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Sustainable Cities and Society 14 (2014) 390396

Contents lists available at ScienceDirect

Sustainable Cities and Society


journal homepage: www.elsevier.com/locate/scs

Sustainable, age-friendly cities: An evaluation framework and case


study application on Palo Alto, California
Jacobo Ruza a , Jung In Kim b , Ivan Leung b , Calvin Kam b, , Sandy Yee Man Ng c,
a

Architect by Universidad Politcnica de Madrid (UPM), Spain


Center for Integrated Facility Engineering, Department of Civil and Environmental Engineering, Stanford University, The Jerry Yang & Akiko Yamazaki
Environment & Energy Building, 473 Via Ortega, Room 292, MC:4020, Stanford, CA 94305-4020, United States
c
Department of Public Health Sciences, Carruthers Hall, Queens University, Kingston, Ontario, Canada K7L 3N6
b

a r t i c l e

i n f o

Article history:
Available online 29 May 2014
Keywords:
Aging population
Geographic information system (GIS)
Sustainable urban planning

a b s t r a c t
The aging population has a tremendous impact on our community and resources. Planning age-friendly
cities is a sustainable solution toward healthy aging and health resources allocation. Our research team
developed a framework to systematically evaluate the age-friendliness of cities. The framework encompasses multiple criteria and includes assessment using web-based geographical information system (GIS)
tools. The analytical framework was applied to Palo Alto, California as an illustrative case study. The study
site was chosen due to its unique characteristics (overall rich community but high income disparity; proportion of senior 30% higher than US average, 80% of whom expressed the desire to continue living in
this community) and its proximity to the research team allowing easy site visits and data access. In this
paper, we discuss the results of our analysis, as well as ongoing development and preliminary results of
an Age-Friendly Cities Scorecard to translate WHO guidelines into tangible and measurable action items.
2014 Elsevier Ltd. All rights reserved.

1. Introduction
The 21st century is characterized by two main trends that have
direct impact on our livelihood. The rst is an urbanized population according to the United Nations (2012), more than half of
the worlds population currently lives in cities. While cities concentrate people, opportunities and services, they also concentrate
risks and hazards for health. These include chronic diseases such as
diabetes and heart diseases as a result of less physical activity and
unhealthy dietary patterns, increased asthma and other pollutionrelated diseases, as well as mental health issues due to stress and
poor living conditions (WHO, 2010). The second is an aging population, especially in developed countries, driven by an increased
life expectancy as well as the aging of the babyboomers. The risks

Corresponding author at: Center for Integrated Facility Engineering, Department


of Civil and Environmental Engineering, Stanford University, Stanford, CA, United
States. Tel.: +1 650723 4945.
Corresponding author at: Department of Public Health Sciences, Carruthers Hall,
Queens University, Kingston, Ontario, Canada. Tel.: +1 613533 2901.
E-mail addresses: jacoboruza@gmail.com (J. Ruza),
calvin.kam@stanford.edu (C. Kam), sandy.ng@queensu.ca (S.Y.M. Ng).
http://dx.doi.org/10.1016/j.scs.2014.05.013
2210-6707/ 2014 Elsevier Ltd. All rights reserved.

of city living impact everyone but seniors (dened as those aged 65


years or above) are particularly vulnerable due to age-related needs
(e.g. decrease in mobility) and preferences (e.g. to stay in their own
homes, and/or near their children and grandchildren). A built environment that is planned incorporating core age-friendly elements
thus plays a crucial role in enabling seniors to live independently
for as long as they wish.
While it is well-established that many social factors act as key
determinants of health, awareness to rethink the effects of the built
environment on health only started to slowly emerge within the
last decade (Jackson, 2003). A major gap still exists as current urban
planning practices do not typically take into account sustainability
with respect to the human factor and the evolving needs based on
population changes. World Commission on the Environment and
Development (1987) denes sustainability as development that
meets the needs of the present without compromising the ability
of future generations to meet their own needs. In order to meet
needs in a sustainable manner requires a balance between social,
environmental and economic factors, also known as the triple
bottom-line (Brown, Dillard, & Marshall, 2006). An aging population has high, varying and complex healthcare needs (WHO, 2007).
To meet such healthcare needs in a sustainable manner will require
the capabilities to project and prioritize the future healthcare needs

J. Ruza et al. / Sustainable Cities and Society 14 (2014) 390396

391

Fig. 1. Evaluative framework developed in this study to understand the needs of the senior population in the city of Palo Alto. Measurable metrics that contribute toward
population needs and services capacity are considered in the evaluation.

of an aging population. Agencies such as the World Health Organization have been urging for the rethinking of the meaning of aging,
to empower senior citizens into leading independent and fulsome
lives. A myriad of research activities occurred and a Guide for AgeFriendly Cities was published (WHO, 2007). However, the guide
remained very high level with little tangible action items or recommendations; it did not gain much traction with urban planners
and policymakers.
The goal of our study is to develop a framework that provides a
systematic structure to evaluate the age friendliness of cities, based
on the WHO published guidelines, complimented with additional
research and enriched with urban planning tools. The proposed
framework encompasses population needs, as well as community
capacities to address those needs. We utilized population health
information and GIS tools to enrich the quantitative rigidity of the
framework as well as add geographical relevance. The utilization
of a framework provides an opportunity for urban planners and
decision-makers to systematically reect on key issues facing aging
communities, and use urban planning practices as levers to impact
changes that will effectively and prudently meet population health
needs.
To illustrate the feasibility of our framework, we applied our
analytical framework to Palo Alto, California as an illustrative case
study. While future work will no doubt improve the frameworks
rigidity, this is, to our knowledge, the rst city planning tool in
development that (i) attempts to proactively address a population
health issue, and (ii) has a specic lens on age-friendliness. Through
this work, we hope to stimulate discussions and further research
in this multidisciplinary area that holds the key to urban health
sustainability.
The project was developed at the Center for Integrated Facility Engineering of the Department of Civil and Environmental
Engineering of Stanford University. Analyses and GIS map views
were performed using ESRI Community Analyst. Part of our results
were presented during an expert workshop, Sustainable Cities,
Better Health, Better Future, on March 2nd 2012 at Stanford
University.

2. Evaluation framework development


To provide systematic structure to our evaluation, the research
team conceptualized and developed the elements of the framework
(Fig. 1) based on two main areas the population needs, and the
community capacity to fulll those needs. We used the Guide for
Age-Friendly Cities developed by the World Health Organization in
2007 as a foundation, and substantiated it through literature review
as well as feedback from experts and industry professionals. In this
rst iteration, all analyzed criteria were treated equal, i.e. weighing
is not a consideration. Weighing was incorporated at a subsequent
stage when we develop a scorecard to complement the framework
(discussed later).
A suite of indicators was selected to demonstrate the various
aspects within the evaluation framework. For example, to understand the populations healthy lifestyle, we used (i) their exercise
level and (ii) their dietary preferences and habits as indicators of
measure. The selection of these indicators were based on review
of national health surveys (e.g. the Canadian Community Health
Survey and the US National Health and Nutrition Examination
Survey), and secondly on the objectivity and quality of the available
data.
The analytical framework was applied to Palo Alto, California
as an illustrative case study. The study site was chosen due to its
unique characteristics (overall rich community but high income
disparity; % seniors is 30% higher than US average, 80% of whom
expressed the desire to continue living in this community) and its
proximity to us allowing easy site visits and data access.
3. Results
3.1. Population needs
Palo Alto is an aged community the percentage of seniors is
high (17.1%) (Palo Alto Department of Planning and Community
Environment) compared to the Bay Area average of 12.3% (San
Francisco Bay Area Census, 2010) or to the US average of 13% (US

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J. Ruza et al. / Sustainable Cities and Society 14 (2014) 390396

Fig. 2. US Population distribution by age in 2010 and projection for 2030. By 2030,
The senior population (age 65+) in Palo Alto is projected to increase from 17% in
2010 to 47% in 2030.

Census Bureau, 2011). Senior population is already an important


element in the community and, according to population trending
data, is projected to grow further with respect to the local population. The latest population distribution and projection for 2030 are
shown (Fig. 2) (Bay Area Census; US Census Bureau, 2012).
Wide regional differences exist in projected population growth
in the State of California. The 65+ population will be the main driver
for population growth in the next decade in Los Angeles County and
the Greater Bay area, whereas in the Sacramento Area, the Inland
Empire and the San Joaquin Valley, the under-65 population will
account for most of the expected growth (Dept. of Finance, State
of California, 2007). In the City of Palo Alto, 47% of the population
will be seniors aged 65 or above by 2030 (Department of Planning
and Community Environment, in press), compared to 21% and 20%
for the Bay Area in California and the U.S, respectively. This has
signicant impacts on healthcare resource planning, as seniors consume more healthcare resources relative to the general population
(Center for Health Workforce Studies, 2006; Rechel, Doyle, Grundy,
& McKee, 2009).
Another noteworthy feature of the City of Palo Alto is that it is a
wealthy community. The average income of Palo Alto residents is
an overwhelming 259% the US average; median value of owneroccupied housing units is 537% of the US average (Department
of Planning and Community Environment, in press; US Census
Bureau). Further, in more than one-third of Census blocks, these
housing units are owned by seniors (Fig. 3) and 34.7% of homeowner
units do not have mortgage, compared to only 23.5% of California State (US Census Bureau). These factors suggest that Palo Alto
residents are relatively nancially well-off and can allocate more
resources toward healthcare.

Fig. 3. Percentage of households with owners over 65 years of age (2010). A signicant number of neighborhoods have more than 24% households where homeowners
are aged 65+.

Fig. 4. Insurance coverage patterns by amount spent on health insurance. The


majority population in Palo Alto has more than $2.7M health insurance, which shows
the relative wealth of this community.

While overall wealthy, income disparity is an issue for Palo Alto.


A high percentage of low income seniors exist in the community
who are struggling to make ends meet, and this is deemed by some
as the silent epidemic. County statistics show that nearly 20% of
Palo Alto seniors are living near or below the poverty line (compared to 15% in California and 20% in the US; Kaiser Foundation),
with 54% of senior households being low-income and hundreds on
affordable-housing waiting lists. The high standard of living of this
otherwise rich community makes it especially hard for this vulnerable group. For instance, over the last 10 years, housing costs
have doubled in the area, making it increasingly difcult for Palo
Alto seniors on xed incomes to remain in the community and live
close to their family after they retire. The income disparity and its
implications to age-friendliness of Palo Alto will be discussed later.
Palo Alto residents are concerned about, and are overall capable of taking care of their health needs. They are well insured with
respect to health care coverage; majority of the Palo Alto population over $1 million insurance in health insurance coverage and
more than 50% of census blocks has more than $1.9 million health
insurance coverage (Fig. 4). In Palo Alto, only 5.7% of population is
uninsured (Peninsula Press), compared to the national average of
15.7% (US Census Bureau). Palo Alto is also a community whose residents embrace a healthy lifestyle. Residents are concerned about
their diet and the quality of food they consume; more than 80%
of census blocks typically buy food specially labeled as organic or
natural (Fig. 5). In addition, residents in majority of census blocks
engage in physical exercise frequently, minimum twice per week
(Fig. 6). We infer that similar patterns pertain to the senior population; additional data will be required to substantiate this point.
The population in this catchment area also has a high consumption
rate of vitamins, dietary supplements and other non-prescription
drugs (average spending of >$100,000 on supplements and nonprescription drugs in over half of the Census blocks) (Fig. 7). This
is consistent with earlier observation that Palo Alto residents are
concerned about their health.
Palo Alto residents have an overall good health status. This
might be partially attributable to their healthy lifestyle and partially
explained by self-selection (i.e. healthy people are more interested
in staying healthy). The obesity rate of San Francisco Bay Area residents is much lower (18.8%) than US average (35.7%); the same is
true for chronic disease prevalence such as Diabetes and hypertension (Esri data, 2011). There is a lower frequency of interaction with

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393

Fig. 8. Percentage of population that visited the doctor more than 8 times within
the last 12 months.
Fig. 5. Number of households that purchases food specially labeled as natural and/or
organic. A signicant number of households in Palo Alto purchase natural and/or
organic food, which is an indicator of wealth and emphasis on healthy living.

health services compared to other neighbor communities residents


in majority (80%) of the Census blocks, the number of people who
visited the doctor more than 8 times within the past 12 months was
below 350 (Fig. 8). The consumption of prescription drugs is also
low in the Palo Alto community compared to the national average
48.5% (Center for Disease Control, 20072010).
3.2. Senior services capacity

Fig. 6. Number of population who exercises at a facility at least twice a week. A


signicant population in Palo Alto exercises, showing their concern of their health.

Fig. 7. Prescription consumption patterns by household annual spending on nonprescription drugs.

To analyze the community services capacity available to the


senior and aging population, we studied the urban infrastructure,
health services and other services in the community.
Researchers have found a positive association between
health and living proximity to green space (Vries, de Verheij,
Groenewegen, & Spreeuwenberg, 2003). In our analysis of Palo Alto,
it was found that even though Palo Alto seems to be very green,
the rate of parks, plazas and other shared open spaces is not as
high as one might expect. Palo Alto has about 4000 acres of open
spaces and parks (proxy 0.06 acre/hab.), but only around 150 acres
of those are within walking distance from urban areas (analyzed
using Google maps). While one might argue that this is partially
compensated by private front and back yards in this afuent neighborhood, the uses of these spaces are very different from what
public spaces can offer. For instance, a public park offers seniors
an opportunity to meet others and to socialize. The positive impact
of social engagement in health and well-being is well documented
(Herzog, Ofstedal, & Wheeler, 2001). The few parks in the surrounding areas are far from the more densely populated areas and are not
very accessible by public transportation. This limits potential benets, especially to seniors who are in social vulnerable groups and/or
have mobility issues.
Our study revealed that the Palo Alto public transportation system is suboptimal, both in terms of geographical coverage and
frequency of service. Through a comprehensive review of bus
routes, coverage and frequencies (analyzed using Google map as
well as publicly available transit information as sources), we identied various areas that are completely inaccessible by public transit;
of the serviced areas, service frequencies can be longer than one
hour. On a positive note, all the systems evaluated are accessible
for the disabled. Overall, transportation needs of the population are
mainly fullled by privately owned vehicles a trend that is more
common in North America than the rest of the world (World Bank
data). Palo Alto residents compensate for the lack of transit services with a high number of private vehicles per household with
an average of 2.20 vehicles/household (Esri data, 2011). While this

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J. Ruza et al. / Sustainable Cities and Society 14 (2014) 390396

is feasible due to high affordability, it is not a sustainable longterm solution as the population ages and loses the ability to drive.
This also poses an urban equity risk for the community, further
marginalizing lower income residents in the area who cannot afford
other private arrangements (e.g. personal aides) as they age.
Health services coverage in Palo Alto is adequate in terms of
number of facilities per population, with 14.9 beds per 1000 persons (calculated based on publicly available hospital information
and 2012 US Census data) compared to the national average of 3.0
(World Bank data). Most of the San Francisco Bay Area is within less
than 10-min driving distance from a hospital an acceptable distance for these types of services. However, the distribution of these
health facilities is arguably not the most efcient and some areas
are very densely serviced, e.g. Stanford Medical Center and V.A.
Hospital are less than 4 miles or 10 min driving one from the other
(calculated using Google Map). While senior services are more
evenly distributed than hospitals, it is important to note that the
overall number of senior services is considered low for an aging area
such as Palo Alto. Further work is needed to analyze how accessible
they are for the senior population and whether they have sufcient
capacity to handle the growing needs of an aging population.

4. Ongoing scorecard development and preliminary results


Further to the comprehensive qualitative evaluation described
above, our research team used the framework developed in this
study as basis to begin building a weighted scorecard to evaluate
the age-friendliness of cities. Scorecards provide a rigid framework on actionable items and a quantitative basis for planning
and accountability. It allows for the tracking of planned, incremental improvements of dened metrics. The scorecard method
has been adopted in construction engineering, including Virtual
Design & Construction (VDC) and Building Information Model
(BIM) scorecards. The Age-Friendly Cities Scorecard introduced
herein addresses the age-friendliness of cities and neighborhoods,
provides actionable guidelines for cities to improve their agefriendliness, and has the potential to standardize urban planning
and public health practices with a set of well-researched evaluation
criteria. It is intended to serve as a helpful planning and communications tool for planners, institutions, decision makers and
governments.
Using World Health Organizations Guide for Age-Friendly
Cities (WHO, 2007) as foundation, eight healthcare-related social
aspects were incorporated into the Scorecard: outdoor space, transport, housing, social participation, respect and social inclusion, civic
participation, community & health services, and communication
& information (other aspects not directly related to health were
excluded). Realizing that each aspect may not contribute to the
age-friendliness of cities equally, we surveyed a group of eight academic and professional experts during a presentation workshop
on prospective weighing. The respondents were asked, in an electronic questionnaire, to rank the relative importance of the eight
healthcare-related community elements based on their impression
and understanding of how these criteria contribute to an agefriendly city in a scale of 05 (5 being the most important). The
questionnaire consisted of eight questions each corresponding to
one WHO category. In analyzing the response, it was found that
among the expert group, community and health services were felt
to be the most important, followed by outdoor spaces, transportation and housing. The category scores ranges, on a scale of 05
(5 being the most important), from 2.67 on civic participation &
employment to 4.71 on community & health services (Fig. 9).
To compare the perceived importance of these healthcarerelated community elements to local residents against expert
opinions, our group also conducted a focus group survey within

Fig. 9. Summary of expert survey on eight healthcare-related social aspects. Each


criterion is rated from 0 to 5, with 5 being the most important. The experts surveyed ranked Community and Health services as the most important, and Civic
participation and Employment as the least important factor toward an age-friendly
city.

the community. The same questionnaire was distributed to a focus


group on Elderly Care and Aging, organized by the Lords Grace
Christian Church (1101 San Antonio Rd, Mountain View, CA 94043),
during one of their quarterly meetings on 11th March, 2012.
Founded in 2011, the mission of the focus group is to help participants share practical wisdom on elderly care and aging, and
nd mutual support during the journey of aging. 26 anonymous
responses were collected after ruling out incomplete and unreturned surveys. The survey asked respondents to rank the relative
importance of the eight healthcare-related social categories to
them. The result ranges average score of 3.76 for outdoor category
to average score of 4.54 for community and health services category
(Fig. 10).
Both experts and LGCCs focus group agree that community and
health services should have the greatest importance in determining a citys age-friendliness (an average high score of 4 from
both groups). While both experts and focus group chose respect
and social inclusion as the second most important criterion, there
is higher consensus among the focus group (an average score of
4.15, vs. 3.43 from the expert group). The focus group and experts
disagreed most greatly on the importance of communication &
information: whereas experts gave it a score of 2.86, the focus
group deemed this factor more important, at a score of 3.88. The

Fig. 10. Summary of survey on the importance of eight healthcare-related aspects.


Each criterion is rated from 0 to 5, with 5 being the most important. The focus
group rates Community and Health services as the most important factor, and Civic
participation & Employment as the least important factor toward age-friendliness
of a city.

J. Ruza et al. / Sustainable Cities and Society 14 (2014) 390396

disagreements in several criteria illustrates that different groups


have different stakes and perspectives when it comes to what
entails an age-friendly city. Further research and validation will
help encompass the proposed criteria in meaningful weights for
scoring purposes.
5. Discussion
Palo Alto is an aging community; based on the fact that up to 80%
of its senior residents expressed the desire to continue living here in
the future in a recent survey (2006), it was of interest to understand
(i) the current age-friendly aspects that appeal to its residents, and
(ii) whether these aspects are sustainable, or whether gaps exist
for potential improvements. As this study has illustrated, Palo Alto
is unique in that it is a very health-conscious community, and residents enjoy good health compared to the rest of the US. The current
healthcare needs of Palo Alto residents are well supported by existing public resources, complemented by residents own provision as
they are generally nancially well-off. That said, as we have seen
throughout the analysis, there are still signicant areas of shortfall
and opportunities for improvement. Improving the quality of the
city services could avoid other foreseeable expenses like healthcare,
and make Palo Alto a more age-friendly and sustainable community.
This study highlighted open spaces, public transportation and
services for aged population as the main areas of improvement
toward a more age-friendly Palo Alto. The survey conducted by
Community Services Department of the City of Palo Alto (2006) conrmed our analysis and revealed that our identied areas in need
of improvement are of top concern for the residents. These changes
will also help address the social disparity in Palo Alto, so that seniors
with lower socioeconomic status are not further marginalized.
Last, but not least, even though Palo Alto is a wealthy community and can to a large extent provide for their own needs, there are
factors beyond an individuals nancial means that the city should
focus on in a proactive manner. For example, most of the Palo Alto
households possess more than one vehicle but in the meantime
alluded to concerns about public transportation service availabilities in the public survey. This is especially important when one
considers an aging population, who will inevitably gradually lose
their ability to drive in the near future. Provision of accessible public
transit is critical in order for the seniors to not lose their autonomy
and compromise their ways of life.
Palo Alto is well-developed and completely urbanized to a large
extent. Based on our analysis, it can be concluded that most of this
urban planning was made with other needs as top focus with little or no regard for senior population needs. As its residents age,
we urge planners and decision makers to act on the items highlighted in this study, as a lack of action will translate to escalating
unmet needs and make Palo Alto unsustainable with respect to its
healthcare resources and provision for its residents to age in place.
6. Conclusion and future work
This paper addresses the knowledge gap for the aging population in existing urban design practices; an evaluation framework
was proposed to address this critical emerging issue. The Palo Alto
case study illustrated that the framework is comprehensive and
feasible to apply. The framework has the potential to serve as a
meaningful planning and communication tool for urban planners
and policy makers to understand the unique needs of their communities and allocate resources in an equitable and sustainable
manner.
The key strength of our framework is that it was built on the
WHO Age Friendly Cities Guide, which is in itself substantially

395

researched and widely consulted and validated with multidisciplinary experts. Our current application on Palo Alto is meant to be
an illustrative example and is by no means denitive due to time
limitations and unavailability of senior-specic data for some of the
criteria. As a continuation of this study, our research team will continue to further develop and build out the scorecard to analyze the
age-friendliness of cities. Our immediate next step on this workstream is to expand on the list of data variables to measure based
on our existing framework.
Since the proposed tool involves policy decision-making and
informs social change, situating the tool well within the politics
of issues and properly engaging stakeholders is equally, if not more,
important than the scientic merits of the tool alone. The survey
and scorecard methodology proposed in this study provides a good
foundation to rene the evaluation framework. The two groups surveyed (academic and industry experts, N = 8; senior focus group,
N = 26) were not meant to be representative but serves as a proof
of concept for the feasibility of the approach. Further renements
can be done through proper use of published and peer-reviewed
stakeholder analysis tools, to identify all stakeholder groups (comprehensive as well as priority stakeholders) and expand our survey
coverage to appropriately reect their preferences and opinions.
This can inform and validate the weight-adjustment of the different indicators, so that the scoring can proportionately reect the
inuence of each element on the quality of life of seniors.
While Palo Alto has its aforementioned unique characteristics,
it is similar to many US cities with respect to healthcare funding
model, delivery and organization. It is also similarly faced with the
global issue of an aging population, which if left unchecked would
affect sustainability of provision of health and social services. We
hope that this work will stimulate discussions and further research
in this multidisciplinary area that holds the key to urban health sustainability, to accelerate the translation of knowledge into adopted
practices that improve the quality of life for the aging population.
Acknowledgements
This research and the expert workshop were partly sponsored
by a Fulbright NEXUS Scholar Award to Dr. Sandy Ng. The work is
enabled through the generous hosting of the visiting scholarship
and resource commitments from Dr. Calvin Kam and the Industry
Programs from Center of Integrated Facility Engineering at Stanford
University.
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