematic teams that facilitated interdisciplinary knowledge exchange while maintaining domain-specific depth. This approach enabled the transformation of abstract smart city concepts into an applicable public health framework through two-stage concept mapping.

Our methodology empirically implements the “conceptual translation” process (Trochim and McLinden, 2017), bridging qualitative expert insights with quantitative structural analysis to systematically identify dimensions otherwise fragmented across disciplines. This transcends both technocentric smart city approaches and traditional healthy city models by integrating data-driven urban governance with inclusive urban policies from the outset. The sequential E-FGI to GCM progression demonstrates how participatory methods can produce rigorous, actionable frameworks for complex urban challenges. This approach could be adapted to other domains where technological and social considerations must be integrated through genuine stakeholder engagement.

Implementation challenges and age-friendly considerations

Using smart technologies to enhance health equity

While concerns persist about the potential of smart technologies to widen existing health disparities, particularly when access, literacy, and governance are uneven (Robinson et al., 2015), our SHC framework underscores how Smart Networking Cities can be strategically designed to promote health equity when grounded in inclusive and ethical digital planning. Smart city infrastructure offers unique opportunities to identify and reduce health disparities when deployed with equity in mind. Geospatial analytics and real-time data systems can help local governments detect service gaps in underserved neighborhoods (Khayal and Farid, 2017). Similarly, digital health platforms, when built with universal design principles, can expand access to healthcare among older adults, people with disabilities, and residents in remote or socioeconomically disadvantaged areas (Czaja et al., 2013; Piau et al., 2014).

Moreover, participatory data governance, including mechanisms that involve citizens in shaping how data is collected, used, and shared, can mitigate digital exclusion and ensure that smart city services reflect community priorities (Cardullo and Kitchin, 2019). This aligns with the broader Health Equity perspective, which emphasizes structural empowerment and inclusivity in health-promoting systems (Marmot and Wilkinson 2006; Gómez et al., 2021). Thus, Smart Networking Cities, as conceptualized in our SHC framework focus on embedding equity-enhancing logic into the design and governance of urban digital systems.

Digital inclusion and age-friendly smart cities

To address the digital literacy challenges faced by older adults, several concrete policy and technological adaptations can be considered. First, community-based digital literacy programs have proven effective in improving confidence and skills among older users (Czaja et al., 2013; Peek et al., 2016). Policies that provide financial support and infrastructure for such programs, especially in underserved areas, can significantly enhance digital inclusion.

Second, the design of user-friendly and accessible digital platforms is critical. Interfaces tailored to older users should consider simplified navigation, larger text and icons, voice-assisted commands, and culturally sensitive content (Czaja et al., 2013). Universal design principles and co-design approaches, which involve older adults in the development of digital tools, are key to ensuring usability and relevance (Marston and van Hoof, 2019; Attaianese and Perillo, 2023).

Third, local governments can implement policy incentives that encourage public-private partnerships for the development of senior-friendly smart technologies. These could include age-inclusive procurement policies, innovation grants, or pilot projects within smart living labs focused on the needs of aging populations (van Staalduinen et al., 2021).

These strategies align closely with the four dimensions of SHCs identified in our study. The Healthy Environment Cities dimension emphasizes accessible healthcare and effective health promotion—key factors in supporting aging in place (Plouffe and Kalache, 2010). Smart Networking Cities can strengthen aging in place through remote health monitoring and improved urban mobility (Reeder et al., 2013), while the Socially Sustainable Cities dimension address issues of social isolation and promotes intergenerational interactions (Buffel et al., 2014), aligning with the Smart Healthy Age-Friendly Environments (SHAFE) concept (de Leeuw and Simos, 2017).

The SHAFE’s contribution to the SHC structure

The SHAFE framework has significantly contributed to the development of the SHC model, both conceptually and normatively. SHAFE’s emphasis on accessibility, digital inclusion, and aging-in-place provided a foundational vision of human-centered smart environment (Dantas et al., 2019) that directly informed the Socially Sustainable Cities and Health Empowering Cities dimensions of our framework.

SHAFE helped foreground the importance of universal design, community participation, and interoperability of health and care systems—principles which were embedded into our expert interviews and concept mapping statements (Dantas et al., 2019; Attaianese and Perillo, 2023). SHAFE served as both reference point and ethical filter through which key SHC concepts were generated, prioritized, and interpreted.

Moreover, SHAFE’s age-friendly lens sensitized our framework to the needs of vulnerable and digitally excluded populations, reinforcing the integration of capabilities and equity perspectives throughout the SHC system (Dantas et al., 2019). Thus, SHAFE can be understood as a catalytic framework that shaped the SHC’s commitment to multigenerational inclusion, ethical technology use, and socially responsive planning.

Our SHC framework both complements and extends existing age-friendly urban concepts. While it shares elements with models like Smart Age-Friendly Ecosystem (SAFE) (Marston and van Hoof 2019) and Age-Friendly Smart Ecologies (CASE) (Torku et al., 2021), it provides a more holistic approach by equally emphasizing social and environmental factors alongside technological innovations. It resonates with the Transgenerational Living Communities and Cities (TLCC) (Marston et al., 2022) while extending this concept through integration with smart technology and health-promoting environments (Batty et al., 2012; Söderström et al., 2014).

The Health Empowering Cities dimension, with its focus on disease prevention and personalized services, offers opportunities to support healthy aging through tailored health interventions and cognitive health initiatives (Hood and Auffray, 2013). By prioritizing the Socially Sustainable Cities dimension alongside technological innovations, cities can ensure that smart health initiatives narrow rather than widen gaps between advantaged and disadvantaged older adults, supporting an intergenerational approach to urban planning (Buffel and Phillipson, 2016).

Global and policy implications

Our findings have significant implications for global urban development initiatives, particularly in relation to the UN Sustainable Development Goals (SDGs). For instance, our emphasis on improved healthcare access and efficient health promotion strategies in the Healthy Environment Cities dimension directly supports SDG 3 targets. The Smart Networking Cities aspect contributes to SDG 11 by leveraging technology for sustainable urban development, while the Socially Sustainable Cities dimension addresses SDG 10 through its focus on inclusive policies and improving quality of life for vulnerable populations. This alignment with multiple SDGs underscores the potential of the SHC framework to contribute to holistic urban development strategies that balance technological innovation, social equity, and environmental sustainability.

Recent research examining smart city technologies globally has shown varying patterns of implementation across regions, with Place-related technologies predominant in Europe and North America, while Peace and Planet-related applications are more common in Asia and developing regions (Jeong and Chung, 2024). This geographical variation suggests the need for context-specific approaches in implementing SHC frameworks.

This study contributes not only to the conceptual understanding of SHCs, but also provides a foundation for translating these insights into practical urban planning strategies. The SHC framework offers urban planners, municipal decision-makers, and policy developers a conceptual toolkit to design cities that are not only smart and efficient, but also equitable, inclusive, and health-promoting. By bridging technology with human-centered planning, and systemic resilience with individual empowerment, the findings provide a roadmap for rethinking urban health in general. In this way, the study contributes to the growing body of knowledge that supports integrated, health-oriented urban governance.

For urban planning practitioners specifically, our findings translate into concrete planning instruments and regulatory frameworks. Health-focused overlay zones can be incorporated into land use plans to prioritize healthcare accessibility and health-promoting infrastructure in underserved areas (Srinivasan et al., 2003; Northridge, 2003; Corburn, 2017) Digital inclusion requirements can be embedded in technology procurement policies, ensuring that smart city investments benefit diverse populations. Equity impact assessment protocols can be mandated for all smart technology deployments, similar to environmental impact assessments but focused on social outcomes. Finally, municipal budgeting can allocate dedicated funding for co-designed pilot projects that test SHC concepts in varied neighborhood contexts before scaling (Jäppinen et al., 2013).

These planning tools operationalize our conceptual framework by institutionalizing the balance between technological innovation, health equity, and social sustainability. Rather than treating these dimensions as separate planning considerations, our findings suggest they should be integrated into unified development standards and performance metrics (Geertman et al., 2015). This integrated approach helps overcome the implementation gap identified in our Go-Zone analysis, where social sustainability principles often receive conceptual support but limited practical prioritization in urban development decisions (Martin et al., 2019).

Strengths and limitations

Our study offers several key strengths, including its innovative two-stage concept mapping methodology and interdisciplinary approach integrating insights from urban planning, public health, and smart city development. The resulting four-dimensional framework, with its identification of key priorities, provides actionable insights for urban planners and policymakers. Furthermore, the clear alignment of our findings with multiple UN Sustainable Development Goals highlights the potential global relevance and impact of the SHC framework.

However, we must acknowledge several limitations. A primary limitation is that while our conceptual framework is comprehensive and theoretically grounded, it has not been empirically tested in real-world settings. Case study applications or pilot implementations in diverse urban contexts would significantly strengthen the framework’s credibility and refine its practical applicability. Future research should prioritize validating this framework across different urban settings, particularly in low-income or developing regions where smart city implementations may vary considerably due to resource constraints and different socio-political contexts (Watson 2015).

While our study recruited experts across various fields, all participants were from the Republic of Korea, potentially affecting the framework’s global applicability. This limitation may affect the generalizability of the framework to other global contexts, where urban health challenges might differ significantly. Future studies should aim to include a more geographically and demographically diverse set of participants to capture the full range of perspectives on SHC implementation across different urban settings.

Additionally, the heavy reliance on expert opinions, while valuable, may not fully capture the perspectives of ordinary citizens or marginalized groups (Cardullo and Kitchin, 2019). Also, the rapid pace and the uneven nature of technological change in urban environments means that some aspects of our framework, particularly in the Smart Networking Cities dimension, may require regular updating to remain relevant (Batty, 2018).

Despite these limitations, our study provides a solid foundation for understanding and implementing SHCs, offering a roadmap for creating urban environments that leverage technological advancements to promote health, equity, and sustainability for all (Yigitcanlar et al., 2018).

Conclusion

As cities worldwide grapple with urbanization, digitalization, and demographic shifts towards aging populations, the Smart Healthy City (SHC) concept offers a promising framework for sustainable and inclusive urban development. In addressing our three guiding research questions, this study developed a structured and empirically grounded framework for SHCs. First, it conceptualized SHCs as composed of four integrative dimensions that bridge health, technology, environment, and social policy. Second, it identified actionable priorities that align with both expert judgment and theoretical objectives. Third, it demonstrated how these priorities differentially contribute to health equity, smart connectivity, and system-level resilience, offering a nuanced understanding of how various aspects of SHCs interact to support healthy aging and intergenerational wellbeing.

A key finding of our study is the potential gap between the theoretical importance of social sustainability and its practical prioritization. While the Socially Sustainable Cities dimension is crucial for achieving health equity, it may not yet be fully reflected in current urban planning priorities. To bridge this gap, policymakers must ensure that socially inclusive initiatives are treated as equally important to technological advancements in smart city planning. Successful implementations in cities like Amsterdam (de Waal and Dignum, 2017) and Barcelona (Calzada, 2018) demonstrate that integrating social sustainability into smart city initiatives is both possible and impactful.

The integration of Smart Healthy Age-Friendly Environments (SHAFE) principles has enriched our framework, particularly in addressing the needs of older adults and other vulnerable populations. By emphasizing accessibility, digital inclusion, and intergenerational design, our SHC framework provides a roadmap for creating urban environments that support health and wellbeing across the lifespan (Dantas et al., 2019).

Conceptualizing SHCs as complex adaptive systems allows us to understand the interconnections between different urban elements and their collective impact on health outcomes (Meadows, 2008; Webb et al., 2018). This systems thinking approach helps identify intervention points that can generate positive cascading effects across multiple dimensions of urban health and wellbeing.

The practical implications of this framework are substantial. We recommend that urban planners and policymakers adopt an integrated approach to SHC initiatives, balancing technological innovations with social sustainability and individual empowerment. The framework’s alignment with multiple UN Sustainable Development Goals underscores its potential to contribute to global urban development agendas, though implementation approaches must be adapted to different regional contexts (Jeong and Chung 2024).

While our study offers valuable conceptual insights, we acknowledge its limitations, particularly the need for empirical validation across diverse urban settings and the geographic limitations of our expert panel. Future research should focus on validating this framework across different cultural and economic contexts, incorporating diverse stakeholder voices, and exploring governance models that can effectively implement these multidimensional strategies. By creating urban environments that are technologically advanced, health-promoting, socially inclusive, and environmentally sustainable, we can significantly improve quality of life for people of all ages while enhancing urban resilience to future challenges.