A Systematic Review of Home Modifications for Aging in Place in Older Adults
Round 1
Reviewer 1 Report
Comments and Suggestions for Authors1. The MINOR scores were given with numbers on what basis the numbers were assigned.
2. The study talked about home modifications either in the introduction or in the results section the modifications done to older adults is missing.
3. The mechanistic approach or the rationale behind the study is not there.
4. The key questions framed is in words not as statements.
5. Even though the study is a systematic review, but the authors could have given in the introduction the important information for this type of study selection.
6. The Multidimensional Analysis of Home Modification for Aging in Place Among Older Adults from line number 288 to 354 most of the points were repetitive.
7. It was mentioned in summary this study confirmed home modification, but it was a systematic review on what basis the authors mentioned the challenges of home modification.
Author Response
[Comments 1]: The MINOR scores were given with numbers on what basis the numbers were assigned.
[Response 1]: Thank you for your valuable feedback. To clarify the basis for assigning MINORS scores, I have explicitly referenced the MINORS scoring method established in the study by Slim et al. (2003): Slim, K.; Nini, E.; Forestier, D. Methodological index for nonrandomized studies (MINORS): Development and validation of a new instrument. ANZ J. Surg.2003, 73, 712–716. https://doi.org/10.1046/j.1445-2197.2003.02748.x
The scoring criteria were applied by this validated methodology to ensure consistency, objectivity, and methodological rigor in evaluating non randomized studies. This approach enhances the transparency and reliabilityof the quality assessment process within the study. I sincerely appreciate your insightful comment, which has helped strengthen the methodological clarity of this research.
“The items are scored 0 (not reported), 1 (reported but inadequate) or 2 (reported and adequate). The global ideal score is16 for non-comparative studies and 24 for comparative studies.”
- pp. 5, line 218-220
[Comments 2]: The study talked about home modifications either in the introduction or in the results section the modifications done to older adults is missing.
[Response 2]: To address the absence of detailed information on home modifications in the Results section, I have included Table 6: Home Modification Details of Studies. This table provides a comprehensive overview of the specific home modifications implemented in the reviewed studies, ensuring that the findings are presented in a clear and structured manner. By incorporating this information, the study now offers a more complete analysis of the modifications applied to older adults, strengthening the alignment between the Introduction, Results, and Discussion sections. I sincerely appreciate your insightful suggestion, which has helped enhance the clarity and completeness of the study’s findings.
“3.5 Home Modification Details of Studies
Table 6 summarizes the home modifications analyzed in 20 studies. Mobility and accessibility improvements and bathroom safety enhancements were implemented in all studies (100%), including threshold removal, doorway widening, stair lift installation, grab bars, and non-slip mats. Fall prevention measures were applied in 18 studies (90%), incorporating non-slip flooring, lighting improvements, and mobility training.
Kitchen and living space modifications were present in 15 studies (75%), while support for independent living was included in 14 studies (70%), involving cooking area adjustments and assistive device provision. Stair safety enhancements(12 studies, 60%) and lighting improvements(10 studies, 50%) were also emphasized. In contrast, hazard removal(8 studies, 40%) and outdoor environment modifications(7 studies, 35%) were reported less frequently.”
- pp. 15~16, line 311-324
[Comments 3]: The mechanistic approach or the rationale behind the study is not there.
[Response 3]: Thank you for your insightful feedback regarding the need for a clearer mechanistic approach and rationale behind the study. In response, I have revised the manuscript to explicitly articulate the theoretical foundation that underpins the interaction between home modifications and aging in place. Specifically, I have integrated the Environmental Press Theory and the Person-Environment-Occupation (PEO) model to explain how an individual’s physical and cognitive abilities interact with their living environment, influencing functional independence and quality of life. These theoretical frameworks provide a structured perspective on the role of home modifications in reducing environmental barriers and promoting safe, independent living for older adults.
To further strengthen this section, I have incorporated evidence from Natalia et al. [25], highlighting the impact of smart home technologies, ramp installations, and bathroom modifications enhancing independent living and safety. This revision ensures a stronger theoretical grounding and provides a clear and well-justified rationale for the necessity of tailored home modifications as a key strategy to support aging in place. I sincerely appreciate your valuable suggestion, which has helped improve the conceptual clarity and depth of the study.
“The interaction between an individual's physical and cognitive abilities and the built environment significantly influences functional independence and quality of life. According to the Environmental Press Theory, balance is maintained when the environment supports an individual's capabilities. However, if environmental demands exceed functional capacity, environmental pressure increases, leading to a decline in quality of life. The physical and cognitive capabilities of older adults interact with their living environment, affecting residential satisfaction and independent living. When housing environments impose excessive demands beyond an individual’s diminished functional capacity, disability and dependence increase, necessitating tailored home modifications[24]. Home modifications are also closely linked to the Person-Environment-Occupation (PEO) Model. This model emphasizes the dynamic interaction among personal (physical, psychological, cognitive), environmental (physical, social), and occupational (daily activity) factors, which together determine functional independence and quality of life in older adults[25]. Natalia et al. [25] particularly highlight that smart home technologies, ramp installations, and bathroom modifications are essential home adaptations that enhance independent living for older adults. These findings suggest that home modifications are a critical strategy for improving functional performance, reducing nursing home admissions, and enhancing overall quality of life.”
- pp. 2, line 69-86
[Comments 4]: The key questions framed is in words not as statements.
[Response 4]: To improve clarity and precision, I have revised this section to ensure that the key research questions are explicitly framed as statements rather than descriptive phrases. In the revised version, the research questions are now clearly structured and well-defined, ensuring that the study’s focus and objectives are effectively conveyed. This refinement enhances the logical flow of the study and strengthens its contribution to policy development, healthcare interventions, and future research directions related to aging in place. I sincerely appreciate your insightful suggestion, which has helped improve the coherence and clarity of the study’s research framework.
“The key research questions of this study are as follows:
(1) Primary Research Question
- What is the comprehensive impact of home modifications on aging in place among older adults?
(2) Secondary Research Questions
- What are the primary types and specific applications of home modifications for older adults?
- What are the multidimensional effects of home modifications on aging in place?
- What are the interactions and comprehensive impacts of health changes and home modifications among older adults?
This study aims to provide scientific evidence to guide policy development, healthcare interventions, and future research, ultimately contributing to the enhancement of aging-in-place strategies.”
- pp. 3, line 101-113
[Comments 5]: Even though the study is a systematic review, but the authors could have given in the introduction the important information for this type of study selection.
[Response 5]: I acknowledge the importance of providing study selection criteria in the introduction; however, I have deliberately chosen not to include them in that section to avoid redundancy.
The Materials and Methods section already presents a detailed description of the inclusion criteria and study selection process, ensuring clarity and methodological rigor. Since systematic reviews require a structured and transparent selection process, I felt it was most appropriate to provide this information comprehensively in the designated section rather than repeating it in the introduction.
[Comments 6]: The Multidimensional Analysis of Home Modification for Aging in Place Among Older Adults from line number 288 to 354 most of the points were repetitive.
[Response 6]: To address concerns regarding redundancy, I have revised the section "The Multidimensional Analysis of Home Modification for Aging in Place Among Older Adults" (lines 288–354)to improve clarity and streamline the content. The content previously presented in Table 6 has been relocated to Table 7, ensuring that key findings are effectively consolidated. Since Table 5 already provides essential analytical results, I have removed repetitive discussions to enhance conciseness and readability.
Additionally, I have excluded aspects related to cultural differences and technological variations, as most of the reviewed studies were conducted in Western cultural contexts and primarily focused on low-tech interventions. To improve the systematic classification of findings, I have reorganized Table 7 by introducing three new categories: the effect of home modifications on enhancing independence in activities of daily living (ADL), the impact of home modifications on home safety, and the impact of home modifications on housing accessibility. These modifications provide a more structured and comprehensive analysis, ensuring that findings are logically presented and easier to interpret.
These revisions improve the logical flow and readability of the study while eliminating unnecessary repetition. I sincerely appreciate your insightful suggestions, which have greatly contributed to refining this section. Thank you again for your valuable feedback.
“3.6 A Multidimensional Analysis of Home Modification for Aging in Place Among Older Adults
This study provides a comprehensive analysis of the impact of home modifications on aging in place among older adults (Table 7). The findings include both statistically significant results and notable trends, even when statistical significance was not observed. The analysis examined the effects of home modifications on fall prevention(12 studies), activities of daily living (ADL) improvement(6 studies), quality of life enhancement(5 studies), and home safety improvements(4 studies). Additional areas of research included housing accessibility(2 studies), modifications for older adults with cognitive decline(2 studies), caregiver burden reduction(2 studies), cost-effectiveness analysis(2 studies), and socioeconomic disparities(2 studies).
Notably, fall prevention and increased independence were the most prominent effects, while housing accessibility and tailored interventions contributed to improved quality of life. Home modifications also reduced caregiver burden, emphasizing the need for economic and policy support. These findings highlight the importance of continued research and policy initiatives to promote independent living and a safe home environment for older adults.”
- pp. 17, line 326-343
[Comments 7]: It was mentioned in summary this study confirmed home modification, but it was a systematic review on what basis the authors mentioned the challenges of home modification.
[Response 7]: We acknowledge the importance of ensuring that our conclusions align with the nature of a systematic review and that the basis for discussing the challenges of home modifications is established.
To address this, I have revised the manuscript to clarify the criteria used for evaluating the effectiveness of home modifications. Specifically, I have classified studies as "Effective" if statistically significant improvements were observed across all measured outcomes. In contrast, studies where some outcomes showed statistical significance but lacked consistent overall results had methodological limitations categorized as "Correlation Identified."
This refinement ensures that the findings are interpreted in a structured and transparent manner, accurately reflecting the scope and limitations of the reviewed studies. I sincerely appreciate your valuable suggestion, which has helped enhance the clarity and rigor of our conclusions. Thank you again for your constructive feedback.
“Effectiveness was classified as “Effective” if statistically significant improvements were observed across all measured outcomes. Studies, where some outcomes showed statistical significance but lacked consistent overall results or had methodological limitations, were categorized as “Correlation Identified”.”
- pp. 10, line 293-296
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsThe systematic review by Su-Min Cha presents a comprehensive analysis of home modifications for aging in place among older adults. The study successfully adheres to PRISMA 2020 guidelines and applies thematic and narrative synthesis methodologies to evaluate the effectiveness of various home modification interventions. The inclusion of 20 studies from diverse regions and methodological approaches enhances the robustness of the findings.
The paper effectively highlights the importance of home modifications in promoting safety, functional independence, quality of life, and reduced caregiving burden. Additionally, it underscores socioeconomic and technological factors affecting accessibility and long-term sustainability. While the study provides valuable insights, some limitations in methodology and interpretation require further clarification.
The study includes a well-structured PRISMA flowchart and a detailed eligibility criteria framework based on the PICO method.
Both randomized controlled trials (RCTs) and non-randomized studies were assessed using PEDro and MINORS quality scales.
Home modifications were analyzed beyond physical safety, including economic, psychological, and social aspects.
The paper discusses low-tech vs. high-tech interventions, recognizing the cost-effectiveness of simple modifications and the potential of smart home technologies.
The study highlights financial constraints and accessibility issues, advocating for policy support for lower-income and rural populations.
But still the manuscript needs refinements as mentioned below.
The review relies on a single researcher and an external expert for study selection and quality assessment, introducing potential bias.
While 65% of studies confirmed the effectiveness of home modifications, the remaining 35% indicated strong correlations but lacked direct evidence.
The study provides qualitative insights but lacks sufficient statistical synthesis.
The paper suggests further research on smart home technologies but does not provide concrete methodologies or metrics for assessment.
Author Response
[Comments 1]: The review relies on a single researcher and an external expert for study selection and quality assessment, introducing potential bias.
[Response 1]: Thank you for your valuable feedback. To address the concern regarding potential researcher bias, I have clarified our methodology in the Materials and Methods section. Specifically, I have stated that an additional external researcher independently reviewed all stages of the study selection process to further minimize bias. This approach was implemented to enhance the reliability and rigor of the study selection and quality assessment process. I appreciate your insightful suggestion, which has helped me improve the transparency of my methodology.
“An additional external researcher independently reviewed all stages of the study to minimize the risk of researcher bias. This approach was implemented to further enhance the reliability of the study selection process.”
- pp. 4, line 183-185
[Comments 2]: While 65% of studies confirmed the effectiveness of home modifications, the remaining 35% indicated strong correlations but lacked direct evidence.
[Response 2]: To address the concern regarding potential researcher bias, I have clarified my methodology in the Materials and Methods section. Specifically, I have stated that an additional external researcher independently reviewed all stages of the study selection process to further minimize bias. This approach was implemented to enhance the reliability and rigor of the study selection and quality assessment process. I appreciate your insightful suggestion, which has helped me improve the transparency of my methodology.
“Effectiveness was classified as “Effective” if statistically significant improvements were observed across all measured outcomes. Studies, where some outcomes showed statistical significance but lacked consistent overall results or had methodological limitations, were categorized as “Correlation Identified”. “
- pp. 10, line 293-296
[Comments 3]: The study provides qualitative insights but lacks sufficient statistical synthesis.
[Response 3]: Thank you for your valuable feedback. I have addressed your concern regarding the lack of statistical synthesis refining both the Results and Discussion sections.
In the Results section, I have provided a clearer summary of the specific home modifications analyzed across studies, presenting the frequency of different intervention types. This revision enhances the clarity and structure of the reported findings.
In the Discussion section, I have acknowledged the significant heterogeneity in intervention methods and assessment tools, which limited the feasibility of meta-analysis. To improve comparability in future research, I have emphasized the need for standardized assessment tools and statistical approaches for quantifying heterogeneity. Additionally, I have highlighted the lack of long-term follow-up data as a key limitation and suggested incorporating appropriate follow-up periods and reliable evaluation methods in future studies.
These revisions aim to strengthen the interpretation of findings and provide clearer guidance for future research. I sincerely appreciate your insightful comments.
“3.5 Home Modification Details of Studies
Table 6 summarizes the home modifications analyzed in 20 studies. Mobility and accessibility improvements and bathroom safety enhancements were implemented in all studies (100%), including threshold removal, doorway widening, stair lift installation, grab bars, and non-slip mats. Fall prevention measures were applied in 18 studies (90%), incorporating non-slip flooring, lighting improvements, and mobility training.
Kitchen and living space modifications were present in 15 studies (75%), while support for independent living was included in 14 studies (70%), involving cooking area adjustments and assistive device provision. Stair safety enhancements(12 studies, 60%) and lighting improvements(10 studies, 50%) were also emphasized. In contrast, hazard removal(8 studies, 40%) and outdoor environment modifications(7 studies, 35%) were reported less frequently.”
- pp. 15~16, line 311-324
“Significant heterogeneity was observed across studies in intervention methods, assessment tools, and participant characteristics, limiting meta-analysis feasibility. Assessment methods ranged from self-reports and clinician evaluations to biomechanical measurements, reducing comparability and generalizability. Future research should adopt standardized assessment tools, such as the Housing Enabler[51] or Westmead Home Safety Assessment (WeHSA)[52], and apply statistical measures like I² statistics and subgroup analyses to quantify heterogeneity [53, 54]. A key limitation was the lack of long-term follow-up data, making it difficult to assess the sustained effects of home modifications. Future studies should establish appropriate follow-up periods, employ objective outcome measures, and use bias assessment tools, such as ROBINS-I[56], to enhance reliability. Sensitivity analyses[53] will further strengthen the findings' validity. By addressing these methodological limitations and proposing specific improvements, future research can provide more robust, evidence-based home modification strategies to effectively support aging in place for older adults.”
- pp. 20, line 400-413
[Comments 4]: The paper suggests further research on smart home technologies but does not provide concrete methodologies or metrics for assessment.
[Response 4]: To address the concern regarding the lack of concrete methodologies for assessing smart home technologies, I have refined both the Discussion and Conclusion sections.
In the Discussion section, I have elaborated on the need for systematic evaluation frameworks to assess the effectiveness of smart home technologies. I have suggested specific models and objective metrics that can measure usability, fall prevention effectiveness, cost-efficiency, and user satisfaction. By incorporating these structured approaches, future research can generate more empirical evidence on the role of smart home technologies in aging in place.
In the Conclusion section, I have outlined future research directions, emphasizing comparative analyses between smart home technologies and traditional home modifications. I have also recommended using standardized models to assess technology adoption and effectiveness, as well as conducting cost-effectiveness evaluations to determine long-term feasibility. Additionally, I have highlighted the importance of developing tailored home modification strategies for different older adult populations.
These revisions aim to strengthen the study’s practical implications and provide a clearer roadmap for future research. I sincerely appreciate your insightful suggestions, which have helped improve the clarity and depth of my discussion.
“Despite the growing recognition of smart home technology, research on its effectiveness and evaluation methodologies remains limited. Future studies should adopt systematic evaluation frameworks to assess its impact. The Technology Acceptance Model (TAM) can quantify user-friendliness, ease of use, and perceived usefulness of smart home systems [53]. Smart sensor-based fall prevention should be evaluated using objective metrics, such as fall incidence, severity, and emergency response time[58]. The cost-effectiveness and sustainability of IoT-based smart homes should be analyzed through installation costs, maintenance expenses, and long-term viability[59]. Lastly, user satisfaction and real-world impact should be assessed through surveys and in-depth interviews to provide qualitative insights[58]. By applying these systematic methodologies, future research can generate empirical evidence, advancing a clearer, more structured understanding of smart home technologies in supporting aging in place.”
- pp. 21, line 438-449
“5.3. Future Research Directions
Future research should focus on comparative studies between smart home technology and traditional home modifications to identify the most effective intervention strategies. To evaluate the effectiveness of smart home technologies, studies should employ the Technology Acceptance Model (TAM) to assess older adults’ technology adoption rates and utilize sensor-based data to analyze fall incidence rates and severity. Additionally, a comparative cost-effectiveness analysis between smart home technologies and conventional home modifications should assess economic feasibility, considering both initial installation costs and long-term maintenance expenses. Further research should develop customized home modification models for diverse older adult populations, including those with severe physical impairments, mild dementia, and economic disadvantages, to determine the most suitable interventions for each group.”
- pp. 24, line 597-608
Author Response File: Author Response.pdf
Reviewer 3 Report
Comments and Suggestions for AuthorsManuscript under consideration aims to provide a systematic review on home modifications for older adults aging in their own environment. The topic is timely and important. Populations of almost all developed countries are aging and care to this becoming an important issue.
Authors justify the need for a review paper in this area, so fits to the general theme of the journal. Literature review is also carried out in a satisfactory manner.
I have the following concerns to be addressed:
- I understand that this is not a “State of the art” paper so the focus on just 20 papers is ok. However, providing so many papers summarizing and describing these papers makes the manuscript long and fuzzy. I suggest a reorganization and removal of some tables, the ones with detailed explanation within the text (especially Table 6)
- Sections 4 and 5 (Discussion and Conclusions) are out of focus in the current form. Each paragraph starts with “This study….” and provides similar contexts. Even paragraphs 3 and 4 on page 23 is exactly same, a duplication!!!
Author claims a systematic analysis but discussions are clearly not. I suggest to author to refrain from using paragraphs starting with “First, second, third….”. Rather bullets can be used. And these bullets must discuss the analysis in a systematic manner. Analysis items defined on Table 7 can be a good classification for discussion dimensions.
I suggest a similar fashion for conclusions. After providing a brief summary (paper itself a summary), conclusions should be provided from categories such as: 1. Theory, 2. Practice, 3. Future Research Directions (last part is especially important. Author must show several clear paths for what to do next in this field with clear justification (directions are present but no scientific justifications). This is the most important responsibility of a review paper)
Author Response
[Comments 1]: I understand that this is not a “State of the art” paper so the focus on just 20 papers is ok. However, providing so many papers summarizing and describing these papers makes the manuscript long and fuzzy. I suggest a reorganization and removal of some tables, the ones with detailed explanation within the text (especially Table 6)
[Response 1]: Thank you for your valuable feedback. To enhance the clarity and readability of the manuscript, I have revised section 3.6 A Multidimensional Analysis of Home Modification for Aging in Place Among Older Adults. First, the content previously presented in Table 6 has been relocated to Table 7, and since Table 5 already provides key findings, I have removed redundant analytical results. Additionally, I have excluded aspects related to cultural differences and technological variations, as most of the reviewed studies were conducted in Western cultural contexts and primarily focused on low-tech interventions. To strengthen the systematic classification of findings, Table 7 has been reorganized into three new categories: (1) the effect of home modifications on enhancing independence in activities of daily living (ADL), (2) the impact of home modifications on home safety, and (3) the impact of home modifications on housing accessibility. These modifications aim to improve clarity, reduce redundancy, and provide a more structured and comprehensive analysis.
The tables and content presented in this study reflect the essential characteristics of the research and are crucial for ensuring transparency and reproducibility of the results. Given the nature of a systematic review, it is important to compare and analyze the differences among the included studies, and presenting key data directly in the main text is appropriate for this purpose. If the tables were moved to the appendix, readers might have difficulty accessing relevant information immediately when interpreting the findings, potentially disrupting readability and logical flow. Additionally, visualizing differences among the studies would become more challenging, which could weaken the study’s core message. Considering that the target audience consists of experts in aging and home modification, including tables in the main text is a more effective approach for delivering the research findings. However, to improve readability, I will consider refining the table format for conciseness and summarizing key points within the main text where necessary. Nevertheless, maintaining the consistency and clarity of the study requires keeping the tables in the main text, and I appreciate your understanding on this matter. Your insightful suggestions have helped refine the logical structure and readability of the study.
“3.6 A Multidimensional Analysis of Home Modification for Aging in Place Among Older Adults
This study provides a comprehensive analysis of the impact of home modifications on aging in place among older adults (Table 7). The findings include both statistically significant results and notable trends, even when statistical significance was not observed. The analysis examined the effects of home modifications on fall prevention(12 studies), activities of daily living (ADL) improvement(6 studies), quality of life enhancement(5 studies), and home safety improvements(4 studies). Additional areas of research included housing accessibility(2 studies), modifications for older adults with cognitive decline(2 studies), caregiver burden reduction(2 studies), cost-effectiveness analysis(2 studies), and socioeconomic disparities(2 studies).
Notably, fall prevention and increased independence were the most prominent effects, while housing accessibility and tailored interventions contributed to improved quality of life. Home modifications also reduced caregiver burden, emphasizing the need for economic and policy support. These findings highlight the importance of continued research and policy initiatives to promote independent living and a safe home environment for older adults.”
- pp. 17, line 326-343
[Comments 2]: Sections 4 and 5 (Discussion and Conclusions) are out of focus in the current form. Each paragraph starts with “This study….” and provides similar contexts. Even paragraphs 3 and 4 on page 23 is exactly same, a duplication!!! Author claims a systematic analysis but discussions are clearly not. I suggest to author to refrain from using paragraphs starting with “First, second, third….”. Rather bullets can be used. And these bullets must discuss the analysis in a systematic manner. Analysis items defined on Table 7 can be a good classification for discussion dimensions.
[Response 2]: To improve the focus and clarity of the Discussion and conclusion sections, I have made substantial revisions to the structure and content. In the Discussion section, I have refined the argument by reducing redundancy and ensuring each paragraph contributes distinct insights. Instead of repeatedly starting paragraphs with “This study…”, I have reorganized the section to provide a more cohesive discussion on the multidimensional effects of home modifications, methodological considerations, and key intervention strategies. Additionally, I have clarified how home modifications impact aging in place by addressing their role in fall prevention, mobility support, and independence, while also highlighting emerging trends such as smart home technologies and policy implications.
The Conclusion section has been restructured to avoid duplication and provide a more concise summary of the study’s theoretical and practical contributions. I have outlined the theoretical implications of positioning home modifications as a multidimensional intervention rather than just structural changes. The practical applications have been revised to emphasize the importance of accessibility, economic feasibility, and interdisciplinary collaboration for successful implementation. Additionally, I have clearly defined future research directions, suggesting comparative studies between smart home technologies and conventional home modifications, cost-effectiveness analyses, and international policy comparisons to establish best practices for aging in place. These revisions aim to enhance readability, remove repetitive content, and ensure a more structured and insightful discussion. I sincerely appreciate your feedback, which has greatly contributed to refining the focus and coherence of these sections.
- pp. 20~24, line 371-619
[Comments 3]: I suggest a similar fashion for conclusions. After providing a brief summary (paper itself a summary), conclusions should be provided from categories such as: 1. Theory, 2. Practice, 3. Future Research Directions (last part is especially important. Author must show several clear paths for what to do next in this field with clear justification (directions are present but no scientific justifications). This is the most important responsibility of a review paper)
[Response 3]: To enhance the clarity and organization of the Conclusions section, I have restructured it into three key categories: Theoretical Implications, Practical Applications, and Future Research Directions.
In the Theoretical Implications section, I have reframed home modifications as a multidimensional intervention that extends beyond structural adjustments to support physical, psychological, and social well-being. I have also emphasized the necessity of standardized assessment tools to improve research comparability and methodological consistency.
The Practical Applications section has been refined to highlight the cost-effectiveness of home modifications while addressing accessibility challenges, particularly for underserved populations. I have underscored the importance of interdisciplinary collaboration and the integration of smart home technologies to enhance independent living for older adults.
The Future Research Directions section has been expanded to provide a clearer roadmap for advancing this field. I have identified key areas for further study, including comparative analyses between smart home technologies and conventional home modifications, cost-effectiveness evaluations, and the development of tailored intervention models. Additionally, I have suggested conducting cross-national policy comparisons to establish best practices for aging in place. These research directions are now supported with more specific justification to strengthen their significance.
These revisions aim to improve the logical flow and scientific depth of the Conclusions section. I sincerely appreciate your insightful comments, which have been instrumental in refining this part of the study.
- pp. 23~24, line 558-619
Author Response File: Author Response.pdf
Reviewer 4 Report
Comments and Suggestions for AuthorsThe article focuses on a current and relevant topic that deserves, therefore, a vote of confidence.
The study presents a systematic review of home modifications for Aging in Place, a topic of growing importance given global demographic changes. By analyzing intervention methods, effectiveness, accessibility, and policy support, it offers a holistic perspective that extends beyond fall prevention to consider quality of life, independence, caregiver burden, and cost-effectiveness, which is compelling.
The abstract should better highlight the knowledge gaps in previous literature to emphasize the novelty of the study.
Regarding the introduction, it initially focuses on South Korea but later portrays the reality of European countries or the U.S. I do not fully understand this connection or the reason for specifically mentioning the South Korean context.
I believe research questions are missing, which would help clearly and concisely address the objectives of the systematic review.
In the materials and methods section, it is necessary to describe what the "PICO Framework" is.
Should the eligibility criteria for study inclusion be concomitant?
What is the rationale for selecting the study time frame of 2010–2024?
I suggest presenting the PRISMA protocol before the results.
Some bibliometric analyses could be presented in a more descriptive and visual manner. It seems that the analysis was done in Excel, which makes it harder for the reader to navigate extensive tables, as if they were expected to analyze them themselves. Some tables seem confusing and could probably be placed in the appendix.
The study analyzes a wide range of home modifications but does not sufficiently differentiate low-cost from high-cost modifications in terms of cost-effectiveness analysis.
The article briefly mentions smart home technologies but does not critically evaluate their feasibility or cost-effectiveness compared to traditional modifications.
The discussion section could better distinguish the findings from their interpretations to improve clarity. Some parts seem somewhat redundant between the discussion and results sections.
The limitations section is underdeveloped. There is no explicit discussion of potential publication bias, study heterogeneity, or data limitations.
The policy recommendations are vague and should specify which types of public funding models or policy frameworks would be most effective, given that this political aspect is one of the research objectives.
A final review of the English language should be conducted, as there are some inaccuracies, and at times, sentences are too long.
Author Response
[Comments 1]: The abstract should better highlight the knowledge gaps in previous literature to emphasize the novelty of the study.
[Response 1]: Thank you for your valuable feedback. To better highlight the knowledge gaps in previous research and emphasize the novelty of this study, we have revised the Abstract accordingly. The updated version now explicitly identifies the limitations of existing research, which predominantly focuses on fall prevention and physical safety while lacking insights into long-term sustainability, social engagement, and cost-effectiveness. Additionally, it emphasizes the underexplored interaction between home modifications and health-related changes, addressing a key research gap. To distinguish this study from prior work, we have clarified its holistic and multidimensional approach, which incorporates functional independence, quality of life, caregiving burden, and technological advancements in analyzing home modifications. The results section has been refined to demonstrate the lack of research on personalized interventions, smart home technologies, and long-term adaptability, further reinforcing the need for innovative and sustainable solutions. In the Conclusions, we have underscored the importance of technology-driven, adaptable home modification strategies and the necessity of interdisciplinary collaboration and policy-focused research to develop comprehensive aging-in-place frameworks. These revisions strengthen the abstract’s focus, making the study’s contributions and its differentiation from prior research clearer. I sincerely appreciate your insightful suggestions, which have helped refine the clarity and impact of the abstract.
“Background/Objectives: The aging population has increased the demand for home modifications to support aging in place. However, existing research primarily focuses on fall prevention and physical safety, leaving gaps in understanding long-term sustainability, social engagement, and cost-effectiveness. Additionally, the interaction between home modifications and health-related changes remains under-explored. This study systematically reviews home modifications, addressing these gaps by considering functional independence, quality of life, caregiving burden, and technological advancements. Methods: A systematic review was conducted following PRISMA 2020 guidelines. One researcher and an external expert performed study selection, data extraction, and quality assessment. Thematic analysis and narrative synthesis were applied to compare study results. Results: Among 20 studies, 13 (65%) confirmed the effectiveness of home modifications in fall prevention, functional independence, and cost savings. Seven studies (35%) highlighted housing accessibility and lifestyle factors. However, few studies examined personalized interventions, smart home technologies, and long-term adaptability. Conclusions: This study emphasizes the need for personalized, technology-driven, and long-term adaptable home modifications. Future research should explore smart home innovations, interdisciplinary approaches, and policy implementation feasibility to develop sustainable aging-in-place strategies. By adopting a holistic perspective, this study provides a new framework for advancing aging-in-place strategies.”
- pp. 1, line 8-25
[Comments 2]: Regarding the introduction, it initially focuses on South Korea but later portrays the reality of European countries or the U.S. I do not fully understand this connection or the reason for specifically mentioning the South Korean context.
[Response 2]: To enhance the global relevance and coherence of the Introduction, we have revised the section by removing country-specific references and incorporating broader demographic trends. In the updated version, we have included United Nations projections to highlight the global aging trend, emphasizing that the proportion of individuals aged 65 and older is expected to reach 16% by 2050, with some regions exceeding 25%. Additionally, we have noted that the global population of individuals aged 80 and older is expected to triple by 2050, further underscoring the increasing demand for aging-friendly housing and social support systems.
These revisions provide a more comprehensive and internationally applicable foundation for the study, reinforcing the significance of Aging in Place (AIP) as a widespread issue. I sincerely appreciate your insightful suggestions, which have helped refine the clarity and focus of this section.
“According to the United Nations, the proportion of individuals aged 65 and older worldwide is projected to reach 16% by 2050, with some regions surpassing 25%[1]. Additionally, the global population of individuals aged 80 and older is expected to triple by 2050, significantly increasing the demand for appropriate housing and social support systems[2]. “
- pp. 1, line 30-34
[Comments 3]: I believe research questions are missing, which would help clearly and concisely address the objectives of the systematic review.
[Response 3]: To enhance the clarity and focus of the study’s objectives, we have incorporated explicit research questions into the manuscript. The revised version now clearly outlines the primary research question, which investigates the comprehensive impact of home modifications on aging in place among older adults. Additionally, we have included secondary research questions that explore the specific types and applications of home modifications, their multidimensional effects, and the interactions between health changes and home modifications. By integrating these research questions, we aim to provide a structured framework for the systematic review, ensuring that the study’s objectives are clearly defined and effectively addressed. These revisions also strengthen the study’s contribution to policy development, healthcare interventions, and future research on aging in place. I sincerely appreciate your insightful suggestion, which has helped improve the clarity and direction of the study.
“The key research questions of this study are as follows:
(1) Primary Research Question
- What is the comprehensive impact of home modifications on aging in place among older adults?
(2) Secondary Research Questions
- What are the primary types and specific applications of home modifications for older adults?
- What are the multidimensional effects of home modifications on aging in place?
- What are the interactions and comprehensive impacts of health changes and home modifications among older adults?
This study aims to provide scientific evidence to guide policy development, healthcare interventions, and future research, ultimately contributing to the enhancement of aging-in-place strategies.”
- pp. 3, line 101-113
[Comments 4]: In the materials and methods section, it is necessary to describe what the "PICO Framework" is. Should the eligibility criteria for study inclusion be concomitant?
What is the rationale for selecting the study time frame of 2010–2024?
[Response 4]: In the Materials and Methods section, we have clarified the concept of the PICO framework and explicitly stated that the eligibility criteria were applied simultaneously. This revision enhances the methodological rigor and consistency of the study selection process. Additionally, the rationale for selecting the study period of 2010–2024 is presented in the Discussion section. This timeframe was chosen to reflect advancements in home modification policies, assistive technologies, and interventions. Furthermore, we acknowledge the potential publication bias associated with focusing on recent studies and discuss the need to include gray literature, such as government reports, conference proceedings, and unpublished studies, to mitigate this limitation. These revisions improve the clarity and justification of our methodological approach. I sincerely appreciate your insightful suggestions, which have contributed to enhancing the transparency and credibility of this study.
“Studies were included if they met all eligibility criteria simultaneously. These were applied concomitantly based on the PICO framework, a widely used approach for formulating research questions in evidence-based practice. The PICO framework consists of four key components: Participants (P), Intervention (I), Comparison (C), and Outcomes (O), which guide the systematic selection of relevant studies”
- pp. 3, line 120-124
“This study reviewed research from 2010–2024 to reflect advancements in home modification policies, assistive technologies, and interventions. However, focusing on recent studies may introduce publication bias, as studies with significant positive effects are more likely to be published. To mitigate this, future systematic reviews should include gray literature, such as government reports, conference proceedings, and unpublished studies[50].”
- pp. 20, line 394-399
[Comments 5]: I suggest presenting the PRISMA protocol before the results.
Some bibliometric analyses could be presented in a more descriptive and visual manner. It seems that the analysis was done in Excel, which makes it harder for the reader to navigate extensive tables, as if they were expected to analyze them themselves. Some tables seem confusing and could probably be placed in the appendix.
[Response 5]: Thank you for your valuable feedback. In response to the feedback regarding the placement of the PRISMA protocol, I have reaffirmed that this study was conducted in strict adherence to the PRISMA 2020 guidelines. Since the PRISMA protocol pertains to study design and methodology, it has been appropriately presented in the Materials and Methods section rather than in the Results section to maintain logical consistency. This approach enhances research transparency and ensures compliance with the systematic review (SR) framework. Additionally, the limitations of bibliometric analysis have been explicitly addressed in the Discussion section. I have acknowledged that heterogeneity among studies, variations in study design, and differences in outcome measurement tools present challenges in quantitative synthesis. To address these limitations, I have proposed future research directions, including the application of advanced statistical techniques and the integration of machine learning for systematic review data analysis.
Furthermore, in the Results section, I have provided a clearer summary of the specific home modifications analyzed across studies, presenting the frequency of different intervention types. This revision improves the clarity and structure of the reported findings, making them more accessible and interpretable. About the extensive use of tables, I fully acknowledge that presenting data in a format that requires readers to interpret them independently may reduce readability. However, due to the nature of a systematic review, it is essential to compare and analyze the differences among the included studies. For this reason, presenting key data directly within the main text plays a critical role in ensuring the transparency and reproducibility of the research.
I have carefully considered the suggestion to relocate some of the tables to the appendix. However, doing so may hinder readers from accessing relevant information promptly during the discussion of findings, which could disrupt the logical flow of the manuscript. Given that the primary audience for this study comprises experts in the fields of aging and home modification, I believe that including the tables in the main text is the most effective way to convey the research results. That said, to improve readability, I have revised the formatting of the tables to make them more concise and have included summarized key points within the text. These modifications aim to strike a balance between maintaining the clarity and rigor of the study while enhancing accessibility for the reader.
“3.5 Home Modification Details of Studies
Table 6 summarizes the home modifications analyzed in 20 studies. Mobility and accessibility improvements and bathroom safety enhancements were implemented in all studies (100%), including threshold removal, doorway widening, stair lift installation, grab bars, and non-slip mats. Fall prevention measures were applied in 18 studies (90%), incorporating non-slip flooring, lighting improvements, and mobility training.
Kitchen and living space modifications were present in 15 studies (75%), while support for independent living was included in 14 studies (70%), involving cooking area adjustments and assistive device provision. Stair safety enhancements(12 studies, 60%) and lighting improvements(10 studies, 50%) were also emphasized. In contrast, hazard removal(8 studies, 40%) and outdoor environment modifications(7 studies, 35%) were reported less frequently.”
- pp. 15~16, line 311-324
“Significant heterogeneity was observed across studies in intervention methods, assessment tools, and participant characteristics, limiting meta-analysis feasibility. Assessment methods ranged from self-reports and clinician evaluations to biomechanical measurements, reducing comparability and generalizability. Future research should adopt standardized assessment tools, such as the Housing Enabler[51] or Westmead Home Safety Assessment (WeHSA)[52], and apply statistical measures like I² statistics and subgroup analyses to quantify heterogeneity [53, 54]. A key limitation was the lack of long-term follow-up data, making it difficult to assess the sustained effects of home modifications. Future studies should establish appropriate follow-up periods, employ objective outcome measures, and use bias assessment tools, such as ROBINS-I[56], to enhance reliability. Sensitivity analyses[53] will further strengthen the findings' validity. By addressing these methodological limitations and proposing specific improvements, future research can provide more robust, evidence-based home modification strategies to effectively support aging in place for older adults.”
- pp. 20, line 400-413
[Comments 6]: The study analyzes a wide range of home modifications but does not sufficiently differentiate low-cost from high-cost modifications in terms of cost-effectiveness analysis.
The article briefly mentions smart home technologies but does not critically evaluate their feasibility or cost-effectiveness compared to traditional modifications.
[Response 6]: Thank you for your valuable feedback. I fully recognize the importance of differentiating the cost-effectiveness of low-cost and high-cost home modifications, as well as evaluating the feasibility and cost-effectiveness of smart home technologies compared to traditional modifications. However, due to the heterogeneity among the 20 included studies, a direct comparative analysis was not feasible. The outcome measurement methods, research objectives, and intervention designs varied significantly across studies, making a systematic cost-effectiveness comparison impractical. To address this limitation, I have explicitly discussed it in the Discussion section, explaining the challenges in conducting a cost comparison and emphasizing the need for standardized economic evaluation frameworks in future research. Additionally, I have highlighted the lack of research on the feasibility and cost-effectiveness of smart home technologies, underscoring the necessity of comparative studies with traditional home modifications.
To enhance clarity, I have revised the Discussion and Future Research Directions sections. In the Discussion, I have included the need for applying the Technology Acceptance Model (TAM) to assess usability, evaluate sensor-based fall prevention measures, and analyze the cost-effectiveness of IoT-based home modifications. In Future Research Directions, I have further elaborated on comparative studies between smart home technologies and conventional modifications, as well as the development of customized intervention models for diverse older adult populations. These revisions aim to clarify the study’s scope, transparently present its limitations, and refine the discussion on future research directions. I sincerely appreciate your insightful feedback, which has significantly contributed to strengthening the depth and focus of this study.
“Despite the growing recognition of smart home technology, research on its effectiveness and evaluation methodologies remains limited. Future studies should adopt systematic evaluation frameworks to assess its impact. The Technology Acceptance Model (TAM) can quantify user-friendliness, ease of use, and perceived usefulness of smart home systems [53]. Smart sensor-based fall prevention should be evaluated using objective metrics, such as fall incidence, severity, and emergency response time[58]. The cost-effectiveness and sustainability of IoT-based smart homes should be analyzed through installation costs, maintenance expenses, and long-term viability[59]. Lastly, user satisfaction and real-world impact should be assessed through surveys and in-depth interviews to provide qualitative insights[58]. By applying these systematic methodologies, future research can generate empirical evidence, advancing a clearer, more structured understanding of smart home technologies in supporting aging in place.”
- pp. 21, line 438-449
“5.3. Future Research Directions
Future research should focus on comparative studies between smart home technology and traditional home modifications to identify the most effective intervention strategies. To evaluate the effectiveness of smart home technologies, studies should employ the Technology Acceptance Model (TAM) to assess older adults’ technology adoption rates and utilize sensor-based data to analyze fall incidence rates and severity. Additionally, a comparative cost-effectiveness analysis between smart home technologies and conventional home modifications should assess economic feasibility, considering both initial installation costs and long-term maintenance expenses. Further research should develop customized home modification models for diverse older adult populations, including those with severe physical impairments, mild dementia, and economic disadvantages, to determine the most suitable interventions for each group.”
- pp. 24, line 597-608
[Comments 7]: The discussion section could better distinguish the findings from their interpretations to improve clarity. Some parts seem somewhat redundant between the discussion and results sections. The limitations section is underdeveloped. There is no explicit discussion of potential publication bias, study heterogeneity, or data limitations. The policy recommendations are vague and should specify which types of public funding models or policy frameworks would be most effective, given that this political aspect is one of the research objectives.
[Response 7]: To enhance the clarity of the discussion section, I have refined the structure to better distinguish research findings from their interpretations, ensuring a more logical flow. Redundant content that was already sufficiently covered in the Results section has been removed or streamlined to avoid repetition. The Limitations section has also been expanded to explicitly address publication bias, study heterogeneity, and data limitations, clarifying their potential impact on the interpretation of findings. This revision strengthens the study’s transparency and methodological rigor.
Additionally, the policy recommendations have been refined to provide more specific guidance. Instead of general suggestions, I have incorporated clear references to effective public funding models and policy frameworks, ensuring alignment with the study’s research objectives and practical implications. These revisions improve the coherence, depth, and policy relevance of the discussion, making the study’s contributions more explicit. I sincerely appreciate your insightful feedback, which has been instrumental in refining the overall structure and clarity of this section.
- pp. 20~24, line 371-619
[Comments 8]: A final review of the English language should be conducted, as there are some inaccuracies, and at times, sentences are too long.
[Response 8]: To enhance the accuracy and clarity of the English language used throughout the manuscript, I have conducted a thorough review and revision of all expressions. This process involved correcting grammatical errors, refining overly long or complex sentences, and ensuring that the writing is more concise and readable. Additionally, academic phrasing has been adjusted to improve the professionalism and logical flow of the paper. These revisions aim to enhance the clarity of the research, making it more accessible to readers while maintaining a high level of scholarly rigor. I sincerely appreciate your insightful feedback, which has been instrumental in improving the overall quality of the manuscript.
Author Response File: Author Response.pdf
Round 2
Reviewer 3 Report
Comments and Suggestions for AuthorsRevisions are completed at a satisfactory level for a review paper
