Accepted for/Published in: JMIR mHealth and uHealth
Date Submitted: Dec 14, 2025
Open Peer Review Period: Dec 14, 2025 - Feb 8, 2026
Date Accepted: Jul 13, 2026
(closed for review but you can still tweet)
Caregiver App Use and Child Behavioral Adherence with Obesity-Related Outcomes in an mHealth App-Assisted Childhood Obesity Intervention: A Secondary Analysis of a Cluster Randomized Trial
ABSTRACT
Background:
Childhood obesity remains a major public health challenge. Mobile health (mHealth) interventions offer a scalable approach to support behavior change, but their effectiveness depends heavily on participant engagement. While both caregiver and child adherence are crucial, few studies have objectively measured and jointly analyzed their impact within digital obesity interventions.
Objective:
This study aimed to evaluate the independent and synergistic effects of caregiver engagement with a health app and child behavioral adherence on obesity-related outcomes in a school-based mHealth intervention.
Methods:
We analyzed data from 684 child-caregiver dyads in the intervention arm of the Diet, ExerCIse and CarDiovascular hEalth (DECIDE)-Children cluster randomized trial, implemented across three socioeconomically diverse regions in China. Caregiver adherence was objectively measured via app usage frequency and total duration. Child adherence was assessed through weekly behavior monitoring scores covering diet and physical activity. Linear mixed models estimated associations between adherence levels and changes in anthropometric and physical fitness outcomes over 9 months.
Results:
Higher caregivers’ app usage frequency and duration were both significantly associated with reductions in children’s obesity-related indicators, such as body mass index (BMI)(β = -0.19, P = 0.005), BMI Z-score (β = -0.08, P = 0.006), and body fat percentage(BFP) (β = -0.70, P = 0.005) for frequency. Greater child behavioral adherence was linked to lower BFP (β = -0.63, P = 0.012) and better physical fitness, including shorter shuttle run time (β = -3.63, P < 0.001) and longer standing long jump distance (β = 2.88, P = 0.005). A significant interaction between app usage frequency and duration was found for rope skipping performance (P = 0.048), suggesting possible synergistic benefits of more frequent and prolonged app engagement. Joint adherence analyses indicated that children in the “high caregiver–high child adherence” group achieved the greatest improvements, including a BMI reduction of -0.22 (P = 0.017), a BFP reduction of -1.18% (P = 0.001), and 7.45 additional rope skipping repetitions (P = 0.003) compared with the “low caregiver–low child adherence” group.
Conclusions:
In this mHealth App-Assisted intervention, high adherence from both caregivers and children was associated with significantly greater improvements in weight status and physical fitness. These findings underscore the importance of co-engagement in digital health programs and highlight the potential of app-supported, family-engaged strategies for childhood obesity prevention. Clinical Trial: ClinicalTrials.gov Identifier NCT03665857
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Copyright
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