## 4 Discussion  
We developed a system to help COPD patients better manage indoor air quality from a user-centered design perspective. We adopted SARs considering the preference and acceptability among elderly patients. The system measures indoor air quality in real time using sensors and provides notifications about air quality through the SAR, along with contextual improvement measures. This approach creates a user experience where patients are encouraged to actively participate in their healthcare and receive feedback through the SAR. We examined whether SARs, which were created for the purpose of interacting with people, can be applied to medical purposes--specifically, self-health management. Rather than an authoritarian self-management of health based on a doctor's prescriptions or instructions, a strategy that empowers people to choose their own health behaviors is considered effective. Our research questions aimed to ascertain whether older COPD patients could comprehend information from the SAR and whether they would adhere to the notifications. We explored the features associated with IAQ enhancement using two separate analytical approaches. Analyzing the 'daily trend of air quality alert occurrences per hour', we noted a significant decrease in 'poor alerts' with a strong linear trend, while 'good alerts' remained unchanged over time. This implies that SAR notifications foster a learning effect among COPD patients. Furthermore, machine learning prediction results indicated the predictability of air quality improvement following alerts. The shift from 'poor' to 'good' air quality 30 min after notification suggests that COPD patients likely took appropriate measures to enhance air quality. Both findings suggest that consistent air quality alerts can incentivize patients to enhance their skills in maintaining IAQ. Moreover, through interviews with patients using the SAR, we confirmed that long-term educational effects can be expected. Patients reported that through repeated alarms, they learned in which situations the 'bad' alarms were triggered, how to respond to these alarms, and how to prevent 'bad' alarms from occurring, all through the guidance provided by the SAR. Therefore, future research should include a larger number of patients and a wider range of guidance to study the long-term effects of air quality changes. We observed psychological barriers to SAR acceptance among older adults. Participants withdrew from the study for various reasons, including 'do not like its shape (doll)', 'too talkative and noisy', 'no time to use it', 'can't hear well what it says', and 'do not like what it says'. Among COPD patients, the proportion of men (gender difference) is high, and all the patients of this study were male. Some elderly male patients tended to feel ashamed of receiving help through the SAR, regardless of its actual skills, because it took the form of a doll. In such cases, the purpose of the intervention in this study was not reached by participants giving up participation or simply turning off the power to the SAR and storing it. [PERSON] (2023) elucidates this phenomenon, noting that what matters is not just the robot's physical appearance but also how its human-like features and social identity fit into the larger social context [57]. In other words, elderly male patients do not merely dislike the appearance of socially assistive robots (SARs); they perceive SARs as appropriate for elderly, seriously ill patients based on social norms, and thus, they do not consider themselves suitable candidates for using SARs. Additionally, some participants encountered difficulties in operating the SAR, such as connecting power or adjusting volume. On the back of the care robot, there is a control panel with a charging port, power switch, and volume switch protruding. When our research team first installed the SAR, we taught elderly patients how to use it and also distributed instructions on how to operate it.