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The \u2018FRESHAIR4Life\u2019 project aimed to optimise implementation of contextually adapted, evidence-based interventions in Greece, Kyrgyzstan, Pakistan, Romania, and Uganda. Selecting appropriate interventions required deliberate, inclusive, and context-sensitive decision-making. This paper outlines the co-creation approach for selecting and adapting interventions, developing implementation strategies and addressing the challenges that arose.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Each country followed a four-step process. First, findings from local situational analyses were consolidated to identify barriers and facilitators across individual, community, and system levels and to map targets for change using the Theoretical Domains Framework. This was followed by a workshop with country-teams to identify key risk factors, target behaviours, relevant populations and settings, and to shortlist potential interventions from the FRESHAIR4Life palette alongside implementation strategies using option grids and ranking. A subsequent stakeholder workshop applied a Socio Technical Allocation of Resources informed approach to elicit perspectives on the interventions\u2019 value using qualitative (Conversation Caf\u00e9 style discussions) and quantitative methods (ratings of need, importance, likely reach, feasibility, and local adaptations required, fixed budget allocation exercises or ranking of options). Finally, selection meetings with country teams finalised intervention choices and implementation strategies, informed by stakeholder input.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Countries chose to target the risk factors that were considered most prevalent and the biggest threat to adolescent health in their settings. Of the four countries addressing tobacco use, Pakistan, Greece, and Romania selected \u2018implementation intentions (If-Then approach)\u2019 for prevention, while Kyrgyzstan selected \u2018very brief advice plus behavioural counselling (VBA+)\u2019 for cessation. All three countries addressing air pollution, Pakistan, Uganda and Kyrgyzstan selected social media campaigns. Key challenges included: (1) establishing a sound basis for selection decisions, which was overcome by adopting a systematic, transparent and inclusive decision process (2) ethical and practical considerations for addressing tobacco\/nicotine use within school-based prevention, tackled by adapting intervention to include offer of cessation support (3) limited evidence-based interventions targeting ambient air pollution, addressed by flexibly moving beyond the palette (4) the evolving nature of implementation strategies and (5) embedding interventions into routine practice, both addressed through flexibility and adaptation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This study shows that, across diverse country contexts, defensible intervention selection depends not only on which intervention is chosen, but on how choices are made and by whom. A transparent, stakeholder-owned co-creation process, involving the target audience of adolescents, helped country teams navigate trade-offs between evidence, local burden, feasibility, fit with routine practice, and ethical obligations, while exposing important evidence gaps for individual- and community-level ambient air-pollution interventions in LMICs.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s43058-026-01044-4","type":"journal-article","created":{"date-parts":[[2026,7,20]],"date-time":"2026-07-20T14:45:21Z","timestamp":1784558721000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["A co-creation approach to selecting and adapting adolescent tobacco and air-pollution interventions and strategies for implementation in diverse countries: insights from FRESHAIR4Life"],"prefix":"10.1186","volume":"7","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0779-6588","authenticated-orcid":false,"given":"Purva","family":"Abhyankar","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander","family":"Lepe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jurjen","family":"van der Schans","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Floor A.","family":"van den Brand","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Faraz","family":"Siddiqui","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Saima","family":"Saeed","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Javeria","family":"Akhter","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amina","family":"Khan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mian Ali","family":"Kamran Baba","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ioanna","family":"Tsiligianni","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Izolde","family":"Bouloukaki","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonios","family":"Christodoulakis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Winceslaus","family":"Katagira","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bruce","family":"Kirenga","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cristina","family":"Isar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adriana","family":"Antohe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anca","family":"Lupu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea","family":"Neculau","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Talant","family":"Sooronbaev","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gulzada","family":"Mirzalieva","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aijan","family":"Taalaibekova","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rianne","family":"van der Kleij","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"D. 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BMC Public Health. 2022;22(1):2402.","journal-title":"BMC Public Health"}],"container-title":["Implementation Science Communications"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s43058-026-01044-4","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s43058-026-01044-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s43058-026-01044-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T17:06:35Z","timestamp":1789578395000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s43058-026-01044-4"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,20]]},"references-count":52,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["1044"],"URL":"https:\/\/doi.org\/10.1186\/s43058-026-01044-4","relation":{},"ISSN":["2662-2211"],"issn-type":[{"value":"2662-2211","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,20]]},"assertion":[{"value":"6 November 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"10 July 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"20 July 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The research was conducted according to the ethical standards as outlined in the Declaration of Helsinki. Ethical approvals for all project activities were granted from the research ethics committees in all included countries. Kyrgyzstan: Ethical committee of the National Center of Cardiology and Internal Medicine named after academician \u041c. Mi\u043fakhimov (NCCIM) (October 2023). Pakistan: National Institutes of Health, Health Research Institute, National Bioethics Committee For Research (NBC-R) (December 2023, January 2025). Greece: Ethics and Research Ethics Committee of University of Crete (February 2023). Romania: The Ethics Committee of Transilvania University of Brasov (CEU) (May 2024)Uganda: The Mulago Hospital Research and Ethics Committee (March 2024, July 2025).","order":1,"name":"Ethics","label":"Ethics approval and consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":2,"name":"Ethics","label":"Consent for publication","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":3,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}],"article-number":"188"}}