Background: Cancer prevention is central to Europe’s Beating Cancer Plan (ECBP), with the European Code Against Cancer (ECAC) providing evidence-based recommendations to reduce cancer risk. The fourth edition (ECAC4) focuses on individual behaviour change; however, effective implementation requires insight into the individual and structural factors influencing adoption. A prior impact evaluation found low public awareness of ECAC4 but high willingness to change behaviour once exposed to its messages. Existing evidence largely focuses on single risk factors or screening behaviours, with limited qualitative research examining how EU citizens perceive the full set of ECAC4 recommendations and what facilitates or hinders their adoption.
Objective: To explore barriers and facilitators to adopting ECAC4 recommendations among the EU population across nine Member States, in order to inform the forthcoming edition and guide future evidence-based cancer prevention interventions.
Methods: An exploratory multi-country qualitative study was conducted with 141 adults aged 18–65 years, with no prior cancer diagnosis, from Bulgaria, Croatia, France, Germany, Ireland, Poland, Portugal, Romania, and Spain. Semi-structured interviews explored perceived capability, opportunity, and motivation related to the 12 ECAC4 recommendations. Transcripts were translated, coded, and thematically analysed using ATLAS.ti, with high intercoder agreement (κ = 0.88). Themes were mapped onto the COM-B and the Theoretical Domains Framework (TDF) to identify behavioural determinants.
Results: Barriers and facilitators were identified across all COM-B domains. While motivation to adopt preventive behaviours was often high, adoption was constrained by capability and opportunity factors, including low health literacy, misinformation and limited self-management skills, and cultural norms, economic constraints, environmental limitations, and healthcare access issues; respectively. Facilitators included early health education and access to reliable information (capability), as well as supportive social networks, universal healthcare, and enabling policies (opportunity). Motivation barriers included entrenched habits and fear, whereas facilitators comprised personal health goals, family responsibilities, and determination.
Conclusion/Implication: Adoption of ECAC4 recommendations is shaped by interlinked individual, social, and structural determinants. Multi-level implementation strategies, improving health literacy, ensuring equitable access, strengthening supportive environments, and tailoring motivational approaches, are essential to achieve sustained behaviour change. By applying behavioural science to understand public perceptions of ECAC4, this study provides actionable evidence to inform ECAC5 and strengthen the implementation of Europe’s Beating Cancer Plan.