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Using a qualitative design informed by implementation science and realist thinking, we analysed data from 22 transcripts of semi-structured interviews with researchers, facilitators, and external stakeholders, alongside 61 logbooks from co-creation sessions. Data were coded deductively using the PROSECO process-evaluation framework, followed by the development of exploratory Context\u2013Mechanism\u2013Outcome configurations. Findings highlight four predominant areas shaping the co-creation process: group dynamics, partnerships, contextual influences, and resources and support. Facilitators included psychologically safe spaces, horizontal communication, consistent facilitation, strong institutional partnerships, motivation driven by purpose and belonging, and access to organizational resources and staff support. Barriers were associated with socioeconomic adversity, unstable infrastructures, logistical constraints, competing priorities, uneven engagement, and challenges in translating complex systems-thinking concepts into youth-friendly practice. Realist interpretations suggest that when structured participation, trust, and relational support were present, they activated mechanisms of ownership, agency, and sustained engagement; conversely, low-resource contexts and activities overload hindered participation, feasibility, and engagement. This study contributes empirical evidence on co-creation processes with adolescents across diverse settings. It demonstrates the combined value of the PROSECO framework and realist-inspired analysis for evaluation and understanding of how context and mechanisms shape co-creation in health-related research. Implications include the need for resourcing relational work, and designing context-sensitive strategies when conducting co-creation with adolescents.<\/jats:p>","DOI":"10.1093\/heapro\/daag134","type":"journal-article","created":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T11:48:30Z","timestamp":1787226510000},"source":"Crossref","is-referenced-by-count":0,"title":["A realist inspired barriers and facilitators evaluation of the co-creation process in the Youth-centred Participatory Action Project"],"prefix":"10.1093","volume":"41","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4135-8549","authenticated-orcid":false,"given":"Maria Fernanda S","family":"Souza","sequence":"first","affiliation":[{"name":"Research Center in Sports, Physical Education, Exercise and Health (CIDEFES), Universidade Lus\u00f3fona , Campo Grande, 376, Lisboa 1749-024, Portugal"},{"name":"CIFI2D, Faculdade de Desporto, Universidade do Porto , Rua Dr. Pl\u00e1cido Costa 91, Porto 4200-450, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6259-2441","authenticated-orcid":false,"given":"Mai","family":"Chinapaw","sequence":"additional","affiliation":[{"name":"Public and Occupational Health, Amsterdam UMC Location VUmc , De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9464-7064","authenticated-orcid":false,"given":"Catarina Santos","family":"Silva","sequence":"additional","affiliation":[{"name":"Research Center in Sports, Physical Education, Exercise and Health (CIDEFES), Universidade Lus\u00f3fona , Campo Grande, 376, Lisboa 1749-024, Portugal"},{"name":"CIFI2D, Faculdade de Desporto, Universidade do Porto , Rua Dr. Pl\u00e1cido Costa 91, Porto 4200-450, Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2620-9932","authenticated-orcid":false,"given":"Leto","family":"Demetriadou","sequence":"additional","affiliation":[{"name":"Public and Occupational Health, Amsterdam UMC Location VUmc , De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-4539-3842","authenticated-orcid":false,"given":"Line","family":"Madsen","sequence":"additional","affiliation":[{"name":"Department of Sports Science and Biomechanics, Faculty of Health Sciences, Southern Denmark University , Campusvej, 55, Odense M DK52-30, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-8426-4632","authenticated-orcid":false,"given":"Vongani","family":"Maluleke","sequence":"additional","affiliation":[{"name":"Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand , Wits Medical School, 7 York Road, Parktown, Johannesburg 2193, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-1373-960X","authenticated-orcid":false,"given":"Lethukuthula","family":"Ndwandwe","sequence":"additional","affiliation":[{"name":"Department of Paediatrics, School of Clinical Medicine, University of the Witwatersrand , Wits Medical School, 7 York Road, Parktown, Johannesburg 2193, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4510-1553","authenticated-orcid":false,"given":"Anita","family":"Okafor","sequence":"additional","affiliation":[{"name":"Department of Physiotherapy, Redeemer's University , off Gbongan - 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