{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T00:56:27Z","timestamp":1789692987761,"version":"4.0.1"},"reference-count":58,"publisher":"JMIR Publications Inc.","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JMIR Aging"],"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n The population of adults aged 65 and older is rapidly increasing, while the availability of caregivers is declining. Smart homes that provide unobtrusive, continuous monitoring and alerting on clinically relevant changes in daily activity patterns offer a potentially innovative solution for aging in place.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n This study aims to evaluate the barriers and facilitators to the adoption of a low-cost smart home embedded within a community-based approach to health monitoring for older adults with multiple chronic conditions and who are experiencing poverty.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n Using a prospective, mixed methods design and iterative community co-design, 46 older adults from 7 different language groups were continuously monitored for 6 months with ambient sensors installed in their homes. Two older adults were monitored for 4 and 5 months, respectively, resulting in a total sample of 48. The system generated alerts based on movement pattern changes and escalated notifications to participants, support persons, community health workers, and nurses. Sensor data were analyzed descriptively to quantify alert patterns and response rates, while written text-based data from in-the-moment surveys, community health workers\u2019 and registered nurses\u2019 notes, and semistructured interviews underwent qualitative descriptive analysis and reflexive thematic coding.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n The system generated 37 million sensor readings condensed into 1.2 million high-level events and 4719 novel alerts. Qualitative data comprised 34,086 words of text. Participants responded to 1.57% (74) of the initial email alerts and 7.79% (368) of the follow-up SMS text message alerts sent when no email response was received. Community health workers and registered nurses responded to 78.36% (n=3698) of the escalated alerts, resulting in 1060 contacts with participants in response to alerts. Clinical contacts resulted in 72 interventions. Three major qualitative themes emerged: (1) Alone, (2) Trust, and (3) Human Connection. Subthemes included Safety, Personalization, and Digital Distress defined as stress associated with interacting with digital health-monitoring systems. Participants rated the system highly (mean likelihood-to-recommend rating 8.68\/10, SD 1.68); however, they expressed a strong preference for phone calls over automated alerts. Cultural expectations influenced adoption, particularly in multigenerational households.<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Communities can effectively engage in technology-delivered health care. Future research is needed to improve technical aspects of smart home monitoring systems, including accurate alerting using machine learning, data visualizations for older adults and health care workers, and culturally sensitive features. Additional work should address how and when to communicate automated messaging, engage older adults with their own data, and integrate sensor-based monitoring into health care workflows. Research should also explore personalization through advanced computational approaches such as machine learning and strategies to reduce digital distress.<\/jats:p>\n <\/jats:sec>","DOI":"10.2196\/88290","type":"journal-article","created":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T21:20:08Z","timestamp":1782854408000},"page":"e88290-e88290","source":"Crossref","is-referenced-by-count":1,"title":["A Community-in-the-Loop Approach to Smart Home Monitoring for Aging in Place: Mixed Methods Evaluation of a Co-Designed Prototype"],"prefix":"10.2196","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0320-6763","authenticated-orcid":false,"given":"Roschelle L","family":"Fritz","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3933-5532","authenticated-orcid":false,"given":"Connie Kim Yen","family":"Nguyen-Truong","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0004-2908","authenticated-orcid":false,"given":"Jennifer","family":"Phipps","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-5989-6405","authenticated-orcid":false,"given":"Ellen E","family":"Hinderlie","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-6737-2181","authenticated-orcid":false,"given":"Yolanda LB","family":"Rodriguez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thai Hien","family":"Nguyen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gabrielle","family":"Barling","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna","family":"Mishuk","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6164-6839","authenticated-orcid":false,"given":"Heather","family":"Schoonover","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5577-4933","authenticated-orcid":false,"given":"Christi","family":"Zuber","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7244-5717","authenticated-orcid":false,"given":"Marilyn","family":"Rantz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1010","published-online":{"date-parts":[[2026,7,23]]},"reference":[{"key":"R1","unstructured":"World social report 2023: leaving no one behind in an ageing world. United Nations; 2023. URL: https:\/\/www.un-ilibrary.org\/content\/books\/9789210019682 [Accessed 07-07-2026]"},{"key":"R2","doi-asserted-by":"publisher","DOI":"10.4054\/demres.2021.45.36","article-title":"National estimates of kinship size and composition among adults with activity limitations in the United States","volume":"45","author":"Reyes","journal-title":"Demogr Res"},{"issue":"2","key":"R3","doi-asserted-by":"publisher","first-page":"187","DOI":"10.1377\/hlthaff.2024.00978","article-title":"The number of family caregivers helping older US adults increased from 18 million to 24 million, 2011\u201322","volume":"44","author":"Wolff","journal-title":"Health Aff (Millwood)"},{"issue":"1","key":"R4","doi-asserted-by":"publisher","DOI":"10.2196\/37347","article-title":"Health monitoring using smart home technologies: scoping review","volume":"11","author":"Morita","journal-title":"JMIR Mhealth Uhealth"},{"key":"R5","doi-asserted-by":"publisher","DOI":"10.1109\/access.2021.3076362","article-title":"Fusing ambient and mobile sensor features into a behaviorome for predicting clinical health scores","volume":"9","author":"Cook","journal-title":"IEEE Access"},{"key":"R6","doi-asserted-by":"publisher","DOI":"10.1016\/j.enpol.2021.112196","article-title":"Knowledge, energy sustainability, and vulnerability in the demographics of smart home technology diffusion","volume":"153","author":"Sovacool","journal-title":"Energy Policy"},{"issue":"1","key":"R7","doi-asserted-by":"publisher","first-page":"10","DOI":"10.1080\/17538157.2021.1923500","article-title":"Ethics and acceptance of smart homes for older adults","volume":"47","author":"Pirzada","journal-title":"Inform Health Soc Care"},{"issue":"1","key":"R8","doi-asserted-by":"publisher","DOI":"10.1007\/s10433-023-00776-9","article-title":"Gerontechnology for better elderly care and life quality: a systematic literature review","volume":"20","author":"Huang","journal-title":"Eur J Ageing"},{"issue":"12","key":"R9","doi-asserted-by":"publisher","first-page":"4847","DOI":"10.1111\/jan.14996","article-title":"Factors influencing community-dwelling older adults\u2019 readiness to adopt smart home technology: a qualitative exploratory study","volume":"77","author":"Dermody","journal-title":"J Adv Nurs"},{"key":"R10","doi-asserted-by":"publisher","DOI":"10.31478\/202212a","article-title":"Health technology for all: an equity-based paradigm shift opportunity","volume":"2022","author":"MacDonald","journal-title":"NAM Perspect"},{"key":"R11","doi-asserted-by":"crossref","unstructured":"Demiris G . Information technology to support aging: implications for caregiving. In: Gaugler JE Kane RL , editors. Family Caregiving in the New Normal. Academic Press; 2015:211-223. [doi: 10.1016\/B978-0-12-417046-9.00012-X]","DOI":"10.1016\/B978-0-12-417046-9.00012-X"},{"issue":"4","key":"R12","doi-asserted-by":"publisher","first-page":"1","DOI":"10.4017\/gt.2020.19.04.385","article-title":"Older Asian immigrants\u2019 perceptions of a health-assistive smart home","volume":"19","author":"Fritz","journal-title":"Gerontechnology"},{"key":"R13","doi-asserted-by":"publisher","DOI":"10.2147\/JMDH.S419923","article-title":"Health care equity through intelligent edge computing and augmented reality\/virtual reality: a systematic review","volume":"16","author":"Lakshminarayanan","journal-title":"J Multidiscip Healthc"},{"issue":"2","key":"R14","doi-asserted-by":"publisher","first-page":"140","DOI":"10.1016\/j.outlook.2018.11.004","article-title":"A nurse-driven method for developing artificial intelligence in \u201csmart\u201d homes for aging-in-place","volume":"67","author":"Fritz","journal-title":"Nurs Outlook"},{"issue":"1","key":"R15","doi-asserted-by":"publisher","DOI":"10.2196\/56692","article-title":"Use of artificial intelligence, internet of things, and edge intelligence in long-term care for older people: comprehensive analysis through bibliometric, Google trends, and content analysis","volume":"27","author":"Chien","journal-title":"J Med Internet Res"},{"key":"R16","unstructured":"Smart home technology for older adults. AgeTech Collaborative from AARP. 2026. URL: https:\/\/agetechcollaborative.org\/insights\/smart-home-tech-for-older-adults\/ [Accessed 07-07-2026]"},{"issue":"10","key":"R17","doi-asserted-by":"publisher","first-page":"860","DOI":"10.1016\/j.jamda.2017.05.012","article-title":"Randomized trial of intelligent sensor system for early illness alerts in senior housing","volume":"18","author":"Rantz","journal-title":"J Am Med Dir Assoc"},{"issue":"3","key":"R18","doi-asserted-by":"publisher","first-page":"281","DOI":"10.1159\/000366518","article-title":"A new paradigm of technology-enabled \u201cVital Signs\u201d for early detection of health change for older adults","volume":"61","author":"Rantz","journal-title":"Gerontology"},{"issue":"7","key":"R19","doi-asserted-by":"publisher","first-page":"62","DOI":"10.1109\/MC.2012.328","article-title":"CASAS: a smart home in a box","volume":"46","author":"Cook","journal-title":"Computer"},{"issue":"3","key":"R20","doi-asserted-by":"publisher","first-page":"820","DOI":"10.1109\/TSMCB.2012.2216873","article-title":"Activity discovery and activity recognition: a new partnership","volume":"43","author":"Cook","journal-title":"IEEE Trans Cybern"},{"key":"R21","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijnsa.2022.100081","article-title":"Nurse-in-the-loop smart home detection of health events associated with diagnosed chronic conditions: a case-event series","volume":"4","author":"Fritz","journal-title":"Int J Nurs Stud Adv"},{"issue":"1","key":"R22","doi-asserted-by":"publisher","first-page":"4","DOI":"10.1016\/j.pmn.2022.08.011","article-title":"Piloting smart home sensors to detect overnight respiratory and withdrawal symptoms in adults prescribed opioids","volume":"24","author":"Wilson","journal-title":"Pain Manag Nurs"},{"key":"R23","doi-asserted-by":"publisher","DOI":"10.58496\/ADSA\/2023\/010","article-title":"Smart real-time IoT mhealth-based conceptual framework for healthcare services provision during network failures","volume":"2023","author":"Albahri","journal-title":"Appl Data Sci Anal"},{"issue":"1","key":"R24","doi-asserted-by":"publisher","first-page":"5297","DOI":"10.1038\/s41598-024-55662-w","article-title":"Internet of medical things and blockchain-enabled patient-centric agent through SDN for remote patient monitoring in 5G network","volume":"14","author":"Rahman","journal-title":"Sci Rep"},{"issue":"6","key":"R25","doi-asserted-by":"publisher","first-page":"68","DOI":"10.1109\/MIM.2021.9513638","article-title":"Home-based assessment of cognition and health measures: the collaborative aging research using technology (CART) initiative and international collaborations","volume":"24","author":"Thomas","journal-title":"IEEE Instrum Meas Mag"},{"issue":"5","key":"R26","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0154535","article-title":"Race, neighborhood economic status, income inequality and mortality","volume":"11","author":"Mode","journal-title":"PLOS ONE"},{"key":"R27","doi-asserted-by":"publisher","DOI":"10.3389\/fpubh.2021.699049","article-title":"Poverty, racism, and the public health crisis in America","volume":"9","author":"Beech","journal-title":"Front Public Health"},{"issue":"1","key":"R28","doi-asserted-by":"publisher","DOI":"10.3912\/OJIN.Vol29No01Man03","article-title":"Poverty in older adulthood: a health and social crisis","volume":"29","author":"Thornton","journal-title":"Online J Issues Nurs"},{"key":"R29","unstructured":"McIver DL . CMS framework for health equity 2022\u20132032. Centers for Medicare & Medicaid Services (CMS); 2022. URL: https:\/\/www.cms.gov\/files\/document\/cms-framework-health-equity.pdf [Accessed 07-07-2026]"},{"key":"R30","unstructured":"Fritz RL Cook D . Identifying varying health states in smart home sensor data: an expert-guided approach. Presented at: Proceedings of The 21st World Multi-Conference on Systemics, Cybernetics and Informatics (WMSCI 2017); Nov 12-17, 2017; Denver, Colorado, USA. URL: https:\/\/www.iiis.org\/CDs2017\/CD2017Summer\/papers\/SA395LR.pdf [Accessed 07-07-2026]"},{"issue":"2","key":"R31","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1145\/3439870","article-title":"Indirectly supervised anomaly detection of clinically meaningful health events from smart home data","volume":"12","author":"Dahmen","journal-title":"ACM Trans Intell Syst Technol"},{"key":"R32","unstructured":"For industry and community partners. Oregon Health & Science University (OHSU). 2026. URL: https:\/\/www.ohsu.edu\/collaborative-aging-research-using-technology\/industry-and-community-partners [Accessed 07-07-2026]"},{"issue":"1","key":"R33","doi-asserted-by":"publisher","DOI":"10.1186\/s12877-024-04702-1","article-title":"Benefits and barriers associated with the use of smart home health technologies in the care of older persons: a systematic review","volume":"24","author":"Tian","journal-title":"BMC Geriatr"},{"issue":"1","key":"R34","doi-asserted-by":"publisher","first-page":"849","DOI":"10.1111\/jan.16945","article-title":"Multi perspective considerations for health smart home: early phase exploratory study","volume":"82","author":"Dermody","journal-title":"J Adv Nurs"},{"key":"R35","doi-asserted-by":"publisher","DOI":"10.54111\/0001\/aaaa1","article-title":"Bioethics principles in machine learning-healthcare application design: achieving health justice and health equity","volume":"79","author":"Fritz","journal-title":"Harv Public Health Rev (Camb)"},{"issue":"4","key":"R36","doi-asserted-by":"publisher","DOI":"10.2196\/12286","article-title":"Applications of machine learning in real-life digital health interventions: review of the literature","volume":"21","author":"Triantafyllidis","journal-title":"J Med Internet Res"},{"issue":"5","key":"R37","doi-asserted-by":"publisher","first-page":"1282","DOI":"10.1007\/s11606-022-07987-3","article-title":"Access to what for whom? How care delivery innovations impact health equity","volume":"38","author":"Szymczak","journal-title":"J Gen Intern Med"},{"issue":"6","key":"R38","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pdig.0000268","article-title":"Healthcare inequity and digital health\u2014a bridge for the divide, or further erosion of the chasm?","volume":"2","author":"Hadjiat","journal-title":"PLOS Digit Health"},{"issue":"6","key":"R39","doi-asserted-by":"publisher","first-page":"1154","DOI":"10.1016\/j.cjca.2024.02.014","article-title":"Challenges in promoting health equity and reducing disparities in access across new and established technologies","volume":"40","author":"Hoagland","journal-title":"Can J Cardiol"},{"issue":"1","key":"R40","doi-asserted-by":"publisher","first-page":"62","DOI":"10.1093\/ehjdh\/ztab005","article-title":"Barriers and facilitators of the uptake of digital health technology in cardiovascular care: a systematic scoping review","volume":"2","author":"Whitelaw","journal-title":"Eur Heart J Digit Health"},{"key":"R41","doi-asserted-by":"publisher","DOI":"10.2196\/42719","article-title":"Barriers to and facilitators of digital health among culturally and linguistically diverse populations: qualitative systematic review","volume":"25","author":"Whitehead","journal-title":"J Med Internet Res"},{"issue":"1","key":"R42","doi-asserted-by":"publisher","DOI":"10.1038\/s41746-023-00899-4","article-title":"Barriers and facilitators to utilizing digital health technologies by healthcare professionals","volume":"6","author":"Borges do Nascimento","journal-title":"NPJ Digit Med"},{"key":"R43","doi-asserted-by":"crossref","unstructured":"Van Hoof J Demiris G Wouters EJ . Handbook of Smart Homes, Health Care and Well-Being. Springer International Publishing; 2017. [doi: 10.1007\/978-3-319-01583-5]","DOI":"10.1007\/978-3-319-01583-5"},{"issue":"1","key":"R44","doi-asserted-by":"publisher","DOI":"10.2196\/53855","article-title":"Centering digital health equity during technology innovation: protocol for a comprehensive scoping review of evidence-based tools and approaches","volume":"13","author":"Burns","journal-title":"JMIR Res Protoc"},{"issue":"2","key":"R45","doi-asserted-by":"publisher","first-page":"284","DOI":"10.1093\/jamia\/ocaa197","article-title":"Putting the social back into sociotechnical: case studies of co-design in digital health","volume":"28","author":"Papoutsi","journal-title":"J Am Med Inform Assoc"},{"issue":"1","key":"R46","doi-asserted-by":"publisher","DOI":"10.2196\/55714","article-title":"Methods, indicators, and end-user involvement in the evaluation of digital health interventions for the public: scoping review","volume":"26","author":"Weirauch","journal-title":"J Med Internet Res"},{"key":"R47","doi-asserted-by":"crossref","unstructured":"Ravizza A Conditi N . Human factors engineering methods for engaging end users in the co-design of healthcare 5.0 technologies. In: Bertolaso M Ilardo ML Ribera J , editors. Healthcare in the Digital Age. Springer; 2025:249-283. [doi: 10.1007\/978-981-96-1437-0_12]","DOI":"10.1007\/978-981-96-1437-0_12"},{"issue":"2","key":"R48","doi-asserted-by":"publisher","first-page":"242","DOI":"10.35844\/001c.129279","article-title":"Nurturing belonging, reflection, and responsiveness in cross-sector partnerships: exemplar from community-based smart health system research","volume":"6","author":"Nguyen-Truong","journal-title":"J Particip Res Methods"},{"key":"R49","unstructured":"Annual update of the HHS poverty guidelines. Federal Register. Aug 18, 2023. URL: https:\/\/www.federalregister.gov\/documents\/2023\/01\/19\/2023-00885\/annual-update-of-the-hhs-poverty-guidelines [Accessed 07-07-2026]"},{"issue":"1","key":"R50","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1002\/nur.20362","article-title":"What\u2019s in a name? Qualitative description revisited","volume":"33","author":"Sandelowski","journal-title":"Res Nurs Health"},{"key":"R51","doi-asserted-by":"crossref","unstructured":"Braun V Clarke V Hayfield N Davey L Jenkinson E . Doing reflexive thematic analysis. In: Bager-Charleson S McBeath A , editors. Supporting Research in Counselling and Psychotherapy. Springer International Publishing; 2022:19-38. [doi: 10.1007\/978-3-031-13942-0_2]","DOI":"10.1007\/978-3-031-13942-0_2"},{"issue":"2","key":"R52","doi-asserted-by":"publisher","first-page":"237","DOI":"10.1177\/1098214005283748","article-title":"A general inductive approach for analyzing qualitative evaluation data","volume":"27","author":"Thomas","journal-title":"Am J Eval"},{"issue":"1","key":"R53","doi-asserted-by":"publisher","DOI":"10.2196\/80000","article-title":"Barriers to and facilitators of digital health technology adoption among older adults with chronic diseases: updated systematic review","volume":"8","author":"Hepburn","journal-title":"JMIR Aging"},{"issue":"14","key":"R54","doi-asserted-by":"publisher","first-page":"1421","DOI":"10.3390\/healthcare12141421","article-title":"Understanding the role of technology anxiety in the adoption of digital health technologies (DHTs) by older adults with chronic diseases in Shanghai: an extension of the unified theory of acceptance and use of technology (UTAUT) model","volume":"12","author":"Chen","journal-title":"Health Care (Don Mills)"},{"issue":"1","key":"R55","doi-asserted-by":"publisher","DOI":"10.1186\/s12889-024-18036-5","article-title":"Barriers and facilitators to health technology adoption by older adults with chronic diseases: an integrative systematic review","volume":"24","author":"Bertolazzi","journal-title":"BMC Public Health"},{"issue":"2","key":"R56","doi-asserted-by":"publisher","DOI":"10.1093\/rescon\/vmag017","article-title":"When voice-based AI becomes a companion: protecting dignity and reimagining human\u2013AI collaboration in aging-in-place","volume":"1","author":"Kuo","journal-title":"Res Connect"},{"key":"R57","doi-asserted-by":"publisher","DOI":"10.3389\/fpsyg.2023.1287486","article-title":"Technology to support aging in place: key messages for policymakers and funders","volume":"14","author":"Genge","journal-title":"Front Psychol"},{"issue":"1","key":"R58","doi-asserted-by":"publisher","DOI":"10.2196\/72716","article-title":"Understanding older adults' technology use preferences and needs from a triangular perspective: qualitative study","volume":"27","author":"Cohen Elimelech","journal-title":"J Med Internet Res"}],"container-title":["JMIR Aging"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/aging.jmir.org\/2026\/1\/e88290","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T22:24:58Z","timestamp":1785536698000},"score":1,"resource":{"primary":{"URL":"https:\/\/aging.jmir.org\/2026\/1\/e88290"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,23]]},"references-count":58,"URL":"https:\/\/doi.org\/10.2196\/88290","relation":{},"ISSN":["2561-7605"],"issn-type":[{"value":"2561-7605","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,23]]},"article-number":"v9i2e88290"}}