To achieve the aim of exploring the use and perceptions of mHealth applications among health care workers and patients, a qualitative study was conducted. Specifically, interviews were carried out to gather in-depth information from HCWs and patients using mHealth apps. The research took place in regions where hospitals feature cutting-edge facilities and currently use mHealth apps for patient management (Riyadh, Madinah, Mecca, Tabuk, Najran, Hall, Northern, Eastern, Al Jouf, Asir, Qassim, Jazan, and Al Baha). These apps are mainly categorized into 4 types: government apps, hospital, insurance, and private clinic apps [14]. Examples of these medical applications include Sehhaty, Qariboon, Health Volunteering, SFHP Riyadh, Tawuniya, Labayh, Al Mostajeeb, and Meena Health, which were introduced in the last 6 years. The Sehhaty app, also known as “My health,” is a robust digital health platform that offers personal health information and promotes knowledge about healthy lifestyles and public health. It was later used for booking COVID-19 vaccine appointments [17,18]. In terms of core functionalities, most of the mHealth apps are designed for general health, such as support or wellness, care delivery, and telemedicine services. Meanwhile, platforms such as Labayh emphasize health education and mental health consultations, addressing specific areas in the health care service delivery [14,17].

The study population and unit of analysis in this study encompass all the HCWs, users and nonusers, and developers of mHealth apps who fulfill the inclusion criteria.

The study used a nonprobability sampling method, specifically purposive sampling, to select participants. Eligible participants included HCWs from hospitals offering mHealth apps for patient management in the identified provinces, patients who are either currently using these apps or nonusers, and developers of these apps. We decided to recruit nonusers because they can equally provide important insights, particularly regarding the barriers to adoption of mHealth apps. mHealth app users are generally classified as either active or passive according to their present usage status. Active users are highly engaged and use the complete provisions in mHealth apps, whereas passive users use the apps occasionally and restrict themselves to a few features [19]. Additionally, participants needed to be aged 18 years or older and willing to give both oral and written consent to take part in the research. For qualitative research, sample sizes are not definite but are still required in selecting the study participants [20]. According to Leedy and Omrod [20], the sample size in qualitative research should range from 5 to 30. Therefore, our target was to recruit about 20‐30 respondents, depending on the attainment of data saturation. Multidimensional approaches, including emails and social media posts, were used to identify and invite participants in this study.

To ensure systematic and organized interviews, an interview guide was developed by the principal investigator (NA) and the supervisor team. Specifically, questions in the interview session were synthesized based on an in-depth review of previous literature and discussion between the researchers. Various studies using either interviews or focus group discussions were reviewed before selecting and modifying the topics, aligning with this study context [4,21-24].

Overall, 2 interview guide sections were developed: 1 for the users and nonusers of mHealth apps and 1 for the HCWs and app developers. For the latter, the questions were further divided to suit the HCWs and app developers. The first part contains their personal sociodemographic information. The second part contained specific open-ended questions on both HCWs’ and app developers’ perspectives regarding users’ awareness and understanding of mHealth apps. Meanwhile, HCWs were asked specific questions on their experience with the use of mHealth apps installed in patients’ personal devices, knowledge of patients’ health data security and privacy, benefits of mHealth apps to their patients, and potential issues that may prompt the patient to stop using the apps. App developers were probed on the security features that may increase the risk of data breaches and those that could be used to mitigate such risks. For the participating patients, similar questions were asked, except that the items were directed to them. The interview questions were presented in English and no translation to Arabic was performed.

Interviews were scheduled with the participants upon communicating with them via email or contact directories. Participants were provided with detailed information about the study and their rights, including the right to withdraw at any time without penalty. The interviews were conducted via videoconferencing platforms such as Zoom (Zoom Communications, Inc) or Google Meet, as preferred by the participants. Once the interview session commenced, participants were allowed to share their views on data privacy, confidentiality, and security issues relating to mHealth app usage. Interviews were audio-recorded, professionally transcribed, and checked for accuracy by another reviewer (NA). Data saturation was attained when no additional information was provided by the participant. It took approximately 25 minutes for each participant to complete the interview.

The ethical approval for this research was obtained from the Biomedical and Scientific Research Ethics Committee, University of Warwick (BSREC 03/22‐23) and the Medical Research & Ethics Committee, Ministry of Health in Saudi Arabia. The interview was designed to ensure that participants’ confidentiality was maintained throughout the research. Informed consent was obtained from all participants prior to the interviews. Videos were turned off during the interview, and only the audio was recorded. Thus, no identifying details were obtained from the participants during the research process. The researcher also stated the confidentiality of all information provided by the participants. Participants were informed that they could decide to withdraw from the study at any time without any penalty. No compensation or incentives were given to the participants. All collected data were stored on a personal computer with a secure password and were accessible only to authorized parties (the supervisory team and the researcher).

Data obtained from the interviews were analyzed using the NVivo software (version 12; QSR International)—a qualitative data analysis software used to organize, code, and identify themes from transcribed data. A thematic analysis was performed in which participants’ responses during the interview session were analyzed in-depth and checked for any interconnection. Some of the quotations were translated from Arabic to English because a few participants responded to some questions in Arabic despite being informed that the interview would be conducted in English. We also edited the quotations lightly for clarity while ensuring that the content is maintained. Transcription was performed by a research assistant who was not involved in the interview process.

An inductive approach was used to synthesize themes directly from the transcribed data by following the procedures described by Braun and Clarke [25], which is considered a robust systematic guide for thematic analysis. First, the data were scrutinized for familiarity, followed by coding systematically and synthesizing subthemes and themes. The generated themes were cross-checked with the participants’ verbatim statements, leading to the development of an initial thematic map. Next, the themes were refined and regrouped to address issues with some unsuitable codes and yield metathemes for more detailed grouping. Finally, the themes were defined and given a name. Thematic analysis was conducted by the first author (NA), and validation of the codes and themes was checked by the second author (MA). All other authors discussed the codes and themes, while discrepancies were addressed through consensus. All the experts and members of the research team discussed and agreed on the emerging themes and interrelated responses.

This study involved 25 participants, comprising HCWs (n=11), mHealth app developers (n=2), and users (n=12). As shown in Table 1, male participants accounted for more than two-thirds of the samples, but they were evenly distributed in terms of age groups. All the participants were married, employed, and with at least a university or higher educational qualification. All the HCWs and app developers were active users of mHealth apps. Although 3 of the 12 patients or users were passive users, they were all recruited from hospitals where they are currently seeking medical assistance. However, despite considering nonusers of mHealth apps in this study, none of the recruited participants was identified as a nonuser. Apart from HCWs and app developers, the remaining participants were patients visiting the selected hospitals in which mHealth apps are primarily used for clinician-patient communication.

The main themes synthesized from the qualitative study are the following: (1) discordant perspectives on the understanding and awareness of mHealth apps, (2) perspectives and awareness of security and privacy of mHealth apps, (3) perceived benefits of mHealth apps, (4) challenges experienced when using mHealth apps (technical difficulties, data security, and data breach), and (5) suggestions to improve the security of mHealth apps. Textbox 1 shows the theme and respective subthemes.

The first question assessed participants’ understanding and awareness of mHealth apps. Discordant perspectives were shared by respondents. Specifically, all HCWs and developers of mHealth apps demonstrated a good understanding and awareness, while patients demonstrated otherwise. Overall, HCWs depicted good mHealth app awareness and understanding while emphasizing that such a level of exposure was lacking among their patients. The main subthemes include factors influencing the usage of mHealth apps, poor awareness among users or patients, and the need for patient education. Some of the comments highlighting this theme are illustrated in the following quotations:

Most users who reflected a good understanding and awareness of mHealth apps emphasized the role of health care providers in data collection, using the garnered data for remote health monitoring, the positive impact of COVID-19 disease on increased usage of telehealth, and general information on the app operations and functionalities.

On the other hand, a few users opined that they were unsure of the reason and purpose for collecting their data. Examples of the responses reflecting users’ poor understanding and awareness of mHealth apps are presented as follows:

Pertinent information was gleaned regarding the challenges faced by health care professionals and patients while using mHealth apps. These barriers ranged from data security and privacy issues to data breaches and technical difficulties. Poor usability encompasses problems with navigation, understanding the features, and slow operation. These problems made some patients prefer visiting their doctors since the app was not effective in delivering mHealth services. These findings are captured in the following statement:

A similar scenario was highlighted by health care professionals, who claimed that the app could be misleading with usability, especially when notifications are delayed and during data updates. These challenges are also linked to the issues of violation of data privacy, incidents of data breach, and technical difficulties.

This study constitutes the first attempt to explore users’ perspectives on issues relating to the privacy and security of data collected via mHealth apps in Saudi Arabia. Besides, there is limited information on how these challenges may affect the adoption and utilization of digital health technologies. In this study, we focused on the users and nonusers of mHealth apps, as well as HCWs and app developers who constitute the predominant stakeholders of these advanced digital technologies in Saudi Arabia.

Regarding the awareness and understanding of mHealth apps, stakeholders in the health care sector, such as HCWs and app developers, demonstrated a good understanding of issues relating to data security and privacy, whereas users and patients were perceived to lack such knowledge. Moreover, patients also demonstrated a diverse understanding of mHealth apps, which aligns with several studies reporting users’ concerns about the security and privacy of sensitive data, including images of body parts and those revealing their identity [22,24,26]. A systematic review by Aljohani and Chandran [13] reported that the ease of access and operation of mHealth apps were among the reasons for hospitalized patients’ concerns about unauthorized access to their health data [13]. However, some patients were not worried about these issues either because of their confidence in data safety and features to prevent data breaches, or they were completely unaware of the potential risks involved. This constitutes an important finding, given that most users in this study were highly educated, indicating possible disturbing levels of ignorance and awareness among medium to noneducated users in the general public. Users who are unaware of data privacy and security features and provisions in mHealth apps may be unable to differentiate between risky behaviors, depending on the type of private data collected by various technologies [27].

On the contrary, the understanding and awareness shown by HCWs are expected since they are more conversant with mHealth apps. They are also more exposed and educated, thereby increasing their perception of the risks and benefits associated with digital health technologies. In order to address the low awareness level among patients, most HCWs suggested the need for patient education and enlightening them on pertinent areas. Numerous studies have taken the same stand by emphasizing brief training or education on data security and assuring data confidentiality and privacy [27-29]. Both Nurgalieva et al [30] and Lewis and Wyatt [31] recommended that patients should be trained and educated to address the external risk factors associated with the violation of users’ privacy and security in mHealth apps.

All the groups of participants in this study provided insights into measures to improve the privacy and security of data used in mHealth apps. Examples include features to improve data security and remote monitoring, making the app more user-friendly and tailored toward the patients’ needs, and providing online consultation for emergencies. Specific security features such as 2-step verification and authentication, as well as the use of thumbprints and strong password requirements, were mentioned by health care professionals and end users. In the same vein, Alwashmi et al [32] opined for the use of an alphanumeric passcode to ensure the protection of mHealth apps rather than using a 4-digit pin, as well as wiping data from the mobile device after a specific number of failed passcode attempts. Nurgalieva et al [30] also emphasized the frequency of notifications and alerts programmed into mHealth apps.

As observed in this study, participants recommended sending notifications to both the health care provider and the patient to ensure extensive review of login attempts or data sharing. A discreet or private notification was advised to prevent any distress to users, particularly in situations where someone mistakenly views the icon. Overall, these recommendations reecho the need for users to have complete control in using their smartphone for mHealth and avoid any intrusion into their daily lives. This event coincides with the personalization and tailoring of newly added features according to patient needs, as mentioned by some respondents. Certain adjustments to the security and privacy features of mHealth apps need to be incorporated by the app developers upon considering patients’ and users’ demographics, as evident in previous studies [4]. However, given the low number of studies reporting the underlying factors influencing patients’ views on data privacy, confidentiality, and security issues in mHealth apps, more research is needed to elucidate the relationships.

Another key recommendation, especially by users, was the need for real-time online consultations for emergency cases. This suggestion stems from the challenges faced in navigating through mHealth apps, which may be time-consuming and ineffective for health care service delivery. Therefore, a specific platform on mHealth apps to facilitate easy and prompt communication with the health care provider’s emergency unit was advocated. Such an intervention will come with several benefits and challenges, particularly in terms of educating users. Regarding the benefits and experience garnered from using mHealth apps, participants mentioned diverse ways in which they have benefited from mHealth apps. It is well established that mHealth apps offer several advantages and benefits, especially during and in the post–COVID-19 era. The subthemes included patient autonomy, remote monitoring, self-care management and medical adherence, and time and cost-saving.

Patient autonomy refers to equipping patients or users, as the case may be, with substantial control of their data. Several users and health care professionals highlighted this view either by using personalization of patient data or by giving them unlimited access. On the other hand, remote monitoring entails online interaction and examination between patients and health care professionals. Consequently, patients were motivated to engage in self-care management and medication adherence, ranging from assessing physical parameters to restricting diet. These events contributed significantly to efficient disease progress monitoring, good communication between patients and health care professionals, and better patient outcomes. Our results corroborate the reports from previous studies, whereby improved health status [33] and better patient-health care professional relationships [34,35] were stated as the main benefits of using mHealth apps.

In terms of participants’ experiences with mHealth, although encouraging comments were highlighted by several users, important barriers were mentioned that require further discussion. These barriers ranged from poor usability to data security and privacy issues, data breaches, and technical difficulties. Concerns about data privacy and confidentiality may discourage patients and end users from using mHealth apps [35]. Likewise, the low levels of privacy and security of patient data contributed significantly to the low adoption rate among the intended users [13]. Past reviews also reported security incidents associated with mHealth apps, such as vulnerabilities to data breaches and malware attacks. The concerns raised by the participants are plausible based on the extensive usage of mobile devices with location sensors in Saudi Arabia, which has facilitated easy access to location-based services [33]. Given the extensive privacy and security issues raised by the stakeholders in this study, cyberspace security can be further explored to improve the security of mHealth environments [4].

Surprisingly, the challenges faced appeared not to deter participants from using the technology, as all the respondents who shared their concerns were active users of mHealth apps. A recent study conducted among mature adults also shared a similar view, as none of the participants stopped using the technology despite their data privacy concerns [27]. This aligns with the widely discussed privacy paradox [36], whereby people engage with technology even when they acknowledge its potential privacy loss issues. Research involving social media, e-commerce, and mobile apps has also demonstrated this phenomenon [37,38]. This paradoxical behavior is likely driven by users’ perception that the immediate benefits of using mHealth apps outweigh their potential or hypothetical risks [27].

This study represents the first attempt to qualitatively explore patients’ and stakeholders’ perspectives regarding the privacy and security of data collected via mHealth apps in Saudi Arabia. Our findings offer insights on possible strategies to improve end users’ and patients’ adoption of mHealth apps and addressing concerns relating to data privacy and security. In terms of sampling, purposive sampling was used to recruit participants with diverse backgrounds (age, gender, app experience, and multiple hospitals). This approach aligns with qualitative research goals of capturing variation and depth. Moreover, qualitative studies are not designed to achieve representativeness or collect data from a representative sample.

Nevertheless, this study has several limitations that need to be acknowledged and considered when extrapolating the findings. We developed the interview guide and conducted the interviews in English, and only a slight translation was performed during the data transcription. Based on this criterion, most of the respondents were highly educated. As for the HCWs and app developers, this procedure is unlikely to introduce a selection bias since these professionals are expected to hold a higher educational level. However, most users and patients also had at least a university degree, indicating that their views on mHealth and privacy may not be representative of the general Saudi population. Nevertheless, it is interesting to note that several users were still unaware and had a limited understanding of privacy and security of mHealth apps—possibly reflecting a more serious problem in the general population.

Despite our plan to include nonusers in the study, all the participants were either active or passive users of mHealth apps. The patients recruited were from hospitals in which mHealth apps are actively used for consultation and follow-up, making it difficult to identify those who are yet to adopt these digital health apps. Therefore, our findings present limited perspectives on barriers among nonusers. This limitation narrows the study scope and insights. Future studies may consider recruiting nonusers of mHealth apps from the Saudi community or hospitals where patients are not compelled to use such apps.

Our interview guide was limited in terms of exploring security issues, which led to the superficial technical aspects raised by the app developers and HCWs. While patients were less aware of these technical aspects, as evidenced from the interviews, app developers and HCWs occasionally mentioned the need for more comprehensive access controls, whereas other critical aspects, such as data storage, encryption, and server-side protection, did not emerge from their responses. Apart from the limited questions that may trigger deeper insights into security-related issues, only 2 app developers were recruited, and HCWs may have limited technical awareness while focusing on health-related data and care delivery when using mHealth apps. Future studies may bridge this research gap by recruiting a larger number of stakeholders comprising HCWs and app developers who are technologically savvy for a nuanced understanding of technical and security issues associated with these digital health technologies.

The results from this study have important implications for mHealth app stakeholders in Saudi Arabia. Both HCWs and developers of mHealth apps have vital roles in addressing the challenges identified in this study, particularly issues relating to data privacy, confidentiality, and security that may affect the adoption and usage of digital health technologies.

Since HCWs acknowledge patients’ low awareness and understanding of mHealth apps and the data collected in the process, they can assist by educating patients to address such knowledge deficits. Patients could be briefed during routine consultations by highlighting the need for recording sensitive data and the purpose of collecting such information. Regarding unauthorized third-party access and potential data breaches, users may benefit from information on the privacy requirements and meeting the standards set by the GDPR and HIPAA, which are designed to ensure that such privacy issues and data breaches are prevented.

Another important aspect is training and educating end users on the existing features and measures to ensure that their data remain secure and confidential. Nevertheless, educational interventions need to be effectively tailored toward the user’s level of awareness and understanding. As evident from this study, users’ less concern about their data privacy and security may arise from being completely ignorant of these potential challenges, or they may perceive that the benefits of using mHealth outweigh the potential risks.

mHealth app developers can also benefit from the research findings, as the concerns raised by patients and end users may culminate in low adoption and usage of mHealth apps [18]. While users are expected to express concerns regarding data privacy and security, it remains unclear whether such concerns influence their behavior and actual use of such apps. This gray area needs more understanding and research. mHealth app developers, particularly in Saudi Arabia, have the opportunity to digest the issues raised by users and strategize on how to improve their current security and privacy measures. Such strategies should be designed and implemented to meet the requirements of HIPAA.

Finally, policymakers can use the research findings in identifying the areas to focus on when developing policies and strategies to facilitate the wide adoption of mHealth apps and achieve the desired outcomes. Accordingly, policymakers can emphasize features to enhance better patient–health care professional relationships, trust, and personal data protection and ensure that health status or medical conditions are not disclosed, as well as brief training or education on data security. Although these points can be relayed to users, trust is a feature that has to be earned, which has to be driven by HCWs and the government.