Privacy, Permissions, and the Health App Ecosystem:
A Stack Overflow Exploration
Mohammad Tahaei

mohammad.tahaei@bristol.ac.uk
Department of Computer Science
University of Bristol
United Kingdom

Julia Bernd

jbernd@icsi.berkeley.edu
International Computer Science
Institute
United States

ABSTRACT
Health data is considered to be sensitive and personal; both governments and software platforms have enacted specific measures
to protect it. Consumer apps that collect health data are becoming
more popular, but raise new privacy concerns as they collect unnecessary data, share it with third parties, and track users. However,developers of these apps are not necessarily knowingly endangering users’ privacy; some may simply face challenges working withhealth features.
To scope these challenges, we qualitatively analyzed 269 privacyrelated posts on Stack Overflow by developers of health apps forAndroid- and iOS-based systems. We found that health-specific access control structures (e.g., enhanced requirements for permissions
and authentication) underlie several privacy-related challenges developers face. The specific nature of problems often differed between the platforms, for example additional verification steps forAndroid developers, or confusing feedback about incorrectly formulated permission scopes for iOS. Developers also face problems
introduced by third-party libraries. Official documentation plays akey part in understanding privacy requirements, but in some cases,
may itself cause confusion.
We discuss implications of our findings and propose ways toimprove developers’ experience of working with health-related
features—and consequently to improve the privacy of their apps’
end users.

CCS CONCEPTS• Security and privacy → Software and application security;
Human and societal aspects of security and privacy; Usability in security and privacy; • Human-centered computing →Human computer interaction (HCI); HCI design and evaluation methods; • Software and its engineering;

KEYWORDS
software developers, health apps, usable privacy, developer forums

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EuroUSEC 2022, September 29–30, 2022, Karlsruhe, Germany© 2022 Copyright held by the owner/author(s). Publication rights licensed to ACM.
ACM ISBN 978-1-4503-9700-1/22/09. . . $15.00
https://doi.org/10.1145/3549015.3555669

Awais Rashidawais.rashid@bristol.ac.uk
Department of Computer Science
University of Bristol
United Kingdom

ACM Reference Format:
Mohammad Tahaei, Julia Bernd, and Awais Rashid. 2022. Privacy, Permissions, and the Health App Ecosystem: A Stack Overflow Exploration. In
2022 European Symposium on Usable Security (EuroUSEC 2022), September 29–30, 2022, Karlsruhe, Germany. ACM, New York, NY, USA, 14 pages.
https://doi.org/10.1145/3549015.3555669

1

INTRODUCTION

Mobile apps, fitness trackers, and sensors provide many users withinsights into their health, and motivation to improve it. The datacollected by these services is often considered sensitive, and many
countries have specific regulations and limitations for working
with it [e.g., 40, 75, 76]. However, health apps1 still share data withthird parties, track users, ask for unnecessary permissions, and use
insecure modes for transferring data [e.g., 37, 60, 63, 74].
In general, app developers face a number of challenges with privacy features, including managing access control, writing privacy
policies, understanding documentation for libraries, translating legal privacy requirements into technical requirements, and findingtime to prioritize privacy in the first place [16, 19, 45, 58, 65, 69,
73, 77, 82]. While literature has explored some of these generalissues from app developers’ perspectives, developers who workwith health data face additional complications, due to the potential
for heightened user privacy concerns and to special regulations. It
is not yet known how these additional complications affect healthapp developers’ management of privacy challenges.
We therefore conducted an exploratory qualitative analysis of
269 privacy-related posts made by health app developers on Stack
Overflow, a popular public forum for programming questions. Our
research questions (RQs) were:
RQ1: What privacy-related challenges do app developers facewhen integrating health-related features?
RQ2: How do the challenges differ when developing health appsfor different platforms?
RQ3: How do health app developers navigate those privacy
challenges?
In addressing these questions, we contribute to research on supporting developers in performing privacy tasks—and thus improving
privacy protection for the end users of those apps.
Our findings identify the major privacy challenges and confusions for Android and iOS health app developers, especially indealing with health-specific requirements regarding access control and permissions; meeting enhanced requirements set by app
stores and health frameworks (i.e., software libraries that provide
1 Throughout, we use the term “health apps” fairly broadly, to refer to any apps withmedical, health, and/or fitness purposes.

EuroUSEC 2022, September 29–30, 2022, Karlsruhe, Germany

access to health sensors and data on mobile devices); and addressing unexpected permissions problems introduced by third-party
components.
We observe that those platform requirements drive most privacy
efforts—and at the same time are a source of many privacy confusions. The discussion compares those findings with prior work. In
addition, we make recommendations about improving documentation to guide compliance with specialized platform requirements
regarding health data, and about tools and information to help
health app developers identify privacy implications of third-party
components.

2

BACKGROUND: HEALTH FRAMEWORKS
AND PERMISSIONS RULES FOR APPLE AND
GOOGLE APPS

This section provides an overview of how health data is handled in
the two major mobile operating systems.
Both Android (Google) and iOS (Apple) devices support app
features that use health data such as heart rate, blood pressure, andstep counts. This health data may be collected from sensors on thesmartphone itself, or from separate devices, including wearable
devices from the same companies or manufactured by third parties.
Android and iOS each have parallel pared-down Operating Systems(OSes) for their own wearable devices, WearOS and WatchOS [8, 28],
respectively, as do some other companies that make wearables. The
wearable OSes can run their own apps, and users can also interact
with them through companion apps on smartphones.
Each company has a proprietary framework for collecting, storing, and working with health-related sensor data. While Apple’s
HealthKit mainly works with on-device data stores, Google Fit’s
data stores are cloud-based, accessed via different APIs depending
on OS and app type. In both frameworks, developers have to definea description for the permissions they want to use in their apps,
including the purpose for accessing any health-related resources.
Android has two permissions for health data, restricted (for reading data) and sensitive (for writing data). They both require developers to pass a verification process; however, accessing restrictedresources requires extra steps, including a security assessment by athird party [29, 31].
Apple has a generic review process for all apps [9] that checks
for any violations of app development guidelines. These guidelines
include specific requirements for health data, but, based on the
documentation, there does not seem to be a separate developer
verification step for health apps.

3 RELATED WORK
3.1 Privacy in Health Apps
Health apps vary from simple fitness apps that count the steps
someone takes in a day to services that work with more sensitive
information about physical and mental health, such as trackers for
symptoms or medications [3, 26, 38, 47].
The number of mobile health apps has grown steadily in the past
decade, increasing more sharply since the COVID-19 pandemic
began [22, 44, 60, 63]. The prevalence of health apps creates a spacefor collecting data and tracking users [e.g. 48, 53, 54, 60, 74, 79].

Mohammad Tahaei, Julia Bernd, and Awais Rashid

These app behaviors may not be disclosed in privacy policies [39,74], and some health apps do not have privacy policies at all [48, 54].
Such behaviors are even found in apps built by governments [37, 60].
Such data-collection overreach occurs despite specific regulations
to protect health data, such as the Health Insurance Portability andAccountability Act (HIPAA) [76] in the U.S. or extra precautions in
the General Data Protection Regulation (GDPR) [75] and the UK
Data Protection Act [40].
Users’ opinions about health app privacy are mixed [e.g., 35, 52,
55, 78, 85], and awareness of specific privacy practices and policies
is low [81]. Some may assume the app would not give away theirdata without their knowledge [46, 81]. Others may have concerns
about sharing their health data with apps, or about which third
parties the app might share it with [e.g., 34, 50, 81, 85].
Yet despite these concerns, many studies show a lack of privacy safeguards in health apps [e.g., 20, 63, 74, 83]. Our study aims
to improve the health app privacy ecosystem by examining how
developers of these apps consider privacy, and how they can bebetter supported in integrating privacy features, which could consequently improve users’ privacy.

3.2

Empirical Privacy Studies With Developers

There has been an increase in the number of privacy-related
posts on Stack Overflow (from 10 to 234 posts between 2008 and2018 [73]), suggesting that privacy is increasingly being discussed
in developer communities.
One recurring challenge is translating privacy requirements,
which can be filled with legal jargon, into technical requirements [e.g., 19, 33, 61, 64, 69]. Developers’ understanding of privacy
might be impacted by several other factors, such as their workplace
and the software development platforms [e.g., 4, 12, 32, 70]. For
example, developers in an interview study often used the languageof security, prominent in their workplaces, to explain privacy topics,
or discussed privacy indirectly via references to privacy policies[33].
Studies of the iPhoneDevSDK and XDA forums [62] and the/r/androiddev subReddit [45] noted an emphasis on informing users
by showing permissions dialogues—which are mobile OSes’ primarypoint of access control for private data resources. Because of thesestructures, app stores and mobile operating systems like Apple and
Google are key drivers of privacy in developer communities [7, 32,
62, 70]; this is discussed further in §6.1.
Regarding health apps specifically, research has explored developers’ security challenges, including lack of knowledge about
security requirements, not having the guidelines, and not engaging
experts in the design process [5, 6]. While prior work studies general privacy challenges for developers [e.g., 16, 45, 61, 73, 77, 82]
and security challenges for health apps [e.g., 5, 6, 51, 74], there
has been no analysis that covers developers’ privacy challenges
working with sensitive health data. We leverage the methods andfindings from these prior bodies of research to fill that gap.

3.3

Studying Developers Using Online Forums

Online forums, such as Stack Overflow, Reddit, and GitHub, havebecome a widely used resource for empirical studies of developers [23, 32, 36, 45, 62, 70, 73, 80, 84]. Such forums provide a richsource of data about about developers—who are often challenging

Privacy, Permissions, and the Health App Ecosystem: A Stack Overflow Exploration

to recruit for empirical studies [24, 41, 72]—via artefacts such as
sample code and written posts.
Studying Stack Overflow, for example, has provided insights
into the privacy and security challenges of developers [23, 73, 84].
Researchers have also identified ways it can be a potential vector
for security vulnerabilities, for example a lab study showing thatcode written using Stack Overflow as a resource is less secure thanusing official documentation or programming books [1, 2], or astudy tracing insecure code in live Android apps to code snippets
in Stack Overflow posts [25]. Such studies show the impact of thisforum on privacy and security of developers’ code and the app
ecosystem.
Our study extends this literature to pinpoint developers’ privacy
challenges in working with health-related features—and meanwhile
highlights the impact of research framing and choice of keywords
on final datasets, and therefore on different studies’ results.

4

EuroUSEC 2022, September 29–30, 2022, Karlsruhe, Germany

iOS app reject because of healthkit
Asked 5 years, 2 months ago

91

We received ethics approval and oversight from our institute’s
ethics committee. The study is in line with Stack Overflow’s termsof service and privacy policy. Contributed content is available under a Creative Commons license and Stack Overflow encourages
academics to use its data for research [14, 15]. For attribution, we
provide hyperlinks attached to post identifiers [13]. Because thedataset contains usernames, we are not able to share it directly withthe community (per our institute’s ethics guidelines); however, thequeries used to collect it are included in Appendix A.

4.2

I am using HealthKit in my app to read users daily steps data and for that I enable
HealthKit in my app.
I uploaded app without NSHealthShareUsageDescription and
NSHealthUpdateUsageDescription key in info.plist .
Apple rejected the app as follow and says this both key must be in info.plist .

NSHealthShareUsageDescription - Share workout data with apps.

I added that key and upload again.
now app rejected with this reason.
Design - 4.2.1 Your app uses the HealthKit or CareKit APIs but does not indicate
integration with the Health app in your Application.
any idea how can I approve it?

METHOD

Study Ethics

Dataset

Collection of initial dataset. We collected data in October 2021,
using the Stack Exchange API [66] to query posts from the five-year
period from 2016/July/01 to 2021/July/01. To find posts about healthapps for Android and iOS, we queried for posts whose title or tags
included a combination of {fitness, google fit, health, medical} with{android, ios, watchos, wearos}.2 We focused on Android and iOS
because they are by far the most widely used mobile OSes [67].
In total, we collected 1,055 unique posts, of which a slight majority were about iOS and WatchOS. This tilt seems unique to healthapps; overall, the ratio of posts with Android or WearOS in the title
or tags to posts with iOS or WatchOS was about 2:1 over the sametime period (more in keeping with Android’s larger market share[21]).
Selection of final dataset. From our initial set of 1,055 posts, weselected a final dataset of 269 posts mentioning privacy-related
topics, including privacy, access permissions, authentication, anddata security (example in Figure 1).
2 We used google fit to make sure we collected posts referring to the Google Fit health-data framework that might not use our other terms in the title or tag, as results from fit
alone were dominated by other meanings of the word. Posts that specifically referredto the HealthKit and Samsung Health frameworks were caught by the search term
health, as we used the LIKE operator to retrieve substring matches.

Viewed 6k times

NSHealthUpdateUsageDescription - Read your daily steps data for calorie count dataios

We created a dataset and qualitatively analyzed 269 health andprivacy-related Stack Overflow posts to answer our research questions.

4.1

Active 2 years, 8 months ago

app-store-connect

healthkit

Share Improve this question

edited Sep 27 '16 at 6:22

asked Sep 27 '16 at 5:48

Divyesh Savaliya

Follow

2,530

2

14

35

should reply to Apple and explain the integration how your app integrates
Figure 1:you
A sample question about permissionswith HealthKit . – Raptor Sep 27 '16 at 6:01
related problems
in an iOS health app [stackoverAre you using the current version or a later version of health kit. Try taking it out and thenputting it back into the system. And resubmit The
it – MNM Seppost
27 '16 at 6:02
flow.com/questions/39716868].
asks about
i'll try it. – Divyesh Savaliya
Sep 27 for'16 at 6:08
required okey
descriptions
in iOS
requesting access to a
resource. why down vote? please mention reason – Divyesh Savaliya Sep 27 '16 at 6:54
1

Hey, what was the final solution? Because when I read to read users daily steps

We chosenarrowdown
thebythehand, rather thandata toit seems
you're only
reading thedata dataset
so you only need
NSHealthShareUsageDescription key, not the NSHealthUpdateUsageDescription
by using query
terms
such
aswhy
privacy,
becauseone. And thatwould bethe reason
you got rejected.
– Nico Febour
22 '17 preliminary
at 22:22
investigations found that posts about our target topics often did notuse such terms in the titles nor tags. In addition, as we noted in §3.2,
previous research has shown that the topic of privacy may come up
indirectly; our inclusion criteria were based on those studies. We
excluded posts about health apps for Android and iOS that were
not about our target topics, as well as a handful that were caught
by our query terms but were not about health apps or were notabout our target OSes.
Selection was performed by the first two authors independently
coding the same 5% of the data for inclusion or exclusion; interrater
agreement for that initial test batch was 81%. They then split thedata and each coded half of the rest, flagging any “maybes” toresolve through discussion. Posts were included if the target topics
were mentioned in any part (i.e., question, answers, or comments).
However, we excluded cases where the posters only mentioned the
topic in passing, for example, in listing potential code errors they
had already checked for.
Posts often referred to Android and WearOS together, or iOS
with WatchOS. Grouping each family of OSes together, there were
496 unique posts about Android and WearOS and 569 unique posts
about iOS and WatchOS (going by titles and tags) in the initial dataset. Of these, 26% and 24.6% were privacy-related, respectively, andthus were included in the final dataset. (See Table 3 in Appendix B
for a breakdown by query term.)

4.3

Qualitative Analysis

The first two authors qualitatively coded the 269 privacy-related
posts. Again, all parts of the posts were included (question, answers,

EuroUSEC 2022, September 29–30, 2022, Karlsruhe, Germany

5

FINDINGS

A quarter of all the posts we collected related to mobile healthapps were about privacy (25.5%), indicating that privacy is a major
source of difficulty in working with health features. As we notedin §4.2, the proportions of privacy-related posts relating to eachof our target OSes (relative to the initial datasets for those OSes)
were similar; neither OS seems to be presenting disproportionately
more challenges as regards health and privacy features. However,as we will describe in detail below, the specific questions for each
OS tended to be different.

5.1

Description of the Final Dataset

Table 1 shows the numbers and proportions of questions in the
final dataset from posters developing for each of the target OSesand health frameworks.3 In addition to smartphone apps, 51 posts
out of 269 (19%) related at least in part to apps for specialized OSesfor wearable sensor devices. For the most part, posters developing
for iOS or WatchOS were using Apple’s integrated HealthKit framework (including WatchKit) and posters developing for Android or
WearOS were using Google Fit, but there were some exceptions
that crossed platform lines. A few developers of Android and iOS
apps were working with health data from other systems.
Privacy vs. access control. The vast majority of posts in our final
dataset were about dealing with access control issues (e.g., permissions or authentication systems), rather than explicitly framed interms of privacy concepts. Stack Overflow users explicitly mentioned data privacy or sensitivity in 8.6% of the posts in the final
dataset (amounting to 2.2% out of all 1,055 health-related posts in
the initial dataset):[A]4 Google Fit restricts write access for the datatypes in HealthDataTypes to only certain developers because health data is potentially sensitive.
[stackoverflow.com/questions/44523685]

5.2

Themes and Changes Over TimeThe number of posts in our final dataset relating to each major OS
is fairly similar overall. As Figure 2 shows, the proportions of posts
3 Except as otherwise noted, OS numbers in this section are based on the more accurate

hand-coding of platforms, based on the entire post. They differ from those given in
Table 3 (in Appendix B), which were based only on title and tags. In particular, posters
asking about apps for WearOS or WatchOS often did not tag them nor mention thewearables-specific OS in the post title.
4 When quoting, we use [Q] for questions, [A] for answers, and [C] for comments.

Android/WearOS

50

iOS/WatchOS

40
Count of questions

and comments). First, they independently analyzed an initial batchof 36 posts, using an inductive approach with open codes [49, 59],
discussed their findings, and identified the major topics or theme
groups. They then independently coded another batch of 36 posts,
discussed, and built an initial codebook. The two coders continued
coding all posts, jointly resolving disagreements, and adjusting thecodebook based on the additional posts as well as input from thethird author. Kupper-Hafner interrater agreement [43] for thematic
coding across all posts was 60% (codes were not mutually exclusive,and posts could have multiple codes). At the same time, one of thecoders also recorded which OS and health-data framework eachposter was developing for.

Mohammad Tahaei, Julia Bernd, and Awais Rashid

30
20
10
0

16 17

17 18

18 19
Creation year

19 20

20 21

Figure 2: Count of health and privacy-related questions overthe five-year period for each operating system (N = 265
posts; does not include posts about multiple OSes).
relating to each major OS changed noticeably across the five years
in the dataset. The spike in posts about Android apps in 2020–21
may have been due to new policies, restrictions, and verification
processes that were introduced for Google Fit in October 2020 andwent into force in May 2021 [30]. The numbers of posts about Apple
HealthKit are less variable. There is a slight dip in 2019–2021; if
there have been fewer major changes to privacy processes than for
Google, documentation may have been better able to catch up, andSO users may be more able to reuse solutions proposed in the past.
Table 2 shows the frequency of each of the themes we identified,grouped into major topics. The following subsections each discussa group of themes in detail. Figure 3 breaks down the frequency ofeach theme over the five years of the dataset, for each major OS(does not include posts about multiple OSes).
5.2.1 Problems and inspirations for posting. The first group of
themes concerns what problem or question inspired the poster
to post on Stack Overflow. Unlike the other groups of themes, weapplied these codes solely based on the initial question asked. The
great majority of Stack Overflow posts about health app permissions or privacy (89.6%) were made because the asker was trying
to figure out how to get access to a protected resource, suchas reading health data either from a framework, a sensor on thesmartphone, or another device, or writing to the framework datastore.5
However, the specific focus of posts about data access tended
to differ depending on which platform the developer was working
with. For example, many of the posts from developers working
with Apple HealthKit were concerned with how to get permissions
requests and permissions justifications right. Such posts often focused on the interaction with the user via the permissions dialog.
5 We report numbers here to demonstrate the frequency with which each challenge ismentioned in our dataset; we do not assume that they represent the frequency withwhich those challenges occur.

Privacy, Permissions, and the Health App Ecosystem: A Stack Overflow Exploration

EuroUSEC 2022, September 29–30, 2022, Karlsruhe, Germany

Table 1: Posts about each operating system and health framework in the final dataset (N = 269).
Operating System

Posts

iOS (only)
Android (only)
WatchOS and iOS
WearOS and Android
Android and iOS
Tizen and Android

108 (40.1%)
107 (39.8%)
32 (11.9%)
18 (6.7%)
3 (1.1%)1 (0.4%)

Health Framework

Posts

HealthKit
Google Fit
Samsung Health
Other framework
Google Fit and HealthKit
Google Fit and Samsung Health
Unspecified
None (but unintended HealthKit; see §5.2.1)

134 (49.8%)120 (44.6%)6 (2.2%)2 (0.7%)1 (0.4%)1 (0.4%)1 (0.4%)4 (1.5%)

Table 2: Frequency of constructed themes. Occurrences were counted at the level of the whole post (N = 269). Views, Answers,
Comments, and Score show the sum of values for all posts with that theme. Score is the difference between up votes and down
votes.

Theme
Theme group: problems or inspirations for asking
Need access to data or resource
Error or crash
App store submission or review problem
Too much/unexpected data access
Unintended attempts to access health data
Theme group: causes or sources of problems
App store requirements
Third-party components
Ethical considerations
Legal requirements
Theme group: proposed solutions
Fix permissions/authentication
Fix other code errors
Not supported; bug; use an alternative option
Follow health-specific requirements in app stores
Theme group: attitudes and wishes
Confusion about requirements/processes
Need better documentation
Clear feedback needed
Frustration with existence of requirements/desire to bypass them
Theme group: references to external sources
Official documentation
Other sources (e.g., how-tos and blogs)
Theme group: mention of data privacy or sensitivity
Mentioned explicitly
A particular source of confusion in iOS was the feedback an app
gets about whether the permissions request was successful. To protect users’ privacy, Apple does not report to the app whether theuser granted or denied a health permission request, only that therequest was successfully made [10]. However, this runs contrary todevelopers’ default assumption of what a returned value of “true”
means for such an action:

Posts

Views

Answers

Comments

Score

241 (89.6%)
100 (37.2%)
22 (8.2%)
11 (4.1%)
4 (1.5%)

186,782
97,682
17,936
9,600
2,318

223
102
27
8
3

341
150
47
14
15

302
140
44
10
5

35 (13.0%)
35 (13.0%)
14 (5.2%)
5 (1.9%)30,014
18,564
10,840
1,815

46
31
16
5

58
63
22
5

58
35
16
2

158 (58.7%)
64 (23.8%)
61 (22.7%)
26 (9.7%)

159,01375,09558,61628,825

195
90
68
44

275
146
135
44

236
136
106
54

73 (27.1%)
51 (19.0%)
27 (10.0%)
14 (5.2%)

45,22457,061
40,660
8,572

70
55
33
16

106
98
46
20

98
101
70
8

132 (49.1%)
80 (29.7%)

128,066
70,967

158
96

239
138

210
122

23 (8.6%)

16,145

32

32

32

[Q]
The
methodrequestAuthorization(toShare:read:completion:) which asks for
authorization always produces a true when thecompletion handler returns—success in my code
below. Even when I decline everything in thesimulator i get a true . . . . [A] You’re misinterpreting
what that success flag means. YES means that thepermission screen was successfully shown and NOEuroUSEC 2022, September 29–30, 2022, Karlsruhe, Germany

Mohammad Tahaei, Julia Bernd, and Awais Rashidmeans that there was an error presenting the permissions screen [quote from official documentation].
[stackoverflow.com/questions/39233297]

cahnges need to be done to remove the referenceof HEALTHKIT framework from the application.
[stackoverflow.com/questions/55442764]

With Google Fit, we found that many more posts were concernedwith how to establish a connection to the framework involved.
Establishing and managing an OAuth client requires extra effort;
Google requires apps to be signed with the developer’s private key
and use a OAuth 2.0 client ID to access Google Fit [27]. Creating
and managing certificates for this connection was a challenge.
Another frequent inspiration for posting was seeking the causeof an error or crash (37.2%). Askers often copy-pasted the error
message or took a screenshot and asked for help or an explanation:

A few questions (4.1%) were inspired by posters discovering (orthinking they had discovered) that their health app had access toa health resource they did not intend it to, i.e., having too muchaccess. In some cases, the developers were trying to find a way to
revoke access because it was causing a problem in their authentication process. In other cases, they simply noticed it and were
confused or concerned:[Q] Once I disable unable to reconnect. if try upload data to google fit I’m getting [this] error. There
was a problem reading the data. com.google.android.gms.common.api.ApiException: 4: The user must be
signed in to make this API call. [stackoverflow.com/
questions/49106474]
Errors and crashes often occurred because the app did not havepermission to access a resource or was unable to authenticate correctly to the API; 95% of the time, this theme co-occured with needresource access. Accordingly, the types of errors differed dependingon the platform in similar ways to resource access problems. One
common cause of crashes in iOS was forgetting to include usage
descriptions (i.e., to explain to users why a permission is needed).
The HealthKit documentation includes a prominent warning about
this [11]; however, it is not clear why it triggers a crash rather
than an error or notification. In Google Fit, troubles with OAuth
certificates sometimes caused errors.
Some questions (8.2%) were prompted by a submission or areview problem in the app stores. Problems included uncertainties
about submission instructions for health apps, automatic rejectionsof submissions that did not adhere to requirements (see §5.2.2), andapps being rejected after review by the store:[Q] I’m having trouble getting my app approved, andto be honest, I’m having trouble understanding what
Apple are on about in this case. My app only uses
HealthKit to create, pause, and finish a workout. It
does not read any data [quote from app store feedback] The problem appears to be with my watchOS
app not asking for permission to use the Health app.
[stackoverflow.com/questions/42568105]
A few posts (1.5%) asked about a specific type of submission
problem in the Apple App Store that was triggered by non-healthapps that accidentally had a HealthKit call or a health permission
listed. In three out of the four cases, the HealthKit references werein third-party libraries, and were difficult for the developer to findand remove:[Q] My xamarin.ios build has been rejected fromthe app center due to reference of HEALTHKIT
framework. I can’t set linker to SDK framework
only because of some 3rd party liberary. Also, I
have uploaded a nee build with mtouch parameter “–linkskip=HealthKit”, still my app got rejected
2nd time. Can anyone please guide me what more

[Q] The problem I have is that when I revoke accessof my app from the user’s account web page the Play
Services client library still lets me use silentSignIn
without a problem. So my question is—is this theproper way to get user’s authorization to accesstheir data? Is there a better or more accurate way?
[stackoverflow.com/questions/49938922]
5.2.2 Causes or sources of issues. This group of themes identifies towhom or what the poster—or a commenter or answerer—explicitly
attributed the cause(s) or source(s) of their problem or challenge.
We captured all such sources, whether they came up as part ofthe problem description or were identified by someone offering
a potential solution. We tried to rely only on explicit statements
rather than drawing inferences based on our own knowledge, as
we were interested in who or what developers themselves see as
the active players in their context.
When talking about why they were having an issue, posters
very often referred to framework requirements or limitations,
i.e., requirements imposed by the relevant health-data frameworks(mostly Apple HealthKit or Google Fit) or by the OSes, or limitations
on what could be done within those frameworks:[A] You should simply request authorization toread/write samples of the HKWorkout sample
type. There are not fine-grained authorization
controls for each individual activity type, suchas HKWorkoutActivityTypeEquestrianSports, in
HealthKit. [stackoverflow.com/questions/41251169]
We did not code for this theme separately and attempt to quantify
it, in part because it was frequently difficult to tell whether a poster
intended to specifically attribute framework requirements as thecause of their issue or was only providing context. However, it isworth noting that framework requirements or limitations were mentioned, or at least indirectly evoked, almost any time posters asked
about problems accessing resources, as well as being frequently
mentioned or evoked in discussions of other types of problems:[Q]Is it still the case that a user cannot grant HealthKit
access on the watch alone even though Watch Series 3 now can be completely untethered via LTE?
[stackoverflow.com/questions/47127864]
Another source of problems or constraints were app store requirements (13%). Posters had sometimes recognized these constraints during development, when they were blocked from accessing a needed resource, but often did not recognize them until
they encountered a submission or review problem. Requirements
included specifications for what should be in the code, includingPrivacy, Permissions, and the Health App Ecosystem: A Stack Overflow Exploration

iOS/WatchOS

EuroUSEC 2022, September 29–30, 2022, Karlsruhe, Germany

Android/WearOS

Problem: need resource access

Problem: error/crash

Problem: submission or review problem

Problem: too much access

Problem: not health

Cause: app store requirements

Cause: third-party components

Cause: ethical considerations

Cause: legal requirements

Solution: fix permissions

Solution: fix other code errors

Solution: not supported, use alternative options

Attitude: follow health requirements in app stores

Attitude: need better documentation

Attitude: confusion about requirements

Attitude: clear feedback needed

Attitude: frustration with requirements

Ref: official documentation

Ref: links to other sources

privacy/sensitivity mentioned

16 17 17 18 18 19 19 20 20 21
Creation year

16 17 17 18 18 19 19 20 20 21
Creation year

16 17 17 18 18 19 19 20 20 21
Creation year

16 17 17 18 18 19 19 20 20 21
Creation year

Count of questions

40
30
20
10
0

Count of questions

40
30
20
10
0

Count of questions

40
30
20
10
0

Count of questions

40
30
20
10
0

Count of questions

40
30
20
10
0

Figure 3: Count of health and privacy-related questions per theme with the two major operating systems (N = 265 posts).

EuroUSEC 2022, September 29–30, 2022, Karlsruhe, Germany

correctly formatted permissions strings and (for some apps) encryption, as well as other types of requirements like disclosing
health data collection and use in the app description, or developer
verification:[Q] Everything works fine when installing the app
from Android Studio or via side-loading. However,once I signed the APK and posted it on Play Store,
the Fit History API part stopped working. . . . I havea hunch that when publishing an app on Play StoreI need to do something special with regards to thefact that my app uses Fit History API. [stackoverflow.
com/questions/49696997]
In particular, many recent posts were inspired by Google’s newverification process specifically for health apps (see §2).
Users sometimes explicitly cited ethical considerations andvalues-based explanations for why health data is or should be considered worthy of protection or special treatment, or how users
should be respected (5.2%):[C] Apple unfortunately won’t allow you to get theApple ID for the user, as this would be a privacy
concern if any app could access that information.
[stackoverflow.com/questions/64049847]
In particular, ethical explanations most frequently cooccured with
explicit mentions of privacy or data sensitivity; however, under ethical considerations, we picked out posts where Stack Overflow users
gave more detailed reasoning about ethics as a source of limitations.
The two themes did not always overlap; for example, permissions
might be described as a transparency mechanism without being
explicitly framed in terms of privacy:[A]
Android10
introducestheandroid.permission.ACTIVITY_RECOGNITION
runtime permission. . . . This is designed to give
users visibility of how device sensor data is used in
Settings. [stackoverflow.com/questions/59189266]Requirements introduced by laws and regulations, including
legal obligation via privacy policies, were mentioned in a few posts(1.9%):[A] And in some regions (such as the USA, and I
suspect even more strongly within the EU), healthprivacy is considered a relatively important & legallyrequired thing. So your app’s users have to officiallyacknowledge and permit your app to read HealthKit
data. [stackoverflow.com/questions/48493980]
For the most part, including in the examples above, ethical andlegal considerations were cited as secondary causes explaining therequirements of the framework or platform in question, often as
context for a quote from official documentation. However, in somecases, they were mentioned as explanations in themselves:[A] This is really a question for a lawyer and something you need to consider in terms of various privacy laws around the world as well as your own
potential liability. I don’t believe that Apple forbids it as long as the user grants you permission.
[stackoverflow.com/questions/66286031]
The situation is similar for explicit mentions of privacy or sensitivity.

Mohammad Tahaei, Julia Bernd, and Awais Rashid

Relatedly, it is worth noting that these explicit mentions of ethicalor legal considerations, or of the privacy or sensitivity of data,
were more often brought up in a comment or an answer thanraised in the original question. In only 14% of the posts citing
ethical considerations and 20% citing legal considerations, and in
only 22% of posts explicitly mentioning privacy or sensitivity, did
those themes come up in the original question. In all of the othercases, the original poster asked a question about access control or
submission problems, and the privacy, ethical, or legal context for
those structures was introduced by someone else.
Third-party components, such as wearables and sensor devices, data sources, tools, and frameworks or libraries—including
other health frameworks such as Samsung or Garmin Health—were
attributed as the cause of a problem as often as app store requirements (13%). This highlights the impact of such components ondevelopers’ workflows:[Q] I use react-native-google-fit [bridge] package to
get the steps data about the user. In my case thispackage works fine in some devices but in some others
cant get any data or response from the google-fit API. . . . I implemented bugnsag to track the steps and theprocess stucks when I call google-fit API to get step
samples. [stackoverflow.com/questions/63613349]
For the most part, developers who mentioned problems with thirdparty components were largely having trouble syncing data (intentionally) or sorting out authentication between the various elements.
But as we noted in §5.2.1, third-party tools and libraries could also
introduce unexpected data calls or permissions requests.
5.2.3 Proposed solutions. We also examined the solutions or resolutions proposed in both answers and comments (including solutions
mentioned by the original poster, if they added a comment or answer to their own question). We looked at both accepted, successful
solutions and solutions that were downvoted or that the original
poster said were unsuccessful or irrelevant, as all of these provide
insight into how developers think about the problems at hand.
A majority of solutions suggested ways that the poster could fix
permissions or authentication requests (58.7%). Suggested fixes
included adding a permission request to code, fixing the syntax
of a permission or authentication request (especially by adding apurpose description), and taking some action to reset permissions
status (e.g., by reinstalling):[A] There are two Info.plist files that need
NSHealthShareUsageDescription and NSHealthUpdateUsageDescription. One in the project file andone in the watch extension file. I had only done
one of these. The strings for these also need to bea reasonable length and cannot be just a couple ofwords. [stackoverflow.com/questions/60081551]
Both Apple and Google require such a purpose description, as wellas an explanation in the permissions dialog about the intended useof the data.
Some of the solutions provided specific advice about how tofollow health-specific requirements in app stores (9.7%) (see§5.2.2). Advice might include registering as a health app developer(or registering test users) with the app store, or disclosing the use

Privacy, Permissions, and the Health App Ecosystem: A Stack Overflow Explorationof health data (via upload checkboxes, app descriptions, and/or
permissions lists):[A] This is Private Policy for my app which uses
HealthKit: [link]. It is fine for Apple Review team.
You should also write that your app uses HealthKit inapp’s description in ItunesConnect (e.g ‘HealthKit displays the amount of steps you need to make today’).
[stackoverflow.com/questions/39688057]
Many suggested solutions (23.8%) involved fixing other aspectsof the app unrelated to privacy, permissions, or authentication.
Fixing other code issues might include updating versions, e.g.,of a library, or fixing the syntax of non-permissions-related code,
as well as removing references to health data in non-health apps:[A] This is a concurrency problem, not a HealthKit
problem. . . . . You have to wait for the answer of requestAuthorization before you continue reading birthday and biologicalSex. [stackoverflow.com/questions/
40396194]
Some answers and (especially) comments suggested that there
was no supported solution for the asker’s problem (22.7%). In
some cases, the operating system or health framework is not designed to allow the desired app behavior:[Q] Does HealthKit report to the cloud that can beaccessed with an API? Or does it need to be an app
that accesses the HealthKit data locally? [A] Thereis no cloud API, you would have to create an app
that reads the HelathKit data and reports it to yourbackend. [stackoverflow.com/questions/60175535]
In other cases, there was an unresolved bug in the system:[C] I think there is an open bug report regarding
reading HealthDataTypes, try following that report tobe updated. [stackoverflow.com/questions/46110711].
In some cases, answers or comments suggested workarounds or
third-party alternatives for unsupported features/bugs.
5.2.4 Developers’ Attitudes and Wishes. Some posters explicitly
expressed their feelings or attitudes about the issue they were
having, or their wishes for changes that they thought would maketheir situation better.6
Posters complained about unhelpful documentation or expresseda need for better documentation (19%). Problems included documentation being difficult to find or understand, missing key information or examples, or relying on sample code that did notwork:
I need my app to read step count from Google Fit.
I’m using health 3.05 package. For now I copied theexample code to see if it works and unfortunately
it’s not. Of course I did every step from this packge
readme. [stackoverflow.com/questions/67432179].
Others complained about unclear runtime error messages,
crashes with no error messages, or unclear app store rejection
notices, and expressed a need for clear feedback (10%):
6 Feelings and attitudes can be more difficult to reliably identify in text. The two coders

tried to rely only on explicit cues, and interrater agreement scores for this group ofcodes were similar to the rest.

EuroUSEC 2022, September 29–30, 2022, Karlsruhe, Germany[C] The first line of the guideline I quoted in myanswer (the guideline you were rejected on) says
apps must “indicate that integration in their app description.” Although I agree that Apple could certainly have been clearer in their rejection notice.
[stackoverflow.com/questions/39716868].
As we noted in §5.2.1, even successfully completed operations could
produce confusing feedback.
Askers and answerers sometimes expressed their confusion
about requirements or processes (27.1%).7 Situations prompting
such expressions included not knowing how to accomplish a task
within the framework, not knowing why code was not achieving
the expected results (including code from suggested solutions), or
not knowing why a particular configuration behaves in a specificway:[Q] The watch face authenticates and receive fit
data. Without actual OAuth Client and a Client ID!
I thought there was some kind of caching in action.
But now it’s several hours and it keeps working. Does
anybody have any idea WHY? How is this possible?
[stackoverflow.com/questions/42228885].
A few posts (5.2%) expressed frustration with the existenceof requirements or a desire to bypass those requirements,8e.g., HealthKit’s or Google Fit’s permissions structures:[C] It seems like permissions overload to require thisas a permission when the user has to grant location
access for this to be useful anyway. [stackoverflow.
com/questions/45437669].
Sometimes, this attitude might result from the differences between
how the two major frameworks handle health data:[Q] Are there any third party which provide data ofapple health kit data using there end points like google
fit provide us via rest api’s [link to documentation][stackoverflow.com/questions/60482930].
5.2.5 References to other resources. Stack Overflow users often
provided links to or quotes from external resources. Those resources
included official documentation (in 49.1% of posts) such as Apple,
Android, HealthKit, or Google Fit web resources, libraries, andtutorials with sample code, or similar resources for third-party
tools. References to other sources (29.7%) included online tutorials,
blogs, example GitHub repositories, and other Stack Overflow posts.
Stack Overflow can in itself function as an aid to understanding
such documentation. In some cases, when question-askers included
quotes from documentation they were trying to follow, they asked
their fellow Stack Overflow users to help explain it. In answers andcomments, users sometimes explained parts of documentation thatthey perceived the asker had misunderstood, as well as pointingout documentation the asker might not have seen.
7 It is likely that many people who decide to ask a question on Stack Overflow arefeeling confused. This theme picks out those who express their feeling of confusion
explicitly in the public forum.
8 This theme captures negative attitudes towards the requirements or limitations
existing in the first place (or demonstrating a desire to get around them), as opposed
to negative attitudes about the difficulty of implementation, which are captured underconfusion about requirements.

EuroUSEC 2022, September 29–30, 2022, Karlsruhe, Germany

6

DISCUSSION

Above, we described the themes we constructed through our qualitative analysis of 269 Stack Overflow posts about privacy andpermissions in health apps for Android or iOS. In the following, we
discuss the implications of our findings and suggest future research
avenues.

6.1

Who Triggers Privacy Discussions?

In our sample, posters did not tend to explicitly frame questionsin terms of data privacy, nor in terms of legal regulations or ethical considerations when dealing with sensitive data. For the mostpart, where those themes came up at all, they were introduced bythose answering or commenting, rather than motivating an initial question—and were most often introduced in the process of
explaining platform and framework requirements.
Since their interaction is with the platforms and their requirements, developers’ motivation is generally to satisfy the requirements so they can distribute their app. For example, the introductionof additional restrictions and verification processes for Google Fit
apps prompted an increase in questions on that topic.
These findings are in line with prior work on health app security;for example, a study with 97 health app developers showed that theirprimary reasons for considering security measures were to avoid
legal issues and financial losses [5]. More broadly, this study adds
to a body of work showing that software development platforms
play a critical role in developers’ motivation to implement privacy
features [7, 32, 62, 73]. For health apps, this role may be played by
the health frameworks that provide the data rather than the OSesor app stores, but the motivational structure is similar.
While we did not observe many questions explicitly discussing
legal issues, regulations can still impact developers’ workflows,
workloads, and privacy concerns. For example, the change in thenumber of questions over the course of 2016–2019 may be related
to how GDPR was reflected in platforms’ changing policies andprocesses for data handling.
Many studies show apps are often noncompliant with privacy
regulations [56, 57], including health apps [63, 74, 83]. Prior work
outlines how privacy regulations in general can encourage attention
to privacy among technology developers—but also the challenges
they may face in implementing them [7, 18, 82]. For example, mobile
app developers find it challenging to find relevant information
hosted by on ad networks’ platforms about the privacy regulations
that pertain to ad services, and to integrate regulation-compliant
ads [71]. However, we believe that regulations may act as a catalyst
for conversations about privacy within technical communities.

6.2

Design Implications for Privacy-Related
Documentation and Review Tools on
Health Features

Improving platforms’ documentation on health-specific requirements. Few Stack Overflow posters questioned the necessity forenhanced permissions structures for health data; most seemed toaccept it as a given. However, many posters expressed confusion
about what the requirements are, and often complained of a lack ofclarity from the platforms about how to comply with their privacy

Mohammad Tahaei, Julia Bernd, and Awais Rashid

requirements. While Apple and Google provide plenty of documentation about their health frameworks, developers seem to still havetrouble interpreting it or finding answers to their questions.
We find that, while there are many resources about developingwith HealthKit and Google Fit—such as online tutorials, videos, andblogs—official documentation (see §5.2.5) is still the most cited resource in our dataset. This highlights how much developers rely on
official documentation; it impacts millions of developers—and therefore millions more users. Improving the quality of documentation
has the potential to impact how developers treat their users’ privacy; as we described in §6.1, platforms are often the main driversof developers’ understanding of privacy.
Developing review tools to detect health data use. One of the recurring complaints we saw among Stack Overflow users (including
developers of non-health apps) was having an app rejected because
they had some health permission listed in their app that they did
not intend to, or because of other problems stemming from thirdparty components [cf. 7, 17, 77]. One solution could be integrating
automatic checks for health data into programming tools or before
submitting an app to an app store. Platforms could benefit fromfewer flags for app reviews, and developers could save time by nothaving to go through the app submission process multiple times.
Improving privacy documentation for third-party tools. A largerscale solution would be to provide incentives and channels forthird parties to better document and communicate the privacy
implications to developers who integrate their components [cf. 68,77]. One potential direction is to start with privacy “nutrition labels”[e.g., 42], borrowing from research on labels for end users, but
accounting for the different needs and understanding of developers.

6.3

Capturing the Broad Framing of Privacy
Discussions in Developer Forums

To capture all the ways that privacy considerations play out insystems that health app developers interact with, we found that weneeded a different approach than previous research. For example,
to analyze how developers themselves conceptualize privacy, Tahaei et al. [73] collected Stack Overflow posts that had “privacy” intheir title or tags. In contrast, for this study, we instead began withposts about health apps for Android and iOS, then hand-picked the269 posts that had a privacy angle. This approach captured broad
aspects of app structure that are motivated by privacy or that haveprivacy consequences (namely, permissions, authentication, encryption, and data security)—whether or not “privacy” is mentioned. If
we had focused only on threads where the discussion specificallymentioned privacy per se, we would have had only 23 posts in our
final dataset—and if we had only included posts where “privacy”
was in the title or tags, we would have had only one post left (apost on privacy policies). Our broad rubric allowed us to collect a
dataset large enough—and comprehensive enough—to provide richinsights into health app developers’ privacy challenges.

6.4

Limitations

Our study may suffer from selection bias, due to our choice of
keywords for the initial dataset and the fact that we only queriedon titles and tags (an approach similar to other privacy and security

Privacy, Permissions, and the Health App Ecosystem: A Stack Overflow Exploration

EuroUSEC 2022, September 29–30, 2022, Karlsruhe, Germany

research on developer forums [e.g., 45, 73, 84]). An alternative
approach might sample random posts, and identify relevant postsby manually coding them; however, this approach would be very
time-consuming relative to the number of relevant posts it would
find.
Among the themes we identified and analyzed in the final dataset,some were more concrete and easily relatable to the posters’ explicit
statements, while others relied more on subjective interpretationof the posters’ intent. Two authors coded each post to improvereliability and reduce bias.
Our sample covers developers who were inspired to post in ahelp forum, meaning almost entirely people who currently had aprogramming problem they wanted to solve. While this fits ourRQs—finding out what the challenges are—it gives a limited viewon how health app developers think about privacy more broadly.
In addition, though Stack Overflow is one of the largest Q&A
websites for developers, our findings may not be generalizable toall health-app developers and developer forums.

of documentation have the potential to substantively improve developers’ understanding of how to accomplish privacy tasks, andof the privacy implications of their choices about app structure.
Increasing such support for health app developers could in turnhave an impact in improving privacy protections in the health data
ecosystem.

6.5

Future WorkIn addition to exploring the potential tools and standards suggestedin §6.2, future research on this topic could: (1) identify a broader
set of challenges (beyond those that could be addressed via Stack
Overflow) by conducting interviews or surveys with health-app
developers; (2) compare how privacy is addressed in documentation for health-specific vs. general software development platforms
and data frameworks, and suggest improvements; and (3) further
examine the interaction between health privacy regulations andregulation-driven platform requirements or software features inchanging health app developers’ privacy practices and workflows.

7

CONCLUSION

Health-specific requirements imposed by Apple and Google haveintroduced new challenges and complications for developers—for
example, Apple’s requirement for specific explanations of healthdata use in app descriptions, or Google’s new submission procedure
with an extra step for apps that use health data. Developers also faceissues caused by unexpected data collection and sharing practicesof third parties, which may violate the health-specific requirements.
The privacy efforts of most developers in our dataset were driven
largely by the requirements and limitations imposed by healthframeworks, platforms, and app stores. However, many developers
found it challenging to figure out how to comply. There were many
complaints about unclear, difficult-to-find, or non-working official documentation, highlighting the value of platforms’ providing
usable documentation about privacy features.
In sum, we found that platforms’ requirements and documentation significantly impact how health app developers engage withand address privacy challenges in dealing with health data. Whileplatforms’ extra privacy measures to protect health data are laudable, we find that the ways they are implemented can turn into
an additional burden on developers. We believe those extra measures need to be easier for developers to work with. A first step
could be to address how privacy is covered in the documentationof health data frameworks, health-tracking devices, and app marketplaces. Improvements in coverage, framing, and organization

ACKNOWLEDGMENTS
This work is partly supported by the UK Engineering and Physical Sciences Research Council (grants “Why Johnny doesn’t write
secure software? Secure software development by the masses”
EP/P011799/2 and EP/V011189/1), the U.S. National Science Foundation (grant CNS-2055772), and the U.S. National Security Agency(contract H98230-18-D-0006).

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system{ios, an{health,google-fit,
medical,andlimits,
operatingsystemandroid,watchos,
wearos}(duefitness}to server
we werenot{ios,able
todroid, watchos, wearos} (due to server limits, we were not able tocombine all into one query).
combine all into one query).
SELECTDISTINCT ∗FROM
Posts p
WHERE((
Lower ( t i t l e ) LIKE ' % f i t n e s s % 'AND Lower ( t i t l e ) LIKE ' %wearos% ')OR (Lower ( t a g s ) LIKE ' % f i t n e s s % 'AND Lower ( t a g s ) LIKE ' %wearos% ')OR (Lower ( t i t l e ) LIKE ' % f i t n e s s % 'AND Lower ( t a g s ) LIKE ' %wearos% ')OR (Lower ( t i t l e ) LIKE ' %wearos% 'AND Lower ( t a g s ) LIKE ' % f i t n e s s % '))INITIAL AND
AND FINAL
FINAL DATASETSBB INITIALDATASETS BY
BYQUERY
QUERY
TERM
TERM

EuroUSEC 2022, September 29–30, 2022, Karlsruhe, Germany

Mohammad Tahaei, Julia Bernd, and Awais Rashid

Table 3: Initial and final datasets of Stack Overflow posts, by query term. These are based on the posters’ tags and titles.
FitnessAll

Privacy Related

HealthAll

Privacy Related

MedicalAll

Privacy Related

All unique1

Google-Fit
All

Privacy RelatedAll

Privacy Related

Android56
13 (23.2%)
76
15 (19.7%) 12
1 (8.3%) 400
119 (29.8%)495
129 (26.1%)iOS
12
3 (25%) 508
128 (25.2%)
50
7
1 (14.3%)
526
132 (25.1%)
WearOS1
1 (100%)000053 (60%)
5
3 (60%)
WatchOS1
0 (0%)
84
15 (17.9%)
0
0
0
0
84
15 (17.9%)
All unique2 67
16 (23.9%) 620
150 (24.2%) 15
1 (6.7%) 407
123 (30.2%) 1,055
269 (25.5%)
1: Total number of posts tagged or titled for the respective OS. Does not equal the sum of the preceding columns because some posts
had multiple health-related keywords.
2: Total number of posts tagged or titled with the respective health-related keyword. Does not equal the sum of the preceding rows
because some posts had multiple OS keywords.