Polarised user reviews of blood pressure self-management apps in Latin American App Store storefronts

INTRODUCTION

Hypertension affects more adults in Latin America than clinical services can control. Pooled estimates show that the number of people aged 30 to 79 years with hypertension doubled worldwide between 1990 and 2019,(1) and population surveys in six Latin American countries found a prevalence of 44.0% with control in only 37.6% of treated patients.(2) In the Southern Cone, awareness, treatment and control were low in a general population sample,(3) and regional programmes have long identified hypertension assessment as a priority of cardiovascular prevention,(4) and disparities in prevalence and control between regions are documented worldwide.(5) Self-management supported by mobile phones is one response. Meta-analyses of trials report larger reductions in systolic and diastolic blood pressure with mobile health self-management than with control conditions,(6,7) although a randomised trial in low-resource urban settings of Argentina, Guatemala and Peru found no net change in blood pressure after text messages and counselling calls.(8)

The pattern expected in app stores is different from the pattern expected in trials. Commercial blood pressure apps are numerous, usually offer a single function, and rarely document expert input: a systematic search of two stores identified 184 apps with a mean quality score of about 2.6 out of 5,(9) 186 apps were found in the United Kingdom stores, most with only one function,(10) and 73 apps in the Chinese market covered on average 37.4% of a usefulness item set.(11) In Brazil, a narrative review of Google Play found 267 hypertension apps, many classified as entertainment, and noted that users tended to believe the information they delivered.(12) Studies that mined user reviews of hypertension apps in China and the United States, and of mental health or weight-loss apps elsewhere, show that written feedback centres on usability, cost and functioning.(13-15) Few apps are expected to use gamification, since a review of top-rated health apps found game elements in 4% of 1680 apps,(16) and evidence that gamification changes health behaviour is mixed and of moderate quality.(17) A skewed distribution of reviews across apps, polarised ratings and a small gamified subset were therefore the expected pattern.

Evidence from Latin American app stores is scarce. In a sample of patients with chronic disease in La Paz and El Alto, most owned a mobile phone,(18) regulatory frameworks for health apps are lacking in countries such as Peru,(19) and barriers to the use of mobile health in developing countries have been reviewed.(20) No study has described what users in Mexico, Colombia, Brazil, Argentina and Chile write about blood pressure apps. This study aimed to describe the written reviews of blood pressure self-management apps in five Latin American App Store storefronts, to estimate the frequency of themes related to usefulness, measurement, reminders, cost and adherence, and to compare reviews of apps with gamification or behaviour-change features with those of the remaining apps.

METHODS

RESULTS

The store searches returned 706 apps, and 239 met the eligibility rule. Releases from 2023 to 2025 accounted for 149 of them, 96.2% were free to download, and 239 apps came from 235 distinct developer names. Health and Fitness held 57.3% of the catalogue and Medical 30.5%. Written reviews dated 2013-2025 existed for 18 apps (7.5%), and 221 apps had none.

The yearly volume of reviews climbed to a peak of 26 reviews (20.0%) in 2025 (Figure 1). The seven years of 2013-2019 held 41 reviews, the three years of 2020-2022 held 39 and the three years of 2023-2025 held 50, and every year of the window had at least one review. Colombia contributed 36.2% of the 130 reviews, Brazil 26.9%, Argentina 20.0%, Chile 10.0% and Mexico 6.9% (Table 1).

The distribution across apps clustered in a handful of titles (Figure 2). The most reviewed app held 36.2% of the reviews (47 reviews in 2 storefronts), the three most reviewed 58.5% and the five most reviewed 77.7%. The second and third apps held 11.5% and 10.8%. Of 18 apps with reviews, 12 had five reviews or fewer and 7 had a single one (median 2), and the Herfindahl-Hirschman index reached 1,815.

No single app held a majority of the reviews, but the most reviewed one was nevertheless set apart in a sensitivity analysis of 83 reviews from 17 apps. That app, first released in 2012 and free to download, averaged 3.06 stars against 2.58 for the rest, and 46.8% of its reviews gave 1-2 stars.

The ratings spread to both ends of the scale (Figure 3). One star was given by 50.0% of the reviews and five stars by 36.2%, and the mean was 2.75 (SD 1.87). Low ratings reached 56.6% without the most reviewed app. Colombia dropped to a mean of 2.19 with 70.2% of reviews at 1-2 stars, whereas Argentina and Chile stood at 3.35 and 3.31. These storefront differences did not reach significance (chi-square p = 0.051; Kruskal-Wallis p = 0.091).

The mean rating coincided with no clear time pattern: it stood at 2.68, 2.56 and 2.96 in the three periods (Spearman rho = −0.25, p = 0.404). The 18 reviews written about the 3 paid apps averaged 2.28 stars, against 2.83 for free apps.

Positive usefulness was the theme with the highest frequency, present in 35.4% of reviews (46 reviews, 10 apps; Figure 4). Cost, subscription and billing followed with 21.5%, logging, charts, export and synchronisation with 20.0%, and measurement not delivered as advertised with 16.9%. Technical failure appeared in 15.4%, usability and language in 13.8% and perceived uselessness in 10.8%. Removing the most reviewed app left positive usefulness and billing as the two most frequent themes (Table 2).

The review texts were short. The median length was 9 words, and 30.8% of the reviews had fewer than five words. Spanish accounted for 65.4% of the texts, Portuguese for 22.3%, English for 3.1% and other or undetermined language for 9.2%, while 50.6% of the eligible apps listed Spanish or Portuguese among their interface languages. No specific theme was coded in 10.0% of the reviews. In Colombia, billing appeared in 21.3% of reviews, measurement complaints in 21.3% and technical failure in 21.3%.

Four themes had few mentions. Routine or sustained use appeared in 6 reviews (4.6%), reading accuracy or consistency in 5 (3.8%), advertising in 2 and reminders or alerts in 1. No review that praised usefulness gave 1-2 stars, whereas 90.9% of reviews on measurement not delivered, 90.0% on technical failure and 82.1% on billing did. The odds of a low rating were 9.9 times higher with measurement complaints (95% CI 3.7-26.8), 9.1 times higher with technical failure and 5.3 times higher with billing complaints, whereas reviews on logging features had odds of 0.22 times those of other reviews. In Colombia, 61.7% of reviews carried a billing, measurement, failure or uselessness complaint.

The sensitivity analysis without the most reviewed app left the pattern in place. Positive usefulness fell to 30.1%, logging and export to 15.7%, billing stayed at 21.7% and measurement not delivered at 16.9%. The odds ratios for a low rating stayed above one for measurement complaints (4.4, 95% CI 1.3-15.4) and technical failure (3.0, 95% CI 1.5-5.9), and the billing estimate lost precision (4.1, 95% CI 0.9-19.0). Reviews in Spanish averaged 2.68 stars (85 reviews) and in Portuguese 2.62 stars (29 reviews).

The contrast with gamified and behaviour-change apps could not be estimated at review level. The lexicon flagged 8 of 239 apps for gamification (0 with a written review; 95% CI of coverage 0.0%-32.4%) and 17 for behaviour-change features, 23 in total. Only 2 of those 23 apps (8.7%) had written reviews, against 16 of 216 (7.4%) among the rest (Fisher p = 0.687), and the two reviews of the featured apps preclude any comparison of ratings or themes.

DISCUSSION

The main finding is the thinness of written feedback relative to the size of the catalogue. Only 7.5% of eligible apps had a written review in these five storefronts, and the reviews that exist clustered in a few titles and in complaints. Published analyses of user reviews of hypertension apps worked with much larger corpora, including 116,686 reviews of 261 apps in China and the United States( 13) and 13,549 reviews of mental health apps,( 14) and even small qualitative designs sampled 569 reviews of weight-tracking apps.( 15) The difference has three plausible origins. The review feed exposes only recent written reviews, app users differ across countries in their likelihood of downloading medical apps and of rating apps, as a survey of 4,824 users in more than 15 countries that included Brazil and Mexico documented.( 21) The catalogue itself was young and fragmented, with 149 of 239 apps released in the last three years of the window and almost as many developers as apps, which leaves little time for any single app to accumulate reviews.

The most reviewed app was released in 2012, which gave it the longest time to accumulate reviews, and the sensitivity analysis showed that the main patterns did not depend on it. Percentages of themes moved by no more than about five points when it was removed, and the share of low ratings rose from 53.1% to 56.6%. The reviews give no basis for ranking apps, because ratings were not related to any feature in earlier work either: a regression on 151 hypertension apps found little evidence that specific features predicted download counts or ratings,(22) and the number of behaviour change techniques did not correlate with ratings of gamified health apps.(16) When a feature was associated with ratings, the features that saved time, allowed data export and gave instructions helped, whereas the tracker function alone detracted.(23) The present data agree on the weight of logging and export, which were the only functional theme linked to better ratings, with a lower odds of a low rating among reviews that mentioned them.

The polarisation of ratings follows from what users complain about. A total of 49.2% of the reviews carried a billing, measurement, failure or uselessness complaint, and these themes were strongly tied to 1-2 star ratings, whereas praise for usefulness never coincided with a low rating. Cost matters in app stores in general: users from some countries are more sensitive to price than others,(21) and cost was among the features associated with ratings in one regression of health apps(23) but pricing was unrelated to quality scores in a Dutch search.(9) The billing complaints appear to concern the mismatch between a free listing and an opaque subscription, with reviewers describing charges they did not expect, cancellations they could not complete and refunds that were denied. This is an interpretation of coded text and not a tested mechanism. The higher share of low ratings in Colombia may reflect which apps happened to be reviewed there, because only 6 apps contributed reviews there; the storefront difference was not significant and should not be taken as a country effect.

Measurement claims deserve separate attention. Reviewers in Colombia, Brazil, Argentina and Chile wrote that the app did not take blood pressure, only stored typed values, or promised a reading that it could not deliver. This is not a user misunderstanding alone. Apps that estimate pressure from a fingertip on a phone camera are marketed widely, yet a clinical test of a camera-based app reported that just 38.1% of 2,895 paired readings fell within 5 mmHg of a reference device,(24) validation studies of another smartphone algorithm were run against reference measurements under formal protocols,(25,26) and a recent meta-analysis noted that many apps lack validation for both blood pressure lowering and measurement accuracy.(7) Brazilian reviewers of Google Play made a related point about the credibility of information, since users tended to believe the content delivered.(12) Complaints about accuracy itself were few here, probably because users who cannot obtain a reading do not reach the question of its accuracy.

Technical failure, usability and language complaints complete the picture and match reviews in other health domains, where poor usability was the commonest reason for abandoning apps( 14) and reviews of medication adherence apps have also been used to explore what users experience.(27,28) For a chronic condition, the loss of a diary is more than an inconvenience, and the reviews on failures included records that could not be saved or that disappeared. The privacy side of this problem lies outside what reviews reveal, but earlier work found that only 30.5% of the 600 most commonly used health apps had a privacy policy,( 29) that privacy assessments of health apps use varied components,( 30) and that Chinese hypertension apps offered less data protection when developed in the mainland.( 11)

The scarcity of reminders and adherence content is the clearest mismatch with the research literature. Reminders and alerts appeared in one review and routine use in 6 of 130, although self-monitoring dominates the functions of hypertension apps while goal setting through reminders, communication with professionals and data export are less common,(31) and engagement with interactive and tailored apps has been linked to better blood pressure outcomes.(32) Users in other settings abandon apps after a short initial use,(33) and dropout limits what mobile health can achieve.(34,35) Our users did not write about those matters, which suggests that the app store review is a poor channel for adherence evidence. Adherence in Latin American hypertensive patients has been studied through other instruments, such as a scale based on the health belief model to measure drug adherence in hypertensive patients,(36) a clinical trial of telephone follow-up with text messages in Colombia,(37) and a prototype motivational app for treatment adherence in Brazil.(38) A Brazilian article describes a free self-monitoring solution with gamification endorsed by medical societies,(39) and none of the apps in our reviews fits that description.

Praise needs careful reading. Positive usefulness never coincided with a low rating and often came with logging or export features, which agrees with a regression in which data export and clear instructions contributed to ratings.( 23) Yet the reviews cannot show that the apps lower blood pressure. A meta-analysis of app-based interventions reported a systolic reduction of 2.76 mmHg at six months, with larger early effects in hypertensive participants that faded later,(7) another review pooled a reduction of 1.45 mmHg,(40) and the Latin American trial of text messages and counselling found no net change in blood pressure.(8) The concept of prescribable apps, defined as available apps with proven effect, was proposed because that evidence is seldom attached to commercial products.(41) A satisfied user and a clinically effective app are therefore different outcomes, and the store review captures only the first.

The method of reading reviews also shapes what is found. Earlier work coded reviews with machine learning and thematic analysis,( 42) annotated sentiment manually for a single health app( 43) or paired a content analysis of apps with a content analysis of their reviews.( 27) Manual coding of 130 short reviews, as done here, allows negated phrases to be handled, which a keyword lexicon could not do in our preliminary output, but it cannot be scaled and was done by one coder. The choice of a manual approach responded to the small volume and does not replace topic models in larger corpora.

The price of apps is a related matter. A content analysis of paid health and fitness apps used developer descriptions to characterise what buyers are offered,(44) and our 3 paid apps with 18 reviews averaged 2.28 stars against 2.83 for free apps. With so few apps this difference is anecdotal, and the billing complaints concerned subscriptions and in-app charges more than purchase prices. Evidence on behaviour change frames what users might expect from an app, since syntheses of apps and health behaviour (45) and of their behavioural functionality (46) describe varied behavioural content, and a usability study of a commercial hypertension app in the Gulf region combined task testing with a four-week real-world use.(47) A trial of a blood pressure management app targeted treatment adherence directly,(48) and the reviews we read contained none of that language.

The gamification contrast could not be answered. Gamification terms appeared in 8 of 239 apps (0 reviewed), and the share is close to the 4% found among top-rated health apps in an international review.(16) Other reviews describe gamified health apps in volume, with archetypes of gamification in 143 apps,(49) an average of 1.4 game techniques per diabetes app(50) and a scoping review of 11 studies in which gamification was used alone in nine and adherence was generally improved or sustained.(51) A review of personal health management makes gamification part of the field,(52) and behaviour-change techniques have been linked to engagement.(53) For hypertension apps in Latin American stores, these designs are rare in the catalogue and absent from the reviews. The finding does not show that gamification is ineffective, only that the public review record cannot evaluate it here.

The catalogue composition adds context. Most eligible apps sat in Health and Fitness rather than Medical, which parallels the finding that a large share of hypertension apps in a Brazilian store review belonged to entertainment and general categories,( 12) and apps with a single function predominated elsewhere.( 10) Apps first released in 2023 or later made up most of the catalogue, and a young catalogue gives most apps little time to be exposed to users. Spanish and Portuguese reviews were similar in mean rating, which gives no sign of a language effect in these data and is compatible with the view that the complaint profile belongs to the apps and their business models. The Portuguese-language evidence from Brazil on apps for hypertension is also still mostly about prototypes and usability, as in the motivational app prototype for people with hypertension,( 38) and not about commercial store behaviour.

Developers of blood pressure apps in Spanish and Portuguese should state clearly whether the app measures pressure or only records it, show subscription terms before payment, and offer export and synchronisation, the functions that reviewers who were satisfied mentioned. Regulators can use the complaint profile as a signal in the regulatory gap described for Peru,(19) and clinicians recommending apps should favour those with a documented prescribable status(41) and take into account the barriers to mobile health in developing countries.(20) Because most patients with chronic disease in a Bolivian sample owned a mobile phone(18) and text messages for a hypertension prevention programme have undergone multi-country validation,(54) the opportunity for self-management support exists; what the reviews show is a market that, for now, delivers it unevenly.

CONCLUSIONS

Written feedback on blood pressure self-management apps in five Latin American App Store storefronts was scarce and concentrated in few apps. Users wrote mainly about usefulness, billing, measurement claims and technical failures, and almost nothing about reminders or adherence. The comparison between apps with and without gamification or behaviour-change features could not be made with these data.

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