In the past years, technological advances, including web-based monitoring systems and mobile phone applications (apps), have changed the consumers' ways of accessing healthcare and enabled the use of digital mechanisms for health monitoring and self-care (1). In terms of legal and public policy considerations, E-health (electronic health) has become important (2, 3).

Mobile health (m-health) interventions, such as mobile health apps (MHAs), have become a fast-growing, assistive technological (AT) form of help in wellness monitoring, the prevention and/or management of diseases, and the improvement of health outcomes, as well as with the therapeutic management of chronic illnesses through the involvement of healthcare and active self-management (4, 5). As mentioned in the digital marketing strategy (2012–2020) by the European Commission, e-health plays a crucial role. It states, “When e-health is applied effectively, it delivers more ‘person-centered' healthcare, which is more targeted, effective, and efficient and helps reduce errors, as well as hospitalization length. It facilitates socio-economic inclusion and equality, quality of life and patient empowerment through greater transparency, access to services and information, and the use of social media for health” (2, 3).

Saudi Arabia (SA) is estimated to have 19.4 million smartphone users (6). Mobile (apps) on the two leading platforms, iOS and Android, have become prevalent (7). Medical apps are defined as any software app that is created for medical or other health-related purposes and is used on a mobile device. There are 32,104 healthcare apps available (8), and their use by patients and clinicians has grown dramatically.

In 2005, the World Health Organization (WHO) adopted decision number 28, urging the ratification of e-health as a way to strengthen health systems. The E-Health Initiative is one of forty initiatives under the Saudi National Transition 2020 program. Its goal is to improve the efficiency and effectiveness of healthcare through the adoption of information technology and digital transformation in order to provide SA citizens with standardized digital medical records by 2020 (9). The Sehha app developed by the Saudi Ministry of Health (SMOH) was introduced in 2018 to offer a fast and efficient means of direct consultation with medical experts, regardless of time or place (10).

MHAs potentially promote the self-management of many diseases in daily life. However, adoption of these apps is still limited, and the knowledge about MHAs' efficient utilization in regards to facilitators and barriers is small. Researchers can use mobile apps to discover new enabling, engaging, and empowering methods to help patients interact, access, record events, and engage in the provided care (11).

Therefore, our study is aimed at optimizing the use of MHAs in delivering effective healthcare services through the following objectives among adult inhabitants of Saudi Arabia during February 2020. The goal is to determine the prevalence of MHAs' usage, explore the context of using MHAs (numbers, types, benefits, advantages, and barriers), and study the determinants of MHAs (the relationship between the use of MHAs and demographic characteristics).

This study was conducted to determine the prevalence, context, and determinants of MHAs' usage among 679 participants in SA, who fulfilled the selection criteria. The majority of the participants (74.1%) were females, Saudis (94.7%), had received University or higher education (72.8%), were married (36.4%), employed (42.7%), and had no comorbidity (56.7%).

The current study reported that the prevalence of MHAs' usage was 325 (47.9%) among the studied participants, which was higher than that reported by Bhuvan et al. in a survey that found that the penetration of MHAs was 351 (34.6%) among 1,014 Egyptian patients (17).

The usage of MHAs was significantly higher among participants who were younger, Saudis, had received University education or a higher level of education, were working, or had a chronic disease (p < 0.05). Higher, non-significant odds were among those aged 20 to <30 years, Saudis, had received University and postgraduate education, and had chronic diseases (OR = 1.021, 0.480, 3.014, 3.372, and 1.268, respectively). Bol.et al. observed almost comparable results, showing that most MHA users were either younger (OR = 0.97; % CI: 0.96–0.98) or highly educated (OR = 1.12; % CI: 1.01–1.24) than non-users among Dutch populations (18). Nunes et al. discovered that age is a significant predictor of acceptance of information and communication technologies (19). This could be explained by the high e-health literacy level among younger, more educated adults who are technology-savvy.

There was no statistically significant relationship between MHA users and non-users regarding sex, as similar results were reported among a large sample of the Dutch population (OR = 1.25; 95% CI: 0.94–1.66) (18). In contrast to the current results, Xie et al. revealed that females were significantly more likely to use health apps than men, particularly with health and medical reminder apps (20). This is because there are gender differences in attitudes toward healthy living. For instance, women care more about healthy living, healthy eating, and being better adherents to public health recommendations for exercise, tobacco and alcohol consumption, and healthy diets when compared to men. In addition, motherhood might be one reason for using more health apps related to pregnancy, postnatal recovery, and baby care, when compared to men.

In our study, 325 MHA users used more than 21 MHAs. These results are comparable with the results of the Bhuvan et al. study, which reported that 48 MHAs were used by 278 participants, all of whom used different types of MHAs for various purposes, such as multi-purpose health apps, fitness apps, period-tracking apps, meditation apps, and health-monitoring apps (17).

Out of the 325 (47.9%) MHA users studied, 47.4% of them had more than three MHAs on their mobile devices and 74.8% downloaded these apps by themselves. This may have been attributed to the fact that different types of MHAs are available for free via the stores of Apple and Google Play (7). This is in addition to the rate of smartphone use being high (6). Also, there are the free Wi-Fi initiatives that allow free Internet roaming for 2 h daily in specific locations, with more than 60,000 free Wi-Fi hotspots in public places across SA, for example, shopping malls, city parks, and hospitals. SA is the region's largest information and communication technologies (ICTs) market, and Riyadh was named the first Arab Digital Capital in 2020 (21).

These findings showed a relatively higher rate of MHA usage than what was reported by Qan'ir et al. who reported that 41.6% of their study participants downloaded at least one MHA, and a maximum being five. Approximately 30% of MHA users (32.4%) reported that they used MHAs a few times per month (22).

The main public sources of information about MHAs were social media 195 (60%), followed by friends and family members (39.4%). This is in agreement with the BBC report about the phenomenon of social media growth in SA reaching the highest social media penetration and making up the largest social media markets in the world. These factors negotiate the use of social media platforms as a proper means of communication and interaction in different contexts (23). Friends and family members recommend the use of MHAs as an essential factor in increasing the apps' credibility and describing the importance of social influence. Therefore, designing health apps to promote wide usage should include adding features publicly demonstrating their usage to a user's close social network. (24). Nearly similar results in another study stated that participants most frequently learned about the MHAs via the following sources in descending order: apps stores, friends/family, web searches, and health professionals (74, 25.2, 19.8, and 19.8%, respectively) (22).

The most commonly used apps were related to daily steps-counting (54.2%), training exercise (46.2%), calories (41.8%), and health consultations (39.1%). The popularity of using these apps could be due to the high prevalence of obesity, physical inactivity, and non-communicable diseases in SA (25, 26), which is increasing the public's interest in managing their diets and lifestyles to stay healthy. These factors relate to the easy usability of theses apps, which could increase users' self-efficacy and willingness to use them. In addition to the reported effectiveness of these apps by more than half of MHA users, this comes in accordance with the study by Bhuvan et al. who stated that multi-purpose apps were used as apps for health, fitness, period-tracking, meditation, and health-monitoring (16).

The main motives of using MHAs among the studied MHA users were, in descending order, to promote their health status (223, 68.6%), lose weight (108, 33.2%), and practice physical exercise (81, 24.9%). Because the majority of MHA users said that using the following applications (those for daily step counting, exercising, calorie counting, and health consultations) was helpful and highly effective in improving their health. Therefore, the required features and specifications of MHAs are considered important aspects in expanding the use of MHAs to satisfy the patients' needs and preferences.

The majority of MHA users reported effective use of the majority of commonly used MHAs in improving their health status. These results were even higher than the results reported by a study conducted in China, in which 37.4% of their participants rated their agreement with the statement “using MHAs is effective and can increase knowledge in addition to improving the effectiveness of the management of health conditions” (20). MHAs are considered respected channels of communication in developing countries, serving to effectively complement conventional, efficient communication strategies and improve patients' relationships between individuals and healthcare providers (HCPs) or systems. This is because patients can use the MHAs for various tasks such as requesting medical consultations and information about their health conditions, making appointments, and viewing their medical records (27).

More than half of the MHA users (54.5%) perceived the MHAs' notifications as useful. Notifications are triggered by the apps as reminders and alerts to encourage the efficient use, interact with the participants, and increase the likelihood of achieving the participants' goals. Also, Mendiola et al. reported that mobile apps that are easy to use, simple, have applicable instructions to manage a condition, and help to share data with designated individuals are all deemed to motivate people to be users (28).

Our current study found that the main advantages of using MHAs were saving time (64%), possibility of following up on the health status at any time (48.9%), and getting correct information (40.9%). Nearly similar results in a Malaysian study stated that the main benefits of MHAs were tracking health status (47%), motivation (41%), and gaining knowledge about health and fitness (9%) (11). Mansour in an Egyptian study reported that some of the advantages of using MHAs include apps being reliable (98.9%), free (98.6%), credible (96.3%), friendly to users (94.6%), simple (93%), convenient (92.9%), accurate (92.6%), and secure (90.6%), as well as being able to increase the speed of finding information (97.2%), provide more information (94.3%), build confidence (93.7%), substitute for a doctor (93.4%), help communication (92.6%), and reduce paper use (92.3%) (5).

In our study, the main reported disadvantages of using MHAs were that they, in order, do not study the medical situation thoroughly (63.1%), lack a continuous follow-up from a specialist (52.9%), and have a low quality of diagnosis and follow-up (40.6%), while in China the main reported disadvantages were the apps' inaccuracy (24%), inconvenience (20.7%), and unfriendly use (18.5%) (11).

The studied participants' main suggestions on how to improve the usage of MHAs included sharing the health files or laboratory results with the follow-up doctors (73.5%), linking the users' health information to their health files (63.3%), and following up on health status using charts. While in a qualitative study, Peng et al. found that participants recommended social influence and social competition, intangible and tangible rewards, entertainment, and hedonic factors as reasons that might motivate people to continue using health applications (24).

There was a relatively large sample size used, including 13 different nationalities, representing both inside and outside of all the 13 administrative regions in SA, using a validated questionnaire.

It was a descriptive study using only a self-administrated questionnaire.

Despite the potential benefits of MHAs, they were used by only about half of the studied participants in SA. The use of MHAs was significantly higher among participants who were younger, Saudis, working, or had a chronic disease. The most effective MHAs in improving health status were apps related to exercise, calories, water uptake, daily steps-counting, and health consultations, all by the MOH Apps. Future research to explore the pros and cons of MHAs' usage is recommended.

To optimize the role of MHAs in delivering effective healthcare services, the integration of many efforts is required, and so we recommend the following: (1) national health education campaigns to increase awareness about the importance, benefits, and types of MHAs, especially among groups who are less likely to use MHAs; (2) using social media and healthcare providers as marketing tools for the newly launched MHAs; (3) developing the MHAs to meet the public's needs and expectations and improve the apps' usability even with people who have little knowledge about mobile technology; (4) encouraging opportunities for researchers, patients, and legislators to work together to improve the usage of MHAs in order to promote and control the health statuses among the public; (5) having health organizations be able to identify high-quality health apps; (6) developing standard evaluation criteria for choosing health apps.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.

SA: conceptualization. SA, NA, and AB: data curation. SA and JS: analysis. NA and AB: investigation and project administration. SA and DO: methodology and supervision. JS: software. SA and AB: validation. DO, BH, and JS: visualization. SA, DO, BH, and JS: writing—original draft preparation. All authors: writing—review and editing. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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