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Smartphone apps are increasingly being used to aid in hypertension self-management, and a large and ever-growing number of self-management apps have been commercially released. However, very few of these are potentially effective and secure, and researchers have yet to establish the suitability of specific hypertension apps to particular contexts.
The aim of this study is to identify the most suitable hypertension app in the context of Saudi Arabia and its health system.
This study used a 2-stage approach to selecting the most suitable app for hypertension self-management. First, a systematic selection approach was followed to identify a shortlist of the most suitable apps according to the criteria of potential effectiveness, theoretical underpinning, and privacy and security. Second, an exploratory qualitative study was conducted to select the most suitable from the shortlist: 12 doctors were interviewed, and 22 patients participated in 4 focus groups. These explored participants’ attitudes towards self-management apps in general, and their views towards the apps identified via the systematic selection process. The qualitative data were analyzed using framework analysis.
In the first stage, only 5 apps were found to be potentially effective while also having a theoretical underpinning and protecting users’ data. In the second stage, both doctors and patients were generally interested in using hypertension apps, but most had no experience with these apps due to a lack of awareness of their availability and suitability. Patients and doctors liked apps that combine intuitive interfaces with a pleasant and clear visual design, in-depth features (eg, color-coded feedback accompanied with textual explanations), activity-specific reminders, and educational content regarding hypertension and potential complications. When the pros and cons of the 5 apps were discussed, 3 apps were identified as being more suitable, with Cora Health rated the highest by the participants.
Only 5 apps were deemed potentially effective and secure. Patients’ and doctors’ discussions of the pros and cons of these 5 apps revealed that 3 out of the 5 are clearly more suitable, with the Cora Health app being judged most suitable overall.
Hypertension is one of the most common chronic diseases in adults, affecting 1 billion people worldwide and causing serious health complications, including stroke, heart disease, and renal failure [
Smartphone use has expanded in recent years, including in Saudi Arabia, where there were 21.8 million smartphone users in 2018. This has resulted in increased access to health apps, which have the potential to assist patients’ self-management, for example, by providing educational information and self-monitoring tools [
Alessa et al [
Although acceptance of an app positively influences its successful use in self-management [
The aim of this study is thus to distinguish those hypertension self-management apps that are effective, secure, and underpinned by sound theory, and to identify the most suitable apps for the Saudi context by exploring their acceptance among Saudi doctors and patients. This study will offer a clear approach to selecting effective, secure, and acceptable apps among the many available on commercial app stores.
This study consists of 2 stages. The first adopted a systematic approach using criteria of potential effectiveness, privacy and security, and theoretical underpinning to identify potentially effective and secure apps. The second stage consisted of a qualitative study assessing doctor and patient attitudes toward and acceptance of apps that meet these criteria.
Alessa et al [
Privacy and security were assessed based on the Online Trust Alliance [
An exploratory qualitative study was conducted to explore participants’ experiences of self-management of hypertension, their attitudes toward self-management apps in general, and their views toward the apps identified via the selection process. This was done via patient focus groups and interviews with doctors. Participants were asked to watch videos providing standardized information about each app and were then asked for their opinions and to rate each app on a 1-to-5 scale (see
The qualitative study was conducted in Riyadh, Saudi Arabia. Convenience sampling was used to recruit doctors and patients [
To be eligible, focus group participants had to be 18 years or older, have hypertension as a primary disease for a minimum of 6 months, and be able to speak and give consent. Exclusion criteria were having a cognitive impairment or pregnancy. The eligibility criterion for doctors was having treated patients with hypertension for a minimum of 6 months. Interested participants were sent an information sheet and consent form. The interview and focus groups were conducted by the researcher (TA) in Arabic, which is the native language of participants and the researcher. The transcripts were translated into English by TA and then back translated into Arabic by a professional translation service to ensure accuracy.
Descriptive statistics were compiled from relevant quantitative data. All qualitative interviews were recorded, transcribed, and then checked for accuracy against the audio files before being translated. Framework analysis was used to analyze the transcripts using NVivo 12 software (QSR International). Framework analysis consists of 5 stages: (1) familiarization, (2) identifying a theoretical framework, (3) indexing, (4) charting, and (5) mapping [
The analysis framework had 2 parts. The first part concerned participants’ attitudes toward self-management apps in general. The second part of the framework examined participants’ attitudes toward 5 specific apps. The a priori themes and subthemes were confirmed by discussion among the study researchers and summarized. Transcripts were indexed according to these themes and subthemes by TA. If emergent themes and subthemes were identified, TA would add them and recheck the other transcripts for this new theme. The final themes and subthemes were agreed upon through regular discussion between all of the study authors.
Twenty-two apps were excluded because they did not have an available privacy policy (n=10) or because they insufficiently protected users’ data (n=12).
Of the remaining 8 apps, 3 were duplicates, meaning they were identical versions of the app available for both Android and iPhone platforms. ESH Care (ESH) was also a duplicate, but the Android version had previously been excluded. Only one version of each of the apps was considered, leaving a total of 5 unique apps: Cora Health (Cora), ESH, LifeCourseHyTen (Hyten), Qardio, and Braun Healthy Heart (Braun).
Privacy, security, and theoretical underpinning of the 30 potentially effective apps.
Number | App name | Version type | TDFa mechanisms of action, n | Privacy and securityb |
1 | Blood pressure-Smart BPc | iPhone | 7 | No |
2 | Fast BP | iPhone | 6 | No |
3 | BP Wiz | iPhone | 6 | No |
4 | Blood pressure and plus diary | iPhone | 7 | No |
5 | BP Grapher simpler | iPhone | 7 | No |
6 | BP matters | 5 | No | |
7 | Braun Healthy Heart | iPhone | 7 | Yes |
8 | Braun Healthy Heart | Android | 7 | Yes |
9 | Qardio | iPhone | 5 | Yes |
10 | Qardio | Android | 5 | Yes |
11 | Blood Pressure (My Heart) | Android | 7 | No |
12 | Blood Pressure Diary | Android | 5 | No |
13 | Homedic | iPhone | 7 | No |
14 | Hemie | iPhone | 4 | No |
15 | LifeCourse HyTen | iPhone | 5 | Yes |
16 | LifeCourse HyTen | Android | 5 | Yes |
17 | Goal Achiever | Android | 7 | No |
18 | Cardio Journal – Blood Pressure diary | Android | 6 | No |
19 | Control tension | iPhone | 6 | No |
20 | Control tension | Android | 6 | No |
21 | ESH Care | iPhone | 7 | Yes |
22 | ESH Care | Android | 7 | |
23 | Paracelsus (Pressure control) | Android | 7 | No |
24 | Blood Pressure Companion | iPhone | 7 | No |
25 | Cora Health | iPhone | 9 | Yes |
26 | HeartStar | iPhone | 7 | No |
27 | Kang BP | iPhone | 6 | No |
28 | BP Diary | Android | 7 | No |
29 | BP Diary | iPhone | 7 | No |
30 | Bprsseo pro | Android | 7 | No |
aTDF: Theoretical Domains Framework.
bApps that meet the criteria for data gathering, sharing, and security have “Yes” indicated, and those that do not have “No” indicated.
cBP: blood pressure.
Twenty-two patients attended four focus groups, with five to six participants in each group. Twelve doctors were interviewed. The participant characteristics are displayed in
Characteristics of the patient's sample (N=22).
Characteristic | Value | |
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50 (33-74) | |
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18-30, n (%) | 0 (0) |
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31-40, n (%) | 4 (18) |
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41-50, n (%) | 6 (28) |
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51-60, n (%) | 8 (36) |
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>61, n (%) | 4 (18) |
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Males | 13 (59) |
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Females | 9 (41) |
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<1 | 4 (18) |
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1-3 | 6 (27) |
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>3 | 12 (55) |
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Less than high school diploma, n (%) | 3 (14) |
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High school diploma | 5 (23) |
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Bachelor’s degree | 8 (36) |
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Master’s degree | 4 (18) |
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Doctorate | 2 (9) |
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Yes | 20 (90) |
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No | 2 (10) |
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iPhone | 15 (75) |
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Android | 5 (25) |
Characteristics of interviewed doctors (N=12).
Characteristics | Value | |
Age (years), mean (range) | 40 (28-57) | |
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Males | 4 (33) |
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Females | 8 (67) |
Work experience with hypertension (years), n (%) | 15.8 (4-39) | |
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Resident doctor | 2 (17) |
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Specialist doctor | 6 (50) |
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Consultant doctor | 4 (33) |
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Yes | 12 (100) |
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No | 0 (0) |
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iPhone | 7 (58) |
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Android | 5 (42) |
Identified themes and subthemes via framework analysis.
Theme and subthemes | Topics | |
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Adherence to self-monitoring BPb, taking required action, adherence to taking medication, adherence to lifestyle, and managing stress |
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Lack of knowledge, busy life, lack of motivation, forgetting, acceptance of disease, asymptomatic patients affecting lack of patient initiative, beliefs about medication, and fear caused by high BP |
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Role of doctors | Education about and encouragement of self-management strategies |
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Current patient knowledge and required information |
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Patients’ experiences in using general apps and HTNc apps, and doctors’ experiences in using health apps or recommending HTN apps |
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Expected useful features of smartphone apps | Self-monitoring and reminders, educational information, and feedback |
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Demographic factors including age, education, and ITd literacy; app usability, app’s language, and doctor support |
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Concerns about using health apps for self-management | Credibility and accuracy, company intentions, patient commitment in using the app, and app usability |
aItalics indicate a priori themes.
bBP: blood pressure.
cHTN: hypertension.
dIT: internet technology.
The majority of doctors noted that most patients take their medication frequently, but some fail to monitor and record their BP. Most patients reported that they tried to monitor their BP and take medication regularly, and tried to stay healthy through diet, exercise, and managing stress. Patients and doctors acknowledged the role of doctors in encouraging patients to effectively self-manage their condition, for example, by setting strategies and goals together, and encouraging patients’ adherence to these.
Several barriers to patients’ involvement in self-management were mentioned. Doctors identified lack of patient initiative, acceptance of the disease, and inaccurate negative beliefs about medication as the most common barriers. However, patients reported barriers such as relying on impractical tools to record data, lack of knowledge relating to hypertension management, lack of motivation, forgetting, busy lifestyle, social pressures, and lack of exercise opportunities.
Doctors and patients believed that lack of patient knowledge negatively affected self-management. Doctors also expressed concern about patients accessing inappropriate or incorrect information. Doctors felt that younger patients and more educated patients tended to be better informed but would not necessarily take greater responsibility for their own health due to a lack of determination or concern.
Most doctors reported having experience of using health apps themselves. Patients had experience of using apps for nonmedical purposes (eg, entertainment, socializing) but only 1 patient had ever used a hypertension self-management app before. The other patients were unaware of their availability or suitability. Doctors also had never recommended health apps to their patients. However, the data showed that participants were generally interested in using hypertension apps to support self-management and expected that these would have useful features, such as self-monitoring of BP.
Among doctors, users’ ages and educational levels were considered the most influential factor affecting use of hypertension apps, whereas for patients, the most important factors were app language and usability.
Doctors expressed concerns about the credibility and accuracy of the apps, and doubt about their continued availability. They felt that they would be more willing to recommend apps that had been scientifically tested, were based on practice guidelines, or had been checked by doctors.
A final framework developed to evaluate 5 apps after completing the analysis process.
Theme and subthemes | Topics | ||
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Accuracy and method of data inputting, and type of data collected | |
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Presentation of feedback and accuracy of feedback | |
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N/Ab | |
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Level of details and type of information (information topics) | |
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Social Support | Communication with others | |
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Content credibility | Credibility | |
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App design, layout, and navigation | |
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Type and intensity of training required | |
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Factors affecting uptake and usage | Demographic factors including, age, education, and ITc literacy; app feature; language; price; privacy; and ads and promotion | |
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Rating and recommendation | App rating, doctors’ willingness to recommend apps, doctors’ estimated uptake, patients’ willingness to use and recommend apps, general recommendations | |
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Expected risks of inappropriate content | Difficulties, including stress, anxiety, and confusion; and decreased app use and poor self-management | |
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Support patients’ self-management | Controlled BPd, empowered self-management, improved compliance and knowledge, and supportive doctors |
aItalics indicate a priori themes.
bN/A: not applicable.
cIT: internet technology.
dBP: blood pressure.
Most doctors and patients liked the 5 apps’ method of presenting data in different formats, such as in graphs and tables. The data showed a preference for apps with high-quality graphs (Cora and ESH care), for feedback that used color coding and supplementary text (Cora), and for the automatic calculation of BMI (Qardio and ESH) or BP average (Qardio, ESH, and Cora). Doctors thought that the feedback of all of the apps could be improved if it offered the feature of setting goals (eg, for BP) that was tailored to patients’ circumstances and demographic.
Participants liked the reminder feature for self-management activities in all 5 apps. Both doctors and patients preferred apps, like Cora, that provide reminders for different tasks (eg, self-monitoring of BP) over apps that provide only a reminder for medication (ESH and Hyten) or a generic reminder for a nonspecified task (Braun and Qardio). A few doctors liked apps that allowed reminders for different medications and doses (ESH and Hyten).
Participants found Qardio’s lack of educational information unhelpful. Opinions varied as to the usefulness of information offered by the other apps. Doctors generally criticized apps, like Braun and ESH, that lacked any information about medication and side effects, but also felt that detailed information about side effects of medication (Hyten) might be off-putting for patients. Participants thought that apps (eg, Cora) that have information about hypertension in general, as well as data on hypertension risks, BP readings, and how to measure BP, would benefit patients.
Participants favored apps that collected detailed information that had easy and clear methods of data entry. They preferred apps that collect other data in addition to BP, such as exercise (Cora and Braun). They felt that some apps are not detailed enough to capture all relevant information (eg, entering the type of exercise) and found the way of entering data in some apps to be more difficult than that in others (Braun), not well organized (Hyten), or likely to lead to typo mistakes (ESH).
Patients had mixed opinions about the social support feature. Some found it useful while others found it unhelpful or unnecessary, given the increased access to social media platforms. Doctors felt that the credibility of educational information should be ensured, either by assessing if the information was based on medical guidelines or by having apps reviewed by other doctors or medical companies. One doctor suggested that profit-motivated app development may not lead to the best quality information being included.
Participants preferred interface designs with easy and clear layouts, where features of the app are easy to reach (eg, with app functions visible in the main menu like in Cora and ESH) rather than embedded in other functions (Qardio and Braun Health).
The muted color schemes of Hyten, Cora, and ESH were considered more user-friendly than were those with strong, bright colors (Braun).
Most doctors and patients thought that some level of training would be required for all 5 apps although they disagreed over the length and intensity that would be needed.
Participants expressed several possible benefits of using these apps. They thought that reminders and monitoring would help to increase their engagement and that educational information could help to increase their awareness of their condition. However, some doctors were concerned that apps with too few functions (eg, Qardio and ESH) may lead to patients becoming bored, or, conversely, that too much detail (Hyten) or a poor layout (Hyten and Braun) would confuse patients.
The doctors’ and patients' full rankings for all of the 5 apps, which was calculated by aggregating each group’s 1-5 ratings. Cora was ranked highest by both doctors (total 51, mean 4.25) and patients (total 97.5, mean 4.4). Hyten was second among doctors (total 43, mean 3.5), while ESH was second among patients (total 85.5, mean 3.6). ESH was third among doctors (total 41.5, mean 3.4), while Hyten was third among patients (total 80, mean 3.8). Qardio and Braun were ranked lowest by patients (total 64, mean 2.9) and doctors (total 30, mean 2.5), respectively.
Doctors and patients made some recommendations for improvements of app features and content. Cora received the fewest suggestions. Some of the recommendations were common for all 5 apps, such as for the tracking of hospital appointments and other medical conditions. The suggestions are presented in full in
Doctors and patients identified different factors that may affect the use of the 5 apps. Age was a factor mentioned by several doctors who felt that 2 apps (Cora and Hyten) in particular may pose difficulties to older users. Some doctors stressed the importance of official endorsement by, for instance, the Ministry of Health, or public health campaigns to encourage patient uptake. Inexperience with smartphone technology was seen as another major potential barrier. Participants also mentioned the unavailability of apps in users’ own language. Most patients did not express concern with privacy of the apps, but this was mentioned by doctors, particularly concerning high-profile individuals. Patients also expressed concern over app prices and the payment methods that might be required.
This study aimed to identify the most suitable hypertension app in the context of Saudi Arabia and its health system using a 2-stage approach: a systematic selection approach that assessed apps according to the criteria of potential effectiveness, theoretical underpinning, and privacy and security; and an exploratory qualitative study involving 12 doctors and 22 patients. The first stage found that only very few apps were deemed potentially effective and secure. The second stage showed that doctors and patients were generally interested in using hypertension apps. Their discussions of these 5 apps’ pros and cons revealed that 3 out of the 5 are clearly more suitable, with Cora being judged the most suitable overall.
The selection approach found that of the 30 apps previously identified as potentially effective [
The qualitative study found that both doctors and patients were interested in using hypertension apps but that most had never used these apps or been recommended them, due to a lack of awareness of their availability and suitability. This is in line with previous research, including that of Morrissey et al [
Morrissey et al [
When the pros and cons of the 5 apps were assessed, 3 apps were identified as being more suitable, with Cora rated the highest in participants’ ratings. Patients and doctors liked these apps because they combine intuitive interfaces with pleasant and clear visual design, in-depth features (eg, color-coded feedback accompanied with textual explanations), activity-specific reminders, and educational content regarding hypertension and potential complications. Apps are more likely to be used and accepted if they include key components, such as pleasing visuals and the facility to personalize, and if they offer other broader functions, such as education [
Doctors and patients expressed somewhat different concerns in identifying the most suitable apps, with doctors generally being more concerned with medical accuracy and patients being generally more concerned with usability, interface, and visual design elements. This is similar to the findings of previous research revealing that doctors and patients often showed somewhat different priorities or preferences regarding mHealth apps even if they agreed to some extent on which is the best overall [
The self-management strategies identified in this present study were largely in line with those identified by Barlow et al [
Previous research has shown that despite the many advantages of using apps in supporting self-management, certain concerns regarding their use persist, such as the accessibility and usability of the app and the effectiveness of these tools [
Previous research has found that doctors are in general less positive than are patients regarding the use of mHealth apps [
The main strength of this paper lies in its development of a rigorous selection approach to identify the most suitable hypertension app(s), which has the potential to be transferred to apps targeting other conditions and in different contexts. There may be some limitations regarding the generalizability of these results. The study used a self-selecting sample of patients. Those who are more interested in and therefore probably more competent with smartphone technology might have been more likely to volunteer, and this might have impacted the results. A number of the patient participants had some preexisting medical knowledge, which may make the findings less generalizable. The number of older participants in the study sample was relatively low, which may further impact the generalizability, especially since the majority of those with hypertension are older people. The selection approach focused on privacy, security, and theoretical underpinning because these criteria were considered as the most important in implementing and using interventions in the health care field. We did not consider other issues such as engagement due to the lack of available information about them. Finally, because none of the identified apps were available in Arabic, standardized video presentations were used to demonstrate how the apps worked, but this might have created a biased presentation of the apps’ functionalities.
This study found that only 5 apps out of 30 could be deemed potentially effective and secure. It was also found that participants were favorable toward the idea of using health apps to aid in the self-management of hypertension. Through patients’ and doctors’ discussions of their pros and cons, 3 apps were identified as more suitable than the others, with the Cora Health app being the most suitable overall. In a next step, this app should be evaluated for its usability and effectiveness.
Interview topic guide.
Focus group topic guide.
Qualitative data.
App preference.
behavior change technique
blood pressure
Braun Healthy Heart
Cora Health
ESH Care
LifeCourseHyTen
mobile health
The authors thank all participants for their significant contributions. TA is an Assistant Professor at King Saud University, which provided funding for this study.
None declared.