Dear Dr. Collins,

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Academic Editor

PLOS ONE

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Reviewers' comments:

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: N/A

Reviewer #2: N/A

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Thank you for the opportunity to review this interesting paper. This study is well designed and well explained in this manuscript.Thank you for the opportunity to review this interesting paper. This study is well designed and well explained in this manuscript.Thank you for the opportunity to review this interesting paper. This study is well designed and well explained in this manuscript.Thank you for the opportunity to review this interesting paper. This study is well designed and well explained in this manuscript.

Introduction:

The need for an intervention with the capacity to address the multiple risk-factors across a number of cancer types is well motivated, as are the advantages of mHealth solutions.

The adoption of the Co-Design approach gives voice to likely end users and is well supported by the referenced literature.

Methods:

The application of Design Thinking is well motivated and appropriate. The referenced Learning Health Systems Framework and Behaviour Change Wheel give structure and the opportunity to translate findings into practical applications, important when the overall aim is to design a useful tool. The manuscript meets the COREQ criteria, as detailed in the Supplementary File.

The adoption of videoconferencing for engagement with panel members is likely to have aided recruitment and engagement. Was the adoption of this engagement strategy motivated by a review of the success of online engagement in other studies or was this for convenience? A comment on this choice could be added.

Was there any PPI involvement in the design of the engagement process?

How the participants were allocated to the initial 5 groups could do with further explanation, particularly how homogeneity was defined. Was it intended that Group 1 would all be IT professionals? Same for the group comprised of community workers. Why did each group consist of females or males only? Explain why homogeneity might be appropriate.

Timelines for the process should be explained. How much time elapsed between workshops?

Participants and recruitment: The limitations section notes that greater representation from low socioeconomic backgrounds, rural and remote communities, and other priority populations would have further enhanced the breadth of insights gained. The online format could have helped with this. Other studies engaged with representative organizations/NGOs in order to reach these seldom heard voices. What consideration was given to reaching these populations?

Additional information could be added to the Supplementary Files:

• the participant information statement, the privacy and confidentiality agreement and the ground rules for participation in the online workshops.

• The online survey completed by participants.

Results & Discussion

Well presented. Findings are interesting, clearly explained and adequately discussed.

On completion of the engagement, were the panel members given an opportunity to provide feedback on the engagement process?

Figure 2 – I struggled to read this image.

Overall, this study/manuscript is an interesting read and makes a valuable contribution to the literature.

Reviewer #2: Dear Manuscript Authors, Dear Manuscript Authors, Dear Manuscript Authors, Dear Manuscript Authors,

Thank you for writing a paper aimed at enhancing knowledge about incorporating community feedback to develop a mobile health app product. Please consider the following comments to provide more clarity in your writing, as well as expand a bit more on the practice implications and inclusivity/diversity of your sample population based on study eligibility and recruitment. Best wishes!

Introduction Section

Line 53: I suggest clarifying that it’s solid tumour cancers for prevention via healthy lifestyle.

Lines 57-58: Please carefully re-write this sentence to make evident certain cancer diseases (a small portion) have evidence-based established guidelines for early detection cancer screening. This could be a supporting reason for why it is critical to consider interventions that can address modifiable behaviors cancer risk factors due to limitations with cancer screening for other cancers.

If you can cite research knowledge relevant to populations in Australia or high-income countries (as a whole), briefly highlight existing evidence related to modifiable cancer risk factors. For example, evidence similar to the paper written by Islami et al. (2024) Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States, 2019. CA: A Cancer Journal for Clinicians.

Participants and Recruitment

Lines 132 – 134: There is mention of “panel members.” Were all participants a panel member? Re-word to make it clear that all or some participants’ role was to be engaged as panel member.

Data Collection

Line 151: Make it clear that the individual workshops or all the workshops were online.

Discussion

Regarding implications for practice, have you considered the feasibility of maintaining an educational/information dissemination product that is accurate, up-to-date, clearly evidence-based, and engaging for the user? How would the users be encouraged to communicate with GP (or other medical professional) to discuss their unique health situation?

Strengths and limitations

The web-based participation is convenient and practical since it allows for human subjects to participate from their personnel space. Although have you considered that the web-based participation requirement may have limited certain types of participants from being a valuable informant? Do you think your data reflects well the younger adult population perspectives and experiences (18 – 30 years old)? Future direction could involve in-person study participation and improve recruitment of young adult populations for the next phases of testing the product.

Reviewer #3: This article describes the co-design of Lifestyle6, a digital health program to reduce cancer risk and support early detection through multiple behavior changes. Using design thinking, the authors engaged multiple community members in iterative workshops to identify barriers, define needs, and prototype a mobile-friendly solution. The study addresses critical gaps in cancer prevention by integrating user-centered design to improve engagement and personalization—key challenges in digital health interventions. Its importance lies in advancing scalable, evidence-based strategies for cancer risk reduction and screening support, which could significantly impact public health outcomes.This article describes the co-design of Lifestyle6, a digital health program to reduce cancer risk and support early detection through multiple behavior changes. Using design thinking, the authors engaged multiple community members in iterative workshops to identify barriers, define needs, and prototype a mobile-friendly solution. The study addresses critical gaps in cancer prevention by integrating user-centered design to improve engagement and personalization—key challenges in digital health interventions. Its importance lies in advancing scalable, evidence-based strategies for cancer risk reduction and screening support, which could significantly impact public health outcomes.This article describes the co-design of Lifestyle6, a digital health program to reduce cancer risk and support early detection through multiple behavior changes. Using design thinking, the authors engaged multiple community members in iterative workshops to identify barriers, define needs, and prototype a mobile-friendly solution. The study addresses critical gaps in cancer prevention by integrating user-centered design to improve engagement and personalization—key challenges in digital health interventions. Its importance lies in advancing scalable, evidence-based strategies for cancer risk reduction and screening support, which could significantly impact public health outcomes.This article describes the co-design of Lifestyle6, a digital health program to reduce cancer risk and support early detection through multiple behavior changes. Using design thinking, the authors engaged multiple community members in iterative workshops to identify barriers, define needs, and prototype a mobile-friendly solution. The study addresses critical gaps in cancer prevention by integrating user-centered design to improve engagement and personalization—key challenges in digital health interventions. Its importance lies in advancing scalable, evidence-based strategies for cancer risk reduction and screening support, which could significantly impact public health outcomes.

My overall feedback is that when I read the paper, I remained confused about what was being developed and the process of development. It wasn’t until I saw the supplements showing the interface that it started to make sense to me, and the supplement that described the workshop structure and activities by stage, and the supplement with the Prototype screenshots. I think my feedback is that the manuscript needs a little more structure, and parallel writing to help the reader understand what is being done and why at each step. Naming or numbering each step consistently might help, or perhaps subheadings would be useful.

My second high level feedback is about the interdisciplinary nature of this paper, which is a strength, but the manuscript would be improved by more clearly defining design-thinking and user experience type constructs mre clearly from the beginning of the manuscript. Overall, there was a lot of describing of “behavior change theories”, largely drawn from health promotion, social psych, etc. type fields of behavioral and social sciences without an equivalent set of terms or elements drawn from design fields. This is a missed opportunity.

Nevertheless, this provides something useful and novel and I think Plos One readers will be interested. The process is scalable and with some suggested editing of the manuscript, I think it makes a good contribution because it provides rationale and a process for co-design. The focus on multiple behaviors is also unique and critical for effective cancer prevention and control.

Below are some minor questions and suggestions

Line 188: Describe “padlet and chat posts” . As a reader I don’t know what these are.

191- Define COREQ guidelines and at least spell out.

192- Clarify who and how “appraise the standard of evidence” was done. This seems like a very important step and there’s not enough details for me to have confidence in this process.

201- personas and empathy maps need to be explained somewhere for those who aren’t experts in this topic. I wonder if the design thinking concepts like this could be added to one of the tables in the supplement that lists all the “behavior change theories” that are elements of theories.

Grammatical confusion in table 3, last row under theme 1 sentence starting “amongst those eligible…”

Line 257- wat is “full settings control”?

Line 256-6: The phrase “This step was completed to facilitate reporting” confuses me. And how is this strong rationale for doing this work? What reporting is being referred to here, and what does that have to do with intervention design and development?

Line 300- This was confusing to me saying things “can be used” made me wonder- is this how the prototype currently works, or a future adaptation that is possible given the prototype design. .

Fig 2 confusing especially part in top right with game of Life and random images.

Minor point- most of the supplements are mislabeled in the online system file name, making it a little confusing.

Another minor point. Several times it is mentioned that intervention components are matched behavioral change theories. This is a little bit of a stretch because few theories are listed, it’s specific theoretically-driven constructs that are being discussed.

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what does this mean?). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Co-design of Lifestyle6, a digital tool targeting multiple health behaviour changes for cancer risk reduction and early detection support

PONE-D-25-26923R1

Dear Dr. Collins,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Dr Buna Bhandari

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: N/A

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: The authors have improved this manuscript based on the comments raised by all reviewers and I am happy to recommend publication.

Reviewer #2: 227: remove additional punctuation

You've produced a superb paper with your revisions. Best wishes for continued work in this area.

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what does this mean?). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our Privacy Policy..-->

Reviewer #1: No

Reviewer #2: No

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