JMIR CANCER Mallafré-Larrosa et al

Original Paper

Development and Promotion of an mHealth App for Adolescents

Based on the European Code Against Cancer: Retrospective
Cohort Study

Meritxell Mallafré-Larrosa1,2, MD; Ginevra Papi1, MSc; Antoni Trilla2, MD, PhD; David Ritchie1, PhD
1
Association of European Cancer Leagues, Brussels, Belgium
2
Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain

Corresponding Author:
Meritxell Mallafré-Larrosa, MD
Association of European Cancer Leagues
Chaussée de Louvain 479
Brussels, 1030
Belgium
Phone: 32 2 256 2000
Fax: 32 2 256 2003
Email: [email protected]

Abstract
Background: Mobile health technologies, underpinned by scientific evidence and ethical standards, exhibit considerable promise
and potential in actively engaging consumers and patients while also assisting health care providers in delivering cancer prevention
and care services. The WASABY mobile app was conceived as an innovative, evidence-based mobile health tool aimed at
disseminating age-appropriate messages from the European Code Against Cancer (ECAC) to adolescents across Europe.
Objective: This study aims to assess the outcomes of the design, development, and promotion of the WASABY app through a
3-pronged evaluation framework that encompasses data on social media promotion, app store traffic, and user engagement.
Methods: The WASABY app’s content, cocreated with cancer-focused civil society organizations across 6 European countries,
drew upon scientific evidence from the ECAC. The app’s 10 modules were designed using the health belief model and a gamification
conceptual framework characterized by spaced repetition learning techniques, refined through 2 rounds of testing. To evaluate
the effectiveness of the app, we conducted a retrospective cohort study using the WASABY app’s user database registered from
February 4 to June 30, 2021, using a 3-pronged assessment framework: social media promotion, app store traffic, and user
engagement. Descriptive statistics and association analyses explored the relationship between sociodemographic variables and
user performance analytics.
Results: After extensive promotion on various social media platforms and subsequent traffic to the Apple App and Google Play
stores, a sample of 748 users aged between 14 and 19 years was included in the study cohort. The selected sample exhibited a
mean age of 16.08 (SD 1.28) years and was characterized by a predominant representation of female users (499/748, 66.7%).
Most app users identified themselves as nonsmokers (689/748, 92.1%), reported either no or infrequent alcohol consumption
(432/748, 57.8% and 250/748, 33.4%, respectively), and indicated being physically active for 1 to 5 hours per week (505/748,
67.5%). In aggregate, the app’s content garnered substantial interest, as evidenced by 40.8% (305/748) of users visiting each of
the 10 individual modules. Notably, sex and smoking habits emerged as predictors of app completion rates; specifically, male
and smoking users demonstrated a decreased likelihood of successfully completing the app’s content (odds ratio 0.878, 95% CI
0.809-0.954 and odds ratio 0.835, 95% CI 0.735-0.949, respectively).
Conclusions: The development and promotion of the WASABY app presents a valuable case study, illustrating the effective
dissemination of evidence-based recommendations on cancer prevention within the ECAC through an innovative mobile app
aimed at European adolescents. The data derived from this study provide insightful findings for the implementation of Europe’s
Beating Cancer Plan, particularly the creation of the EU Mobile App for Cancer Prevention.

(JMIR Cancer 2023;9:e48040) doi: 10.2196/48040

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KEYWORDS
adolescent health; cancer prevention; digital health; ECAC; European Code Against Cancer; health promotion; mHealth; mobile
app; mobile health; NCD; noncommunicable disease; primary prevention

with their lifestyles and risky behaviors, including alcohol and

Introduction tobacco consumption, as well as sedentary and poor dietary
Background habits [12,13]. Consequently, enhancing adolescents’ awareness
of the prevention messages within the ECAC and how
Cancer cases are on the rise due to changes in demographics modifiable lifestyle factors can influence cancer risk is
and exposure to risk factors, adding to the significant financial imperative for shaping their lifelong patterns of healthy
costs already linked to the disease [1]. Europe has a tenth of the behavior.
world’s population but accounts for a quarter of the world’s
cancer cases. In 2020, a total of 2.7 million people in the To grow and develop in good health, adolescents require access
European Union (EU) were diagnosed with the disease, and to information, including age-appropriate comprehensive cancer
another 1.3 million people lost their lives to it [2]. Moreover, prevention education. It is widely recognized that adolescents
in 2018, the financial burden of cancer in Europe due to health heavily rely on web-based information; however, they frequently
expenditure, loss of productivity, and informal care costs was fall victim to misinformation concerning modifiable risk factors
€199 billion (US $213 billion) [3]. Unless we take decisive and healthy lifestyles [14]. Moreover, their strategies for
action, the number of lives lost to cancer in the EU is set to evaluating information tend to be unsophisticated and inadequate
increase by more than 24% by 2035, making it the leading cause [15]. This underscores the importance of offering them easily
of death in the EU [4]. The significant expected increase in the accessible, robust, and evidence-based information.
number of cancers demands measures to encourage the Mobile Health Technologies for Cancer Prevention
prevention of the disease.
Mobile health (mHealth) technologies, underpinned by scientific
The European Code Against Cancer (ECAC) [5] has been a key evidence and ethical standards, exhibit considerable promise
health literacy measure used by the public and third sectors and potential in actively engaging consumers and patients while
since the 1980s to promote mainstream cancer prevention [6]. also assisting health care providers in delivering evidence-based
The ECAC, which is a trusted preventive tool free of commercial care across the cancer control continuum [16]. This is
influence providing a reliable synthesis of the latest scientific substantiated by the WHO, which acknowledges that digital
evidence on cancer prevention, suggests that around 40% of tools are an asset in supporting healthy lifestyles and addressing
cancers in Europe could be prevented through a mix of NCDs [17].
individual- and population-level actions known to be effective
[5]. The current fourth edition of the ECAC aims to inform Numerous mobile apps with a focus on cancer often emphasize
people about how to avoid or reduce their exposure to patient empowerment and self-care [18,19] or concentrate on
carcinogens, adopt behaviors that can lower their risk of addressing specific risk factors and types of cancer [20,21].
developing cancer, and participate in organized screening Hence, these apps may not inherently suit the context of healthy
programs through 12 easy-to-follow recommendations that do adolescents. Regarding concerns on the effectiveness of
not require any special skills or advice [5]. The available app-based interventions in promoting healthier lifestyles, the
evidence that cancer can be greatly prevented in Europe, coupled results are mixed and heavily reliant on the primary
with support from the World Health Organization (WHO) for recommendations being conveyed. For young adults, these
an inclusive, life-course approach to cancer prevention in its interventions have proven to be successful in promoting smoking
worldwide action plan for the prevention and control of cessation [22], improving dietary habits [23], managing weight
noncommunicable diseases (NCDs) [7], sets a strong case for [24], and reducing alcohol consumption [25]. Adolescents have
targeting adolescents and young people to multiply the benefits also benefited from digital tools, particularly in terms of
[8]. improving their diet [26-28] and promoting sun protection habits
[29,30]. Additionally, positive results have been observed when
The Importance of Adolescent Health for Cancer using apps that target multiple health risks simultaneously, both
Prevention in review studies [31,32] and primary research [33,34].
Adolescence, as defined by the WHO, spans from the 10th to However, these apps lack comprehensiveness in addressing the
the 19th year of life and represents a period characterized by entirety of modifiable risk factors recognized by the ECAC.
rapid and pivotal growth and transformation, second only to Considering the widespread adoption of mobile technology
infancy [9]. During this life stage, individuals undergo among adolescents and the findings from the literature
substantial changes in their physical, cognitive, and psychosocial mentioned above, leveraging smartphone technology to promote
development. This is a crucial phase for the establishment of behaviors that enhance adolescents’ health literacy regarding
positive habits and the development of behaviors that can exert cancer risk factors appears promising. Therefore, we developed
a lasting influence on both their current and future health, as a novel mobile app (WASABY) to encourage the adoption of
well as the health of their potential children [10]. a healthy lifestyle for the purpose of cancer prevention within
The welfare of adolescents varies considerably across European the adolescent subpopulation.
countries [11]. Some of the health issues they face are associated

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App Rationale leagues’ multidimensional interventions can effectively foster

The WASABY app (hereafter “app”) was developed by the the adoption of evidence-based cancer prevention
Association of European Cancer Leagues (ECL) as an recommendations among the adolescent demographic.
evidence-based, educational mHealth tool to facilitate the App Description
dissemination and comprehension of age-appropriate messages
Within the WASABY app, users are guided through the
outlined in the ECAC to a demographic of healthy adolescents
completion of 10 interactive modules designed to dispel
within Europe, spanning the age range of 14-19 years. In
common cancer prevention myths. Each module is structured
particular, the app was designed to impart knowledge on
around one of the prevention recommendations from the ECAC
modifiable cancer risk factors and guidance on mitigating
and features a combination of videos, practical tips, and
individual risk in a fun and interactive way. Importantly, it does
interactive quizzes.
not dispense medical advice for patients with cancer or any
other vulnerable or ill populations. In compliance with EU privacy regulations, users are required
to create a personal account and insert their personal details and
The app was primarily devised with the intention of being
lifestyle factors in order to access the app (Figure 1, screenshot
seamlessly integrated into preexisting or new health promotion
1). Once logged in, users can navigate the app from the home
and cancer education programs and interventions carried out
screen, as shown in screenshot 2 in Figure 1. From the home
by cancer-focused civil society organizations (hereafter “cancer
screen, users can access any of the 10 interactive modules, where
leagues”) across Europe. Indeed, despite being publicly available
they can read practical recommendations, view engaging videos,
for download in the Google Play and Apple App stores, the
and participate in interactive quizzes (Figure 1, screenshot 3).
ECL did not intend solely to develop a new app; rather, we
Each module consists of 4 sections: a teaser question, a short
wished to enhance the effectiveness and reach of cancer leagues’
introductory video, easily digestible facts, and a self-assessment
initiatives and provide them with a valuable tool for assessing
quiz. The self-assessment quizzes are made up of 3 questions
knowledge acquisition regarding the ECAC at no cost.
(Figure 1, screenshot 4). Users receive detailed explanations
In a subsequent phase, the ultimate goal would be to determine upon selecting their responses.
whether the integration of the WASABY app into cancer
Figure 1. Structure overview of the WASABY app.

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Returning to the home screen, users can review their profiles, perceptions, attitudes, and intentions related to health behaviors.
earn reward badges, and track their progress. Additionally, they Consistent with similar apps assessed in the existing literature
can access the final quiz and the ranking of the top learners. and using a methodology evocative of the well-known Duolingo
Regarding the badges, the app uses an incentive-based Language app [37], the app was also grounded in a conceptual
mechanism wherein achievement badges are unlocked upon framework of gamification, characterized by spaced repetition
completing each module, with icons becoming colorful as users learning techniques aimed at promoting efficient and effective
advance in their learning (Figure 1, screenshot 5). By clicking learning, especially in achieving long-term information retention
on the progress button, users can monitor which modules they compared to concentrated massed practice [38].
have completed, have not started, or are currently ongoing
Third, the 10 content modules and associated quizzes that
(Figure 1, screenshot 6). Upon the completion of all modules,
resulted from the selection of specific ECAC messages and their
users have the opportunity to take a final quiz to test their
operationalization through the HBM underwent a series of
knowledge.
revisions, which were conducted by cancer leagues to assess
Importantly, real-time progress data are recorded, enabling users their adequacy, comprehensibility, and accuracy. We used a
to share their progress and quiz results with friends and other structured approach to ensure the adequacy and accuracy of the
players. This contributes to the creation of an international content. Initially, we used the nominal group technique to
ranking list of “top learners” across Europe. These features collaboratively define the scope of each module. Subsequently,
foster a competitive spirit, instill a sense of accomplishment, an iterative expert review process engaged specialists from both
and encourage the repeated use of the app. medical and educational domains within the ECL’s network of
cancer leagues. These experts critically assessed and refined
Aim of the Study the content to enhance its clarity and alignment with user needs.
In this paper, we present the preliminary findings of the design, Subsequent refinements were made to ensure that the messaging
iterative development, and promotion of the WASABY app, would be suitable for a reading level appropriate for 12-year-old
made available to European adolescents in real-life settings. children. This was achieved following beta and alpha tests with
The objectives of this study were threefold: (1) to analyze data the app’s target population.
pertaining to the app’s promotion on social media, (2) to assess
the traffic generated on Google Play and Apple App stores, and WASABY App Testing
(3) to evaluate the level of user participation and engagement The beta version of the app was developed for Android devices
with the app. and made available in the 27 EU member states (plus the United
Kingdom). It underwent a first round of testing through a
Methods web-supported 19-item questionnaire to assess comprehension
and suitability of the app’s content. From May 27 to June 10,
WASABY App Development 2020, a social media campaign was used to recruit 83 testers
The WASABY app’s content was developed by drawing upon within the app’s target group (ie, healthy 14- to 19-year-olds
the ECAC’s scientific evidence [5]. Specifically, a total of 6 residing in Europe) from 25 EU countries to participate in the
cancer leagues located in Spain (Asociación Española Contra beta test (Multimedia Appendix 1).
el Cáncer), the United Kingdom (Cancer Focus Northern Originally developed in English, the app was later translated
Ireland), Slovenia (Zveza slovenskih društev za boj proti raku; into 6 additional languages (French, German, Italian, Romanian,
Association of Slovenian Cancer Societies), France (La Ligue Slovenian, and Spanish) and adapted to be used on iOS devices.
contre le Cancer), Switzerland (Krebsliga), and Romania It underwent a second round of testing (alpha test) to check for
(Societatea Româna de Cancer) were engaged in this process. functionality and technical aspects through a dedicated 18-item
Additionally, a total of 111 adolescents aged between 14 and questionnaire, enrolling a total of 28 testers: 4 individuals per
19 years from 25 EU Member States actively participated in 2 language and 2 per platform (Android and iOS). The final
testing rounds. version of the app included feedback implemented from the 2
First, a selection of relevant ECAC messages (specifically, subsequent rounds of testing and was made available in all
ECAC messages 1-7 and 10-11) was made, taking into countries of the WHO Europe region in both the Google Play
consideration the age group of the target audience. Second, and Apple App stores.
materials sourced from the ECAC’s scientific website [35], Study Design and Population
which served as the foundation for the content of the app, were
operationalized by applying the health belief model (HBM) We conducted a retrospective cohort study using data from the
[36]. The operationalization of the HBM within the WASABY app’s database of registered users, covering the period from
app involved the strategic design and presentation of content February 4 to June 30, 2021. The sample size was determined
that aligned with the core constructs of the model. The process based on the available retrospective cohort of 976 registered
involved integrating educational modules and interactive users. Exclusion criteria were applied to users outside of the
elements to raise awareness of the risks of unhealthy behaviors, age target group (14- to 19-year-olds) and those with invalid or
emphasizing the benefits of adopting healthy habits, providing partially missing registration data. Anonymized data were used
practical strategies to overcome barriers, and incorporating cues for all analyses. This study adhered to the STROBE
to action to boost users’ confidence in making positive lifestyle (Strengthening the Reporting of Observational Studies in
changes. Thus, the app’s content was crafted to influence users’ Epidemiology) reporting guideline [39].

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WASABY App Evaluation Framework Variables from the user registry database were collected,
A 3-pronged evaluation framework was developed with including anonymized user identification, demographics (birth
indicators reflecting the promotion of the app on social date, sex, country, region, and language), anthropometrics
media, the traffic generated on Google Play and Apple App (height and weight, through which BMI was calculated), and
stores, and the level of engagement exhibited by app users. self-reported cancer risk factors (physical activity, tobacco use,
Instagram-powered analytics were monitored and analyzed and alcohol consumption). The database also contained
monthly during the study period. Variables collected included: information on the completion of the app’s modules according
accounts reached, content interactions, profile visits, website to 3 variables (visits, readings, and completed auto-evaluation).
taps, top posts, and follower-specific analysis. The app’s traffic Variables were operationalized to serve as proxies for the
in app stores was analyzed through Google- and Apple-powered following constructs: content interest, content completion, and
key performance indicators (KPIs), including product page quiz completion (Table 1 presents details on variable definition
views, product installations, conversion rate, deletions, crashes, and assessment). Overall, the app as a tool was considered
and average rating [40,41]. Such KPIs were stratified by country, completed upon 100% module reading registry.
date, and download source.

Table 1. Variables capturing WASABY mobile app individual user performance. Each variable was assessed separately for each of the app’s 10 content
modules.
Variable Construct Definition and interpretation
Module vis- Content inter- Variable registering the amount of page visits into a specific module. Interest was operationalized as a continuous
its est variable, by which greater values capture greater interest.
Module Content Variable registering the click on “I have read it” button present at the end of each module. Content completion was
readings completion operationalized as a dichotomous variable, considered complete if 1 or more readings were recorded.
Completed Quiz comple- Variable registering the number of completed quiz questions per module (7 available per module, with unlimited response
autoevalua- tion opportunities). Quiz completion was operationalized as a dichotomous variable, by which a given module’s autoevalu-
tions ation was considered complete if 3 or more questions were registered.

Statistical Analysis Results

We performed descriptive statistics based on frequencies (for
The results we present below have been organized according
categorical variables) and mean and median values (including
to the 3 components of the app’s evaluation framework.
SD for continuous ones). Statistical differences among users’
app completion (outcome variables) according to demographic Social Media Promotion
(age and sex) and self-reported risk factors (tobacco, alcohol, A 10-day social media campaign, beginning on World Cancer
and physical activity; independent variables) characteristics Day (February 4, 2021), was run on Instagram to launch and
were tested using the Mann-Whitney Wilcoxon test at .05 promote the app. The boosted social media posts reached
significance level. Outcome variables were treated as continuous 851,149 people and received 2,470,418 impressions.
(details on their operationalization are in Table 1). Odds ratio Subsequently, the app was promoted again during European
(OR) and 95% CI were used to assess the interrelation of the Week Against Cancer (May 25-31, 2021) through an organic
independent variables mentioned above with a proxy for the social media campaign, which received 3799 impressions, as
app’s completion. The WASABY app was considered completed well as GDPR-compliant targeted emails sent to over 100
upon 100% of the module reading, and thus the outcome variable contacts within the ECL’s network of cancer leagues and youths.
was dichotomized. All statistical analyses were performed using As of June 30, 2021, the app’s dedicated web page on the ECL’s
the R software (version 4.2.1; R Foundation for Statistical website [42] had been visited 10,315 times.
Computing).
WASABY App Store Traffic
Ethical Considerations
Between January and June 2021, the app received a total of
This project received ethical approval through the WASABY 3426 impressions on both the iOS and Android stores, resulting
project consortium (EC PP-2-5-2016). Data collection and in 1109 downloads. This translates to a 32.37% (1109/3426)
storage were managed by Adhere Health Inc (formerly conversion rate, which was largely influenced by the World
Salumedia Tecnologías S.L.U). The storage of the database Cancer Day and European Week Against Cancer promotional
adhered to the General Data Protection Regulation (GDPR) and web-based campaigns. Over the same period, 645 app deletions
the corresponding Spanish regulation. Correspondingly, a were reported, which are to be contextualized given the 2-week
privacy policy, legal notice, and terms of use were formulated completion time frame under which the app was designed.
(Multimedia Appendix 2). All participants agreed to the terms Additionally, on the iOS platform, an average of 3.32 sessions
of use upon app registration independently, that is, without per active user were recorded. A summary of the app stores’
parental approval being required. All data from the WASABY KPIs is found in Multimedia Appendix 3.
app registration database were obtained in anonymized form
for the purposes of the analysis hereby presented.

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WASABY App User Engagement were included in the study cohort. Table 2 includes a summary
During the study period, a total of 976 users were fully of the sample demographics. As more than half (n=392, 52.4%)
registered in the app’s database. After applying all inclusion of the sample was composed of users from Slovenia, this
and exclusion criteria, 748 users aged between 14 and 19 years subgroup is reported separately.

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Table 2. Demographics of users registered in the WASABY app database.

Demographics Overall (N=748), n (%) Slovenia (n=392), n (%)
Age (years)
14 76 (10.2) 8 (2)
15 200 (26.7) 103 (26.3)
16 186 (24.9) 104 (26.5)
17 187 (25) 123 (31.4)
18 71 (9.5) 43 (11)
19 28 (3.7) 11 (2.8)
Sex
Female 499 (66.7) 281 (71.7)
Male 179 (23.9) 63 (16.1)
Unreported 70 (9.4) 48 (12.2)

Countrya
Belgium 7 (0.9) N/Ab
Bulgaria 16 (2.1) N/A
Czechia 13 (1.7) N/A
Denmark 1 (0.1) N/A
Germany 13 (1.7) N/A
Estonia 12 (1.6) N/A
Ireland 12 (1.6) N/A
Greece 14 (1.9) N/A
Spain 14 (1.9) N/A
France 5 (0.7) N/A
Croatia 23 (3.1) N/A
Italy 25 (3.3) N/A
Latvia 21 (2.8) N/A
Lithuania 17 (2.3) N/A
Luxembourg 3 (0.4) N/A
Hungary 12 (1.6) N/A
Malta 5 (0.7) N/A
The Netherlands 9 (1.2) N/A
Austria 2 (0.3) N/A
Poland 34 (4.6) N/A
Portugal 13 (1.7) N/A
Romania 49 (6.6) N/A
Slovenia 392 (52.4) N/A
Slovakia 13 (1.7) N/A
Finland 5 (0.7) N/A
Sweden 6 (0.8) N/A
United Kingdom 10 (1.3) N/A
Switzerland 1 (0.1) N/A
Northern Macedonia 1 (0.1) N/A

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Demographics Overall (N=748), n (%) Slovenia (n=392), n (%)

Language interface
English 351 (46.9) 46 (11.7)
Spanish 11 (1.5) 0 (0)
Italian 18 (2.4) 0 (0)
German 16 (2.1) 0 (0)
Slovenian 350 (46.8) 346 (88.3)
Romanian 2 (0.3) 0 (0)
French 6 (0.8) 0 (0)
Height (cm)
130-140 1 (0.1) 1 (0.3)
140-150 2 (0.3) 1 (0.3)
150-160 61 (8.2) 28 (7.1)
160-170 330 (44.1) 182 (46.4)
170-180 257 (34.4) 134 (34.2)
180-190 82 (11) 40 (10.2)
190-200 11 (1.5) 5 (1.3)
Unreported 4 (0.5) 1 (0.3)
Weight (kg)
30-40 2 (0.3) 0 (0)
40-50 65 (8.7) 30 (7.7)
50-60 266 (35.6) 148 (37.8)
60-70 231 (30.9) 115 (29.3)
70-80 102 (13.6) 56 (14.3)
80-90 48 (6.4) 26 (6.6)
90-100 18 (2.4) 9 (2.3)
100-110 8 (1.1) 4 (1)
110-120 2 (0.3) 2 (0.5)
120-130 6 (0.8) 2 (0.5)

BMI (kg/m2)
10-18 89 (11.9) 35 (8.9)
18-20 180 (24.1) 94 (24)
20-25 359 (48) 203 (51.8)
25-30 84 (11.2) 43 (11)
30-35 18 (2.4) 9 (2.3)
35-40 7 (0.9) 4 (1)
>40 7 (0.9) 3 (0.8)
Unknown 4 (0.5) 1 (0.3)

a
8 countries within the World Health Organization Europe region were excluded, given there were no registered users in the WASABY app database
(Cyprus, Iceland, Liechtenstein, Norway, Montenegro, Albania, Serbia, and Turkey).
b
N/A: not applicable.

Overall, the mean age was 16.08 (SD 1.28) years with a median accounting for 66.7% (499/748) of all users (Slovenia: 281/392,
of 16 years, similar to Slovenia’s cohort (mean 16.31, SD 3.83; 71.7%). The app’s interface was predominantly accessed in
median 16 years). Female users were overrepresented, English (351/748, 46.9%) or Slovenian (350/748, 46.7%).

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Self-reported anthropometric data were used to estimate BMI, Self-reported behavioral risk factors related to tobacco smoking,
and the cohort had a mean of 21.86 (SD 4.18) kg/m2. alcohol consumption, and physical activity were collected upon
Approximately 72.1% (539/748) of users fell within the 18-25 registration (Table 3). Most users identified themselves as
kg/m2 range, which is considered normal according to nonsmokers (689/748, 92.1%) and reported either no or
international standards. infrequent alcohol consumption (432/748, 57.8% and 250/748,
33.4%, respectively). Moreover, 67.5% (505/748) of users
indicated being physically active for 1-5 hours per week.

Table 3. Self-reported risk factors upon use registration in the WASABY app.
Self-reported risk factors Overall (N=748), n (%) Slovenia (n=392), n (%)
Tobacco use (cigarettes per day)
None 689 (92.1) 361 (92.1)
1-5 38 (5.1) 22 (5.6)
5-10 14 (1.9) 8 (2)
10-20 4 (0.5) 0 (0)
≥20 3 (0.4) 1 (0.3)
Alcohol consumption (frequency)
None 432 (57.8) 221 (56.4)
Rarely 250 (33.4) 131 (33.4)
Only on weekends 50 (6.7) 27 (6.9)
Often 12 (1.6) 10 (2.6)
Everyday 4 (0.5) 3 (0.8)
Physical activity (approximate hours per week)
Sedentary 70 (9.4) 28 (7.1)
1 125 (16.7) 61 (15.6)
3 238 (31.8) 121 (30.9)
5 142 (19) 84 (21.4)
>5 173 (23.1) 98 (25)

The individual and overall app’s performance was investigated (276/748) reading all of them and 34.5% (258/748) finishing
through 3 variables (defined in Table 1 and results presented in all self-assessment quizzes. Notably, Slovenian users
Table 4). In aggregate, the app’s content garnered substantial demonstrated the highest level of engagement: they were most
interest, as evidenced by 40.8% (305/748) of users accessing likely to access all modules (190/392, 48.5%), read the modules’
each of the 10 individual modules. Similarly, a comparable contents (167/392, 42.6%), and complete the quizzes (145/392,
proportion of users completed the modules, with 36.9% 37%).

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Table 4. WASABY app performance metrics in terms of app interest, content completion, and quiz completion (operationalized variable description
available in Table 1).
App use constructs Overall (N=748), n (%) Slovenia (n=392), n (%)
App interest (number of modules visited)
0 36 (4.8) 31 (7.9)
1 101 (13.5) 43 (11)
2 75 (10) 30 (7.7)
3 72 (9.6) 22 (5.6)
4 47 (6.3) 18 (4.6)
5 48 (6.4) 23 (5.9)
6 33 (4.4) 18 (4.6)
7 14 (1.9) 6 (1.6)
8 7 (0.9) 2 (0.5)
9 10 (1.3) 9 (2.3)
10 (all) 305 (40.8) 190 (48.5)
Content completion (number of modules read)
0 139 (18.6) 75 (19.1)
1 86 (11.5) 30 (7.7)
2 62 (8.3) 27 (6.9)
3 53 (7.1) 19 (4.9)
4 41 (5.5) 17 (4.3)
5 35 (4.7) 18 (4.6)
6 27 (3.6) 18 (4.6)
7 11 (1.5) 7 (1.8)
8 6 (0.8) 2 (0.5)
9 12 (1.6) 12 (3.1)
10 (all) 276 (36.9) 167 (42.6)
Quiz completion (number of modules with quiz completed)
0 171 (22.9) 88 (22.5)
1 83 (11.1) 29 (7.4)
2 61 (8.2) 31 (7.9)
3 62 (8.3) 31 (7.9)
4 37 (5) 16 (4.1)
5 29 (3.9) 17 (4.3)
6 18 (2.4) 10 (2.6)
7 9 (1.2) 5 (1.3)
8 6 (0.8) 6 (1.5)
9 14 (1.9) 14 (3.6)
10 (all) 258 (34.5) 145 (37)

Significant differences were observed by sex in terms of the Additionally, significant variations were noted in the
number of modules visited, read, and quizzes completed (P=.02, abovementioned associations concerning self-reported user risk
P=.047, and P=.03, respectively), with male users being less factors based on dichotomized tobacco consumption (P=.04,
likely to complete the overall app (OR 0.878, 95% CI P=.07, and P=.03). Self-reported tobacco users demonstrated
0.809-0.954). Conversely, there were no differences found by a reduced likelihood of completing the app (OR 0.835, 95% CI
age group (dichotomized as 14-16 years vs 17-19 years) in the 0.735-0.949). No notable distinctions were detected concerning
abovementioned tested associations. alcohol consumption or physical activity. Finally, while
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evaluating the app’s performance based on individual modules, result suggests that covering multiple domains of cancer
a decreasing linear relationship was observed while progressing prevention is feasible without deterring user interest and
through module 1 (on tobacco) to module 10 (on cancer adherence.
prevention; Figure 1).
As shown in Figure 2, a decreasing linear relationship was
observed in the app’s completion across the 10 individual
Discussion modules, with the highest level of interest and completion
Principal Findings reported for module 1 (focused on tobacco), which gradually
decreased until module 10 (focused on the ECAC). While it is
The results of the WASABY app pilot study have demonstrated reasonable to expect a decline in user retention across the
the potential of an mHealth app to promote evidence-based modules as users progress through the app [46], the added value
cancer prevention recommendations to European adolescents. of the WASABY app concept lies in addressing the multiple
While most mHealth apps addressing cancer prevention have recommendations of the ECAC. Therefore, if users discontinue
focused on specific risk factors (such as body weight [43]) or using the app after completing the initial modules that focus on
specific cancer sites (such as breast cancer [44]) and a plethora lifestyle-related risk factors, they will not benefit from the
of interventions targeting patients with cancer and survivors of crucial knowledge related to cancer prevention, particularly
cancer have been developed [45], there is currently no other myths and misconceptions (addressed in module 9), thereby
comprehensive app based on the ECAC that specifically targets reducing the potential impact of the app. The data from the pilot
adolescents aged between 14 and 19 years, to the best of our also showed that sex was a predictor of completion of the
knowledge. modules. This may be explained by an overrepresentation of
The app was successful in engaging a large proportion of users female users, with approximately two-thirds of users identifying
across all its modules, with 40.8% (305/748) of users visiting as female. Conversely, nonsmoker users were more likely to
all 10 modules. Similarly, 36.9% (276/748) of users completed adhere throughout the content until the last module, underlining
each module, and 34.5% (258/748) completed the entire app the importance of understanding the sociodemographics of the
autoevaluation assessment, indicating that over one-third of target audience to best target the messaging in novel digital
users in the pilot study completed the app. Given that the content health interventions [47]. Additionally, such characteristics shall
of the app covers a wide range of cancer risk factors and be considered as well in the promotion and recruitment methods
protective measures as outlined in the ECAC, this encouraging for app users to achieve a more representative reach among the
target population.
Figure 2. WASABY app performance metrics by module (1-10) in terms of app interest, content completion, and quiz completion.

Comparing the results of this study with the findings of previous lifestyle risk factors can be effective in improving physical
studies in the literature becomes difficult when considering the activity and fruit and vegetable consumption, indicating the
small population sizes and heterogeneous designs of mHealth potential for multirisk factor application targeting adolescents
interventions. A systematic review and meta-analysis reported [48]. An earlier scoping review on apps to promote healthy
that eHealth school-based interventions addressing multiple lifestyle among adolescents concluded that the ability to set

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personal goals enhances self-monitoring and increases awareness entirely through social media channels. Therefore, much of the
[49]. The review also determined that most apps were data collected for this study relied on self-reporting, and no
implemented as part of therapy or to strengthen school programs, measures were in place to validate user app registration.
supporting the original conceptual design of the pilot Additionally, due to the scope of the study analysis, which was
intervention for the WASABY app [49]. Additionally, a total rather exploratory, no adjustments by age or sex groups were
of 2 umbrella reviews published in 2023 on digital interventions conducted in the statistical analysis. Lastly, the data reported
to moderate alcohol consumption in young people and physical were insufficient to determine whether the app promotion was
inactivity and nutrition in young people [50] identified the only reaching health-literate populations within the target group.
potential of digital interventions to increase physical activity It is, therefore, not possible to determine whether the app’s pilot
and improve nutrition in school-age children and reduce alcohol reached a representative cross-section of the population or if it
consumption in certain subpopulations of younger people, was installed and completed by individuals who were already
especially if active feedback is provided by the mHealth more likely to comply with the recommendations of the ECAC.
intervention. The overall body of evidence is characterized by This would be a key area of further research in future studies
substantial heterogeneity, inconsistent population groups, and on mHealth tools.
intervention definitions. This indicates that the effectiveness of
mHealth tools for health promotion may suffer from the small
Future Recommendations
effects of interventions, which remain detectable for a short The app was developed to promote and encourage adolescents
period of time after the conclusion of the intervention. to follow the ECAC recommendations. Evidence suggests that
the ECAC is not well-known among the general public [51].
Finally, during the pilot period, the promotion strategy of the Therefore, the app could help to improve awareness and,
app relied partially on the support of nongovernmental subsequently, knowledge and adherence to these
organizations (NGOs) to increase awareness and ultimately recommendations. With this objective in mind, the European
integrate the app into their existing multidimensional health Commission has mandated the development of the “EU Mobile
education programs. Cancer leagues are key NGOs acting as App for Cancer Prevention” under Europe’s Beating Cancer
primary promoters of the ECAC at the national, regional, and Plan [52]. The results and lessons learned from the WASABY
local levels, marking them out as ideal promoters of the app. app should be taken into account for this new EU endeavor. To
Cancer leagues were involved in the cocreation process from improve adherence and retention, future iterations of the app or
the early stages of the app’s development. Notably, the number comparable tools should further gamify its content, providing
of downloads was particularly influenced by the endorsement motivation and incentives to complete each module. It is also
and promotion of the app through the national leagues, with essential to consider the sociodemographic characteristics of
users in Slovenia demonstrating the highest engagement rates the target population when promoting apps to ensure they reach
across all modules. They were most likely to access all modules a more diverse and representative population. Engaging with
(190/392, 48.5%), read the modules’ contents (167/392, 42.6%), NGOs to cocreate and promote the WASABY app was
and complete the quizzes (145/392, 37%). This highlights the beneficial, but further research is required to assess the
success of the Zveza slovenskih društev za boj proti raku feasibility of embedding the app as an intervention within a
(Association of Slovenian Cancer Societies) in adopting the broader health education program. Furthermore, it is necessary
WASABY app for youth-targeted initiatives and demonstrates to evaluate the impact of knowledge acquisition of the ECAC
that with committed support from a key stakeholder for the recommendations on the intention to adopt the recommendations
promotion of the app, it is possible to achieve good uptake. in daily life.
Limitations Conclusions
There are several limitations that should be acknowledged. First, The experience gained from designing, developing, and
as this study was designed to evaluate the outcomes of the promoting the WASABY app provides a valuable case study
design, development, and dissemination of the WASABY app, on the effective dissemination of evidence-based
the evaluation framework’s scope was limited in terms of time recommendations on cancer prevention within the ECAC
and reach. As a result, certain dimensions, such as knowledge through an innovative digital health tool aimed at European
acquisition and user retention, could not be adequately evaluated adolescents. The data obtained from this study show the
due to the lack of monitoring of KPIs over a longer period (ie, potential of an mHealth app that addresses multiple risk factors,
at 6 and 12 months after completion). Additionally, the fidelity thus laying the groundwork for the creation of new tools to
of the tool implementation was impacted by the COVID-19 encourage healthy lifestyles and mitigate NCDs. The insights
pandemic. The initial plan was to pilot the tool through in-person derived from the study also hold significance for the
demonstration at existing health education outreach programs implementation of Europe’s Beating Cancer Plan, particularly
organized by cancer leagues in 6 European countries. However, the development of the “EU Mobile App for Cancer Prevention”
the app’s promotion and dissemination had to be conducted [52].

Acknowledgments
The authors would like to thank the following individuals within the cancer leagues who participated in the collaborative process
of creating the content for the WASABY app: Sebastian del Busto (Asociación Española Contra el Cáncer); Gerry McElwee
(Cancer Focus Northern Ireland); Maja Primic-Žakelj, Urška Ivanuš, and Katja Jarm (Zveza slovenskih društev za boj proti raku);

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Annick de Gaulle (La Ligue contre le Cancer); Florian Suter (Krebsliga); and Adriana Melnic (Societatea Româna de Cancer).
Additionally, the authors extend their acknowledgment to the Association of European Cancer Leagues (ECL) Youth Ambassadors
for the European Code Against Cancer (ECAC), whose pivotal role in disseminating and promoting the WASABY app on social
media is highly appreciated. The development of the app was overseen by the ECL secretariat team, with technical assistance
provided by Adhere Health Inc (formerly Salumedia Tecnologías S.L.U.) and graphic design work executed by Outcrowd Studio
as subcontractors.
The project through which the WASABY mobile app was developed and this paper was submitted for publication has received
funding from the European Commission’s Pilot Projects scheme under grant agreement PP-2-5-2016 (#769767). The opinions
and findings presented in this publication are those of the authors and do not necessarily reflect the views of the European
Commission. The European Commission and its agencies are not responsible for any use that may be made of the information it
contains.

Data Availability
The WASABY app’s content is available on GitHub [53]. The data that support the findings of this study are available from the
corresponding author upon reasonable request.

Authors' Contributions
MML contributed to conceptualization, methodology, formal analysis, writing, and original draft preparation. GP was involved
in project implementation, writing, reviewing, and editing. AT performed writing, reviewing, and editing. DR contributed to
conceptualization, supervision, project administration, methodology, writing, reviewing, and editing.

Conflicts of Interest
None declared.

Multimedia Appendix 1
WASABY App testing results from a web-supported 19-item questionnaire to assess comprehension and suitability of the App’s
content.
[PDF File (Adobe PDF File), 10205 KB-Multimedia Appendix 1]

Multimedia Appendix 2
Privacy policy, legal notice, and terms of use.
[DOCX File , 40 KB-Multimedia Appendix 2]

Multimedia Appendix 3
App stores' key performance indicators.
[DOCX File , 13 KB-Multimedia Appendix 3]

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Abbreviations
ECAC: European Code Against Cancer
ECL: Association of European Cancer Leagues
EU: European Union
GDPR: General Data Protection Regulation
HBM: health belief model
KPI: key performance indicator
mHealth: mobile health
NCD: noncommunicable disease
NGO: nongovernmental organization
OR: odds ratio
STROBE: Strengthening the Reporting of Observational Studies in Epidemiology
WHO: World Health Organization

Edited by T de Azevedo Cardoso; submitted 09.04.23; peer-reviewed by N Ribeiro, M Brinzac; comments to author 16.06.23; revised
version received 09.09.23; accepted 27.10.23; published 25.11.23
Please cite as:
Mallafré-Larrosa M, Papi G, Trilla A, Ritchie D
Development and Promotion of an mHealth App for Adolescents Based on the European Code Against Cancer: Retrospective Cohort
Study
JMIR Cancer 2023;9:e48040
URL: https://cancer.jmir.org/2023/1/e48040/
doi: 10.2196/48040
PMID:

©Meritxell Mallafré-Larrosa, Ginevra Papi, Antoni Trilla, David Ritchie. Originally published in JMIR Cancer
(https://cancer.jmir.org), 25.11.2023. This is an open-access article distributed under the terms of the Creative Commons Attribution
License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work, first published in JMIR Cancer, is properly cited. The complete bibliographic information,
a link to the original publication on https://cancer.jmir.org/, as well as this copyright and license information must be included.

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