Privacy and data governance in gamified health apps in Latin America

INTRODUCTION

A health app that awards points for logging a meal, ranks a user against friends in a step count or unlocks a badge after a clinic visit works only if it keeps a detailed record of what the person does and where the person is. Mavroeidi et al.(1) examined this dependence from a design perspective, listing the game elements that gamified applications apply and relating each of them to privacy requirements. They concluded that some game elements can lead to privacy violations, a result that places data protection inside the design of gamification rather than after it. Arora and Razavian(2) reached a compatible position from the ethics side, describing a darker side of gamified health and fitness apps and proposing a framework that sets out the responsibilities of their designers.

In Latin America the same designs reach users through a regulatory setting that is uneven. Alegre et al.(3) surveyed the regulations in force in 21 Latin American countries and found that electronic medical records were legally regulated in 16 and telehealth in 19, with confidentiality and professional secrecy mentioned in only eleven countries for telehealth and nine for electronic records. That survey concerns clinical records and teleconsultation, which are services delivered by professionals. A gamified app downloaded from a store and used by a person outside any clinical relationship is a different object, and the laws that apply to it are the general data protection statutes. Muñoz-del-Carpio-Toia et al.(4) argued that the privacy of health data requires special procedures in health systems and proposed legislative harmonization across the region, which indicates that the statutes are not aligned even where they exist.

The empirical work on apps in the region is small and scattered. Rojas Mezarina et al.(5) reviewed mHealth apps created, uploaded or used in Peru and concluded that existing norms do not fully cover the evaluation of security and privacy of data. González (6) reported what the authors described as the first investigation of its kind in Mexico, identifying the most used mobile health applications during the first year of the pandemic and the transparency conditions that they offered for data processing. Reis et al.(7) built a corpus of privacy policies of popular apps in Brazilian Portuguese and assessed it against the Brazilian data protection law. Each of these studies answers a part of the question for one country, and none of them was designed around gamification. Mendoza et al.(8) describe a gamified Mexican app and its data safeguards, but as part of a development report and not as a privacy evaluation.

What these authors left open is whether the privacy and governance evidence produced in and about Latin America says anything specific about health apps that rely on game elements, and which features of the regional framework would matter most for them. The present narrative review addresses that gap. Its objective is to synthesize publications from 2012 to 2024 on privacy practices and data governance of health apps in Latin America, giving separate attention to gamified designs, and to identify the questions that remain unanswered. Four questions guided the work: what data the apps and their policies are reported to collect and disclose; how legal and institutional analyses describe the protection of health data processed by apps; what the pandemic experience with contact-tracing apps revealed about governance; and what clinicians and users report about privacy when they use digital tools.

DEVELOPMENT

The core publications are unevenly distributed across countries. Twenty of the 42 concern Brazil, one of them (the OCARIoT app) also Greece and Spain; three concern Mexico, two Peru, two Colombia, one Argentina and one Ecuador, and the rest cover several countries or the whole region, as the regulatory survey of 21 countries and the clinician survey of 13 do. No core publication centers on Chile, Uruguay, Costa Rica or the Caribbean, so statements about those countries rest on the regional studies only. The sections that follow group the publications by what they examined.

DISCUSSION

The main finding of this review is that the privacy evidence for gamified health apps in Latin America is indirect. The publications that name gamification describe how apps were built or tested, and the publications that assess privacy and governance concern health apps in general, contact-tracing tools or clinical systems. This difference between what the gamified reports say and what the privacy reports examine is the pattern that runs through the four axes, and it is why the review can describe what is known about the regulatory and audit context but not how leaderboards, badges and social features affect the exposure of users in the region. Mendoza et al.(8) come closest to bridging the two, since their gamified app is documented with encryption, a privacy notice and consent, yet even their report describes safeguards without an independent test of them, so the bridge is partial.

The first comparison concerns the audits. Rojas Mezarina et al.(5) found that about half of the ten most used apps in Peru gathered information that could be leaked, changed or lost. Huckvale et al.(47) examined 79 apps certified by a national accreditation program in the United Kingdom and observed that 70 transmitted information online, that none encrypted locally stored personal information, and that 23 of 35 apps sending identifying information did not encrypt it. The two studies differ in design, since the Peruvian review classified apps by the information they gather and the possible risks, whereas the British study tested transmission and storage by protocol. Despite this, both show that the declared purpose of an app and its observed handling of data can part ways, and the British result adds that accreditation based on developer disclosures did not prevent the gap. The consequence for Latin America is that the registry or repository proposed by Rojas Mezarina et al. would need technical testing in addition to disclosure, which none of the Latin American audits applied. Dehling et al.(48) had earlier set out an approach to assess information security and privacy implications from the health specificity of the data an app handles and the possible damage from leaks, an approach that could organize regional audits.

The policy findings follow a similar line. Reis et al.(7) reported policies of excessive length and poor readability, and Benjumea et al.(49) found in a sample of 31 cancer apps from the Spanish version of Google Play that 29% had no privacy policy and that 39% scored below 50 of 100 points on a fairness scale built on the European regulation. Their sample was of apps in Spanish and not of Latin American apps, so it does not describe the region, but it indicates that the Brazilian corpus is not an isolated result. Farag et al.(50) studied 46 apps in European and Canadian markets that crowdsource health data and noted inconsistency and ambiguity in their policies that challenge comprehension, trust and informed consent. This is relevant to the Mexican app of Mendoza et al.,(8) which relies on crowdsourced product registration, and shows that crowdsourcing combined with gamification raises consent questions that go beyond the study participants. A difference between the sets is that the Latin American corpus is general-purpose whereas the others are health specific; the comparison supports a similar direction of findings and not a similar magnitude. Benjumea et al.(51) add that assessment criteria across 24 studies were heterogeneous and that each article defined a different set of items, which implies that numbers from different audits should not be compared without a shared instrument.

On gamification itself, the regional silence contrasts with the design literature. Mavroeidi et al.(1) derived a conceptual model of which game elements conflict with privacy requirements, and Ruggiu et al.(52) argued that gamification at work raises concerns about privacy because of massive collection, storage and processing of data, and that privacy by design can strengthen autonomy. Their setting is occupational, and the health relevance is by analogy, yet the mechanism of continuous data collection to feed game mechanics is the same. Spahl et al.(53) reviewed ethical aspects of gamified digital mental health interventions for young people in 38 publications and found privacy among the ethical principles discussed, together with a limited interpretation of ethics as research ethics. The regional reports of Andrade-Romo et al.(9) and Morais Pereira Simões et al.(10) fit this description, because ethics approval and consent are reported while the handling of in-app data is not. The Mexican game for men who have sex with men is a case where the omission carries weight, as the platform used a leaderboard and an invitation feature and the abstract describes a population facing stigma and discrimination. The comparison with Spahl et al. suggests that this is a pattern of the field and not a regional peculiarity.

The legal analyses raise a different point. The Brazilian authors repeatedly describe a gap between statute and practice, from Barreto Junior and Faustino(19) before the law entered into force to Souza(28) and Falcão et al.(27) after it, and Moraes and Prado(26) observe that the deterrent assumed in the literature was fear of professional punishment, which does not describe a company that publishes a consumer app. This explains why Bezerra and Alves(18) describe the regulation of apps as difficult when they are downloaded freely from stores and used directly by the person. The explanation for divergence among the authors lies in what each analyzed: those who studied public platforms, such as Falcão et al.(27) and Souza,(28) focus on state duties and constitutional rights, while those who studied the health sector or clinical systems, such as Hawryliszyn et al.,(23) focus on organizational compliance. Neither group analyzed a commercial gamified product. The statutory texts leave an open question for such products, because the exception for health protection is tied to procedures of health professionals and entities and the general consent route carries duties of specificity.(33) The Argentine statute shows the same structure with free, express and informed consent and a security duty for controllers,(34) while Rojas Mezarina et al.(5) show that in Peru such norms exist but do not fully cover the evaluation of security and privacy of apps. The pattern across countries is that general statutes exist, and that the application to apps is missing.

The pandemic apps provide the comparison that most clearly shows the role of trust. Goyeneche et al.(35) observed that adoption fell with distrust of anonymity policies, whereas Agudelo-Londoño and Núñez Avilés (36) documented in Colombia the citizen concerns that explain such distrust, such as scarce confidentiality guarantees. Barker et al.(37) argued that privacy should be seen as a public good and not as an opponent of tracing, a position at odds with the view, implicit in the willingness figure of 61% reported by Goyeneche et al., that people accept trade-offs in an emergency. The two positions can be reconciled by noting that the same survey found very low understanding of data use, so the willingness may be less informed than it appears. For gamified health apps that depend on sustained use, the implication is that the engagement measured by retention may rest on the same low understanding. The review does not have evidence that this happens in the region, and the point is offered as a hypothesis to be tested.

For clinicians, the survey of Cherrez-Ojeda et al.(42) and the survey of de Oliveira Figueiredo et al.(43) are consistent in showing concern combined with practice. Physicians in Ecuador named privacy as their main barrier, and clinicians across 13 countries nevertheless shared clinical data through messaging apps while most reported not knowing the legal rules. The two surveys differ in sampling and size, and the second is a self-selected online sample of 125 respondents, so the proportions cannot be generalized. Alegre et al.(3) help to explain the combination, since they found that confidentiality was explicit in the regulations of only a minority of countries for telehealth and electronic records. Muñoz-del-Carpio-Toia et al.(4) answer with a call for harmonization, a proposal that this review supports for health apps, with the qualification that harmonization in text is only a first step. Suver and Kuwana(54) note that improving privacy and confidentiality notices is part of the response, and McCarthy(55) reported that in the United States federal privacy laws do not apply to much of the information consumers give to mobile health devices, which shows that the issue of apps outside the clinical relationship is not specific to Latin America.

Children and adolescents deserve a separate comparison because gamification is often aimed at them. Contreras(30) compared national policies on the data of school children in Latin America and tied the vulnerability of minors to their understanding of risks, their age and their background, while the Brazilian law requires, for children's data, specific consent given by at least one parent or legal guardian and public information on the types of data collected.(33) Barbosa et al.(15) treated privacy as a design requirement for a tool used in pilots with children, and their survey found that the need to synchronize different children's accounts and privacy were among the reasons for building it. Ippoliti and L'Engle(56) reached a convergent conclusion from a global landscape of mobile programs for adolescent sexual and reproductive health in low- and middle-income countries, of which 13% of the 17 projects were in Latin America, when they stated that more understanding is needed about data privacy challenges, especially among younger adolescents. Spahl et al.(53) reported that vulnerable groups were one of the four ethical themes in gamified mental health tools for young people. The sources converge in treating minors as a group with specific needs, but none of them measures what a gamified health app collects from a child in the region, so the convergence rests on principle and not on measurement.

A final comparison concerns what design can do. Zhou and Parmanto(57) asked 40 participants with mild or moderate depression to rate five privacy protection methods of mHealth apps and found a preference for methods with customizable modules in multi-purpose apps, because of their convenience and strong protection. The sample is small, comes from outside the region and concerns mental health apps, so it cannot be transferred directly. It nevertheless suggests that privacy controls which users can adjust, for example to hide their position on a leaderboard, may be accepted by users, and it fits the proposal of Mavroeidi et al.(1) to consider privacy from the early stages of the design of gamified applications. Pinto et al.(22) and Hawryliszyn et al.(23) address the organizational side with governance measures such as mapping and mitigation of risks, which would apply to developers and public agencies that run gamified health programs. The combination of adjustable controls at the interface level and documented governance at the organizational level is a reasonable design target that the reviewed evidence supports in parts but has not tested in the region.

The strengths of this review are the combination of five sources, the use of three languages, which brought in 18 publications that English-only searches would have missed, and the use of the full text and statutory text for the gamified cases and the laws. Its limitations are specific. First, selection was not systematic, and publications may have been missed, particularly in national journals not indexed by the sources used; a future update should add searches in regional repositories and use a protocol registered in advance. Second, the evidence for most publications comes from abstracts, so details that appear only in the full text, such as the safeguards in a report whose abstract does not mention them, may be missing; a full-text pass over the 14 audit and gamified reports would address this. Third, the assignment of studies to axes was assisted by an AI model and awaits verification, which could be solved by independent coding by two authors. Fourth, only the Brazilian and Argentine statutes were read in their official texts, and the Colombian, Mexican, Peruvian and Chilean laws appear only through secondary literature; the authors should add official texts for these countries. Fifth, the Brazilian law was read in its original publication, and subsequent amendments were not reviewed; a verification against the consolidated text is needed before the provisions are cited in policy work. Sixth, many sources are legal commentaries and not empirical studies, which limits the weight of statements about practice; future work should pair legal analysis with technical testing of apps.

The practical implications follow from the findings. App evaluation in the region should add a privacy and data-sharing module that includes leaderboards, social features and invitation functions, and that uses a shared instrument so that results can be compared, as the heterogeneity described by Benjumea et al.(51) suggests. Regulators could publish app-level guidance that clarifies when consent is the basis of treatment for consumer health apps and how children's data should be handled, building on the comparison of national policies by Contreras.(30) Developers could follow the example of the OCARIoT app(15) and report privacy and data-controller management as design requirements. Researchers who publish trials or pilots of gamified apps could report data storage, encryption, retention and sharing, which the reports of Andrade-Romo et al.(9) and Morais Pereira Simões et al.(10) omitted. Finally, studies that ask users of gamified health apps in the region about what they know and accept regarding their data would fill the most visible gap in Table 1.

CONCLUSIONS

Privacy and data governance evidence on health apps in Latin America comes mainly from audits in Peru, Mexico and Brazil, from legal analyses concentrated in Brazil, from the pandemic experience with contact-tracing apps, and from surveys of clinicians, and it reports weak safeguards, poor transparency and a gap between general data protection laws and their application to apps. Gamified health apps from the region are documented mainly as development reports and trial protocols, and only one describes concrete privacy safeguards, so the effect of game elements on data exposure in the region has not been assessed. The best-supported recommendations are to audit leaderboards, social features and data sharing with a shared instrument, to give children's data and sensitive populations specific attention, to publish app-level regulatory guidance, and to ask users of these apps what they know about the use of their data.

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