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\begin{document}

\title{A Delphi method investigation to prioritise activity-related
determinants thought to affect mental health in adolescent populations}



\author[1]{Jackie Parsonage}%
\author[2]{Professor Mona  Eklund}%
\author[3]{Helen Dawes}%
\affil[1]{Oxford Brookes University Faculty of Health and Life Sciences}%
\affil[2]{Lund University}%
\affil[3]{University of Exeter}%


\vspace{-1em}



  
  \date{June 18, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Introduction Emergent mental illness during adolescence affects daily
functioning, causing disruption to daily activities, routines, and
patterns. Multiple inter-related personal, social and environmental
determinants influence the onset, nature and subsequent course of those
difficulties. Research suggests a bi-directional relationship exists
between mental health and activity choices. Activity-focused
interventions such as occupational therapy may improve adolescent mental
health related outcomes. In this study, we identify and select which
activity-related determinants should be prioritised in the development
of an occupation therapy-based intervention for adolescents with
emerging mental health difficulties using expert consensus. Method A
modified two-round Delphi survey method was conducted with occupational
therapists and researchers to ascertain a consensus opinion on the
prioritisation of specific activity-related determinants that influence
16-to 17-year-olds' Results Eighty-nine determinants were identified and
prioritised. Fourteen of these were personal activity-related
determinants including `types of activity' in which young people engage,
the `balance of activities' in which they engage, their `over and under
consumptions of activities', and their `underdeveloped occupation-based
coping skills'. The expert panel prioritised `personal self-confidence',
`values', and `perception of confidence' in relation to the activities
adolescents do. Conclusions This study generated a detailed picture of
the activity-related determinants that are important in adolescence, and
aligns with the adolescent model of occupational choice. Our findings
have potential to inform activity-related intervention development and
policy. Further research is needed, particularly to understand young
people's perspectives on these determinants and to investigate the
determinants that would benefit from further empirical research.%
\end{abstract}%



\sloppy


\textbf{Introduction~}

Emergent mental illness during adolescence affects daily functioning,
causing disruption to daily activities, routines, and patterns. Multiple
inter-related personal, social and environmental determinants influence
the onset, nature and subsequent course of those difficulties. Research
suggests a bi-directional relationship exists between mental health and
activity choices. Activity-focused interventions such as occupational
therapy may improve adolescent mental health related outcomes. In this
study, we identify and select which activity-related determinants should
be prioritised in the development of an occupation therapy-based
intervention for adolescents with emerging mental health difficulties
using expert consensus.

\textbf{Method}

A modified two-round Delphi survey method was conducted with
occupational therapists and researchers to ascertain a consensus opinion
on the prioritisation of specific activity-related determinants that
influence 16-to 17-year-olds'

\textbf{Results}

Eighty-nine determinants were identified and prioritised. Fourteen of
these were personal activity-related determinants including `types of
activity' in which young people engage, the `balance of activities' in
which they engage, their `over and under consumptions of activities',
and their `underdeveloped occupation-based coping skills'. The expert
panel prioritised `personal self-confidence', `values', and `perception
of confidence' in relation to the activities adolescents do.

\textbf{Conclusions}

This study generated a detailed picture of the activity-related
determinants that are important in adolescence, and aligns with the
adolescent model of occupational choice. Our findings have potential to
inform activity-related intervention development and policy. Further
research is needed, particularly to understand young people's
perspectives on these determinants and to investigate the determinants
that would benefit from further empirical research.

\textbf{Keywords} : Occupational Therapy, Social Determinants of health,
Young People, Mental health, Delphi Technique

\textbf{BackGround}

\textbf{Selecting and prioritising determinants for an occupation-based
intervention}

The emergence of mental illness during adolescence is known to affect
daily functioning, specifically disrupting daily activities, routines,
and patterns (Parsonage, 2016; McGorry \& Mei, 2018) with potentially
long lasting consequences for the individual, their family and society
(Patton \& Temmerman, 2016; Patton \emph{et al.} , 2016). Conversely, a
narrative review of leisure activities and a multi-level theoretical
framework of mechanisms of action suggests the relationship between
mental health and activity choices is actually bi-directional
(Fancourt\emph{et al.} , 2021). Neuroscience provides further insight
illuminating potential mechanisms by which engaging in activity within
one's environment affects adolescent brain development and may present
an opportunity for intervention (Larsen \& Luna, 2018).

Novel interventions are needed to address rising levels of adolescent
mental health difficulties internationally (Mei \emph{et al.,} 2020).
Reviews highlight the limitations of current approaches (Das et al,
2016). Developing interventions using an occupational therapy approach
to improve mental health shows potential (Kirsh \emph{et al} ., 2019).
Although there is limited research supporting this approach in
adolescent populations (Parsonage-Harrison \emph{et al} ., 2022).
Occupational therapy approaches incorporate a focus on the person, and
their daily activities (known as occupations) in the context of their
environment (Creek, 2006). The evidence-base for using activity in
adolescent populations to improve mental health remains problematic
(Parsonage-Harrison \emph{et al} ., 2022 \& Das et al 2016). Effective
intervention development requires the identification, selection and
prioritisation of determinants or factors affecting behaviour change to
improve health outcomes (Bartholomew-Eldredge \emph{et al.} , 2016).

The onset, nature, and subsequent course of mental health difficulties
may be improved if multiple inter-related personal, social and
environmental determinants are addressed (Viner \emph{et al.} , 2012;
McGorry \emph{et al.} , 2014; Patel \emph{et al.} , 2018; Mei \emph{et
al.} , 2020), minimising the disruption to an individual's life. The
value of addressing determinants at sub-clinical symptom threshold
levels before severe functional impairments emerge is strongly advocated
internationally, but remains a challenge (McGorry, \& Mei, 2018).
Knowledge of the effects of these many determinants on the emerging and
early stages of mental health difficulties is limited (Cairns \emph{et
al.} , 2015; Bale \emph{et al.} , 2020). Earlier qualitative work
identified determinants connected to adolescents' choices about the
activities they do (Parsonage et al., 2020). The work, highlighting a
process of considering time factors, appraising values and priorities,
interaction with the situational context and an exploration of skills
and occupational repertoire, that through experience shapes the
development of an adolescent's future self (Parsonage et al., 2020).
Given the potentially modifiable nature of many of these determinants,
knowing which are realistic to attempt to change and have greatest
influence on health outcomes, is important for intervention development.

A wealth of experiential knowledge based on using activity to improve
adolescent mental health exists internationally in the form of
clinically practicing occupational therapists and researchers, that can
help to inform intervention development for adolescent populations.
Multiple methods exist to identify and prioritise determinants when
developing interventions, we adopted Intervention Mapping framework for
intervention development, which advocates a systematic consultation of
the literature and a wide variety of stakeholders at all stages of the
development process (Bartholomew-Eldredge \emph{et al.} , 2016).
Stakeholder involvement helps maintain focus on issues of concern;
ensures intervention acceptability to the target population; increases
expertise on the project; and improves external validity
(Bartholomew-Eldredge \emph{et al.} , 2016). Involvement reduces
researcher bias towards certain topics or ideas and can highlight ideas
the researcher may not otherwise have thought of (Bartholomew-Eldredge
\emph{et al.} , 2016).

This paper reports on a novel Delphi study conducted with an expert
stakeholder group of occupational therapists and researchers working
with adolescents or related researching topics. The study was undertaken
to select and prioritise the determinants connected with what activities
or occupations young people choose to do, in their daily lives, that
influence their mental health. To the best of the author's knowledge, no
study has previously been conducted with occupational therapists and
researchers, to prioritise occupation or activity focused determinants
related to adolescent choice that may affect or influence mental health.

\textbf{Aim}

To establish an expert consensus view of which occupational determinants
should be prioritised within the development of an occupation
therapy-based intervention for adolescents with emerging mental health
difficulties.

Ethics

The study received approval from Oxford Brookes University Research
Ethical Committee (UREC no.191347).

\textbf{Method: The Delphi method and seeking consensous}

An electronic two round Delphi survey method was chosen, designed to
establish an expert `consensus of opinion' evolving from individual
experts' anonymised judgements, disclosed through multiple iterative
rounds of questionnaires (Keeney \emph{et al.} , 2001;
Dimitrijevi\selectlanguage{polish}ć\selectlanguage{english}\emph{et al.} , 2012; McPherson \emph{et al.} , 2018; Sossa
\emph{et al.} , 2019). The method is suited to addressing
practice-related problems where human judgement is required to solve
complex problems (Powell, 2003; Steurer, 2011; Dimitrijevi\selectlanguage{polish}ć \selectlanguage{english}\emph{et
al.} , 2012; Donohoe \emph{et al.} , 2012) and has previously been used
to prioritise determinants important to adolescent mental health (Cairns
\emph{et al.} , 2015; Bale\emph{et al.} , 2020). This method enables the
inclusion of participants from a broad range of geographical areas
(McPherson \emph{et al.} , 2018), and makes the distribution, collection
and analysis of data cost-effective and time-efficient (Dimitrijevi\selectlanguage{polish}ć
\selectlanguage{english}\emph{et al.} , 2012; Donohoe \emph{et al.} , 2012), all of which were
important for this study.

Recruitment and selection of the expert panel

The representativeness of the expert panel is important and the
selection of experts is influenced by the information the researcher
wants to gather (Steurer, 2011). We set the following criteria for our
expert panel; Participants must hold a qualification as an occupational
therapist and have experience of working with adolescents, or be a
researcher, working with adolescents with an occupation focus. These
criteria were checked by potential participant's responses to
self-report and verification questions. The research team identified
potential participants through specialist groups and the peer reviewed
literature. Each potential panel member received an email invitation to
participate. We opted for a minimum of twenty participants, reflecting
the typical numbers used in the Delphi studies literature, and in light
of the lack of formal recommendations in the literature (Keeney \emph{et
al.} , 2001; Dimitrijevi\selectlanguage{polish}ć \selectlanguage{english}\emph{et al.} , 2012).

Questionnaire development

The Delphi study was structured in two parts. The first part consisted
of an information sheet followed by seven consent related questions and
questions designed to check about the expert panel members experience.
The second part was formed of six questions informed by the intervention
mapping framework. Each of the 59 occupation related determinants
identified in relation to adolescents' mental health through three
earlier studies (Parsonage \emph{et al.,} 2020,
Parsonage-Harrison\emph{et al.} , 2022, Parsonage, 2022) were organised
under the appropriate question heading. As suggested by Dimitrijevi\selectlanguage{polish}ć
\selectlanguage{english}\emph{et al.,} (2012) to ensure reliability, the questionnaire was
piloted. The questionnaire format was developed for distribution using
Qualtrix XM (Qualtrix, 2005), then piloted by three researchers before
being distributed via email following amendments. The development of
round two followed the same process.

Delphi rounds

We conducted a modified two round Delphi study, replacing the
open-questions round typically used in round one of a Delphi with a
ranking question round (Keeney \emph{et al} ., 2011). Participants were
given the option to add additional qualitative information in round one.
Three rounds were originally planned but due to a moderately high-level
agreement after the second-round, coinciding with the beginning of Covid
pandemic, the research team agreed a third round was not required and
should not be conducted to avoid unnecessary burden on clinicians.

Based on their professional opinion, participants completing the first
Delphi round were given the option to add determinants before ranking
them according to which they considered had the greatest impact on
mental health. Following the closure of round one, the data was exported
from Qualtrix XM (Qualtrix 2005) into Microsoft Excel (Microsoft
Corporation, 2016). In round two, participants received a summary of
their responses, and a summary of the whole panel's results. The
rationale was to provide the participant with an opportunity to reflect
on their choices (McPherson \emph{et al.} , 2018), and encourage a
response to round two (Murphy M.K. \emph{et al.} , 1998; Powell, 2003).

Achieving consensus

Delphi studies aim to achieve a consensus opinion, defined as the
general agreement arrived at (McPherson \emph{et al.} ,
2018).Considerable variability exists in how consensus is both defined
and achieved (Bowles, 1999). We chose a frequently used ranking system
(Powell, 2003), using a weighted points system to reflect the number of
times an item was selected and its position in the ranking, resulting in
a total score. This total score was used to rank and identify the
consensus. A further non-parametric assessment, Kendall's W coefficient
of concordance, was used to consider the extent of agreement between
those rating each round (Sossa \emph{et al.} , 2019) The following
divisions can help to provide a benchmark for considering levels of
agreement (Landis and Koch, 1977): poor agreement = less than 0.20, Fair
agreement = 0.21 to 0.40, Moderate agreement = 0.41 to 0.60, good
agreement = 0.61 to 0.80 and very good agreement = 0.81 to 1.00.

\textbf{Results}

Twenty people agreed to participate as panel members. Two blank
responses were excluded. One participant submitted a partial and a
completed response, only the completed questionnaire was analysed. A
computer error effecting consent questions was identified, so the
research team sent an additional email to 11 of the 17 respondents to
confirm full consent. This resulted in at total of 15 consenting expert
panel members in round one, who were invited to take part in round two.
The second Delphi round received 13 responses.

Of the fifteen panel members in round one, four self-identified as a
researcher and twelve as state registered occupational therapists
working with adolescents. Thirteen participants reported at least five
years of work experience, while six indicated they had over 10 years'
experience. All but one panel member agreed with the statement that in
their professional opinion the way adolescents spend their time affects
their wellbeing. Responses from round one added a further 30
determinants, to the original 59 determinants previously identified (see
Figure 1 for details). All of the determinants included in the Delphi
are available in Appendix 1.

Add here Figure 1

In question one, round one item scores ranged from 36 to 175 and 18 to
154 in round two. The most frequently selected determinants relating to
what adolescents do, that affects their mental health, were: `types of
activity' (n154) and `balance of activity' (n137). These two
determinants achieved the highest level of agreement (31\%) in round one
and increased in round two to 90\% and 60\% respectively. The item
ranked third was the `pressure to conform' (n130) but the level of
agreement decreased from 27\% to 20\% between rounds (See Table 1 for
details).

Insert Table 1 here

In question two, concerning the behavioural determinants affecting
adolescent activity-related performance and wellbeing, scores ranged
from 53 to 167 in round one and 30 to 100 in round two . The level of
agreement in round one between the two highest prioritised determinants,
`under-developed coping skills' (n167) and `over or under consumption of
activities' (n153) is very similar at 33\% and 31\%. In round two `over
or under consumption of activities', referring to concerns about the
amount of time spent in an activity, was ranked highest with n100
(67\%), and above that of `under-developed coping skills' (n95),
referring to the skills an adolescent has to cope with life's
challenges, was rated highest in round one. After these first two
determinants, the next highest-ranking items are `inadequate balance of
activities', referring to the balance between the various activities a
person does, and `risk behaviours', referring to activities that put an
individual at risk of harm. In question 2 of the second round, the
highest level of agreement for the ranking of any of the 17
determinants, was 67\%, for items prioritised as most important and
least important. The lowest level of agreement, 22\%, was for the
midrange prioritised items.

Question three concerned which personal determinants have the greatest
impact on mental wellbeing, scores ranged from 59 to 173 in round one
and 28 to 146 in round two. `Personal self-confidence' (n146), was
ranked as having the greatest impact on mental wellbeing, and the level
of agreement increased from 46\% to 70\% between round one and two. The
ranking, for `perception of competence' (n120), `personal skills'
(n113), and `cultural values' (n102), changed between rounds, but the
level of agreement increased. At an interpersonal level (question four),
scores ranged from 19 to 119 and the determinants most likely to
influence adolescents' choices about what to do were thought to be
`peers' and `siblings', with `peers' scoring the highest level of
agreement (90\%) between panellists. The next highest level of agreement
was observed in the lower ranked determinants (80\%) `counsellors' and
`other professionals'. The level of agreement between middle ranked
determinants was low, ranging from 20\% to 50\%.

In question five, scores ranged from 38 to 145 in round one and 21 to
169 in round two. `Geography and locality' (n169) was the
community-based determinants ranked highest across rounds with an
increased level of agreement. Next were two items, `social determinants'
(n151) and `nature and quality of family relationships' (n151), with a
level of 50\% agreement. Panellists' comments suggest this question was
difficult to answer because of the variety of different community
settings which exist, and because the impact of the environment depends
on an adolescent individual's circumstances.

Finally, in question six, Scores ranged from n59 to n101 in round one
and n17 and n75 in round two. The highest ranked societal or
organisational determinant thought to affect mental health, which had
the highest level of agreement, was `local council investment in
services' (n75). The first three highest ranked determinants did not
change position in the ranking between rounds, but the level of
agreement on the ranking increased. Across the different questions it is
evident ranking remains similar between rounds, while the percentage
level of agreement appears to increase. Agreement appears be greatest at
the upper and lower ends of the ranking with the items in the middle
showing lower levels of agreement.

In addition to the percentage level of agreement achieved with regard to
the rankings of determinants for each question, the agreement between
those rating items between rounds was examined, using the non-parametric
test, Kendal's co-efficient of concordance (Kendal's W) (Sossa \emph{et
al.} , 2019), the results of are recorded in the table 2.

Insert Table 2 here

Table 2 shows the level of agreement between round one and round two,
has increased from that observed in the first round. The observed levels
of agreement for round one of the Delphi can be rated as poor,
increasing to a moderate level of agreement in round two (Landis and
Koch, 1977).

\textbf{Discussion}

Eighty-nine different occupational related determinants thought to
affect adolescents' mental health were ranked and prioritised. This
Delphi study achieved a level of agreement on the prioritisation of
determinants with each question but the results highlight a range of
different responses when ranking the determinants. The results suggest a
range of modifiable and non-modifiable determinants and that the
importance of each of them may vary. Our findings highlight the
complexity of rating activity related determinants against each other,
and the need for consideration of the nuanced areas affecting
occupational choices in adolescent populations. These findings are
supported by earlier research that highlighted the complexity
adolescents experience when making choices about what to do with their
time, highlighting a process of weighing up four domains against each,
which are `considering time factors', `exploring skills and occupational
repertoire', `Interacting with the situational context' and `appraising
values and priorities (Parsonage 2020). Occupational therapy literature
suggests a complex interrelated relationship exists between the
subjective concept of `occupational balance' and the objective concept
of `patterns of daily activities' that have implications for health
(Eklund \emph{et al.} , 2017).

In our study occupational therapists and researchers ranked the
determinants `types of activity', `balance of activity', `pressure to
conform' and `freedom of choice' as highest for their effect on mental
health. The expert panel ranked determinants linked to behaviours
affecting occupational performance and health. The highest ranked
included `under and over consumption of activities', `underdeveloped
coping skills', and `inadequate balance of activity types'. The
prioritisation of these determinants is important in adolescent
populations and provides a valuable life course perspective for
occupational therapy research targeting adolescent mental health.
Prioritised determinants can be used to focus adolescent mental health
research, and may be particularly relevant to occupational therapists.
For example, an occupational therapy theory informed intervention for
adolescents with emerging mental health difficulties is currently being
developed by the first author based on the top three prioritised
determinants from the first three questions.

In this study a moderate level of agreement was reached, the levels of
agreement increased between rounds and the rankings remained mostly
consistent for items at the upper and low ends of the scale. The panel
of this study was small, vulnerable to selection bias, and may not
represent all views given the loss of some participants during the
study. This should be balanced against the fact that the occupational
therapy profession is small and specialised. The panel had a high number
of years of relevant experience and responses may reflect an
evidenced-based approach embedded in clinicians' thinking. A brief
sensitivity checking exercise conducted at a conference in 2022 as part
of disseminating the findings, using question one, suggests those with
experience of mental health issues as adolescents organised items in a
similar way to our study results. This study highlights the need for
more research into the impact of occupational determinants on adolescent
mental health and research is needed to ensure adolescents' perspectives
are properly captured.

In summary, the use of the Delphi methodology enabled access to the
valuable, experiential knowledge of researchers and those providing
interventions to adolescents with mental health difficulties, and the
selection and prioritisation of occupational determinants that affect
mental health. To the best of the authors' knowledge, this is the first
Delphi study identifying and prioritising occupational determinants that
affect mental health in adolescents and could help to inform
activity-based interventions targeting adolescent's mental health
difficulties.

\textbf{Acknowledgments:}

Jackie Parsonage-Harrison acknowledge the following support

The support of The Elizabeth Casson trust for providing the funding to
undertake this research.

At the time of conducting this study Professor Helen Dawes was supported
by the Elizabeth Casson Trust and the NIHR Oxford Health Biomedical
Research Centre. At the time of writing this paper Professor Helen Dawes
is supported by Exeter Biomedical Research Centre, NIHR

Jackie Parsonage-Harrison would like to acknowledge the support of the
National Institute for Health Research (NIHR) Oxford Health Biomedical
Research Centre, NIHR Oxford Health Clinical in Research Facility and
the Oxford Institute for Nursing, Midwifery and Allied Health Research
(OxINMAHR) in helping to write this paper.

The views expressed in this paper are those of the authors and not
necessarily those of the NIHR, UK National Health Service, the UK
Department of Health and Social Care, The Elizabeth Casson Trust or the
Oxford Health Biomedical Research Centre.

\textbf{Data Sharing}

Data available on request due to privacy/ethical restrictions

The data that support the findings of this study are available on
request from the corresponding author. The data are not publicly
available due to privacy or ethical restrictions.

\textbf{Conflicts of Interest statement}

There are no conflicts of interest to disclose.

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\textbf{Tables}

Table 1: Determinants, ranking, score and percentage agreement between
rounds for question 1 to 6

\textbf{Question 1: What adolescents do that affects mental wellbeing?}\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\textbf{Determinants} & Delphi Round 1 & Delphi Round 1 & Delphi Round 1
& Delphi Round 1 & Delphi Round 1 & Delphi Round 1\tabularnewline
& \textbf{Rank} & \textbf{Score} & \textbf{\% Agree} & \textbf{Rank} &
\textbf{Score} & \textbf{\% Agree}\tabularnewline
Types of activity. \emph{E.g. sleep, exercise, social media, creative
arts, pets, time with friends, reading, time with family, schoolwork.} &
1 & 175 & 31\% & 1 & 154 & 90\%\tabularnewline
Balance of activity. \emph{E.g. such as the particular combination of
activities that meeting basic needs, like food, safety, security,
personal development} & 2 & 156 & 31\% & 2 & 137 & 60\%\tabularnewline
Pressure to conform. \emph{E.g. to achieve, to identify a future career
path, fit in with friends.} & 3 & 132 & 27\% & 3 & 130 &
20\%\tabularnewline
\textbf{Question 2: What behaviours adversely affect adolescent's
activity performance and consequently their mental well-being?} &
\textbf{Question 2: What behaviours adversely affect adolescent's
activity performance and consequently their mental well-being?} &
\textbf{Question 2: What behaviours adversely affect adolescent's
activity performance and consequently their mental well-being?} &
\textbf{Question 2: What behaviours adversely affect adolescent's
activity performance and consequently their mental well-being?} &
\textbf{Question 2: What behaviours adversely affect adolescent's
activity performance and consequently their mental well-being?} &
\textbf{Question 2: What behaviours adversely affect adolescent's
activity performance and consequently their mental well-being?} &
\textbf{Question 2: What behaviours adversely affect adolescent's
activity performance and consequently their mental
well-being?}\tabularnewline
\textbf{Determinants} & \textbf{Rank} & \textbf{Score} & \textbf{\%
Agree} & \textbf{Rank} & \textbf{Score} & \textbf{\%
Agree}\tabularnewline
Over or under consumption of some activities \emph{e.g. social media,
passive activities} & 2 & 153 & 33\% & 1 & 100 & 67\%\tabularnewline
Underdeveloped coping skills & 1 & 167 & 31\% & 2 & 95 &
44\%\tabularnewline
Inadequate balance of activity types \emph{e.g. balance of self-care,
leisure \& work} & 3 & 144 & 33\% & 3 & 89 & 44\%\tabularnewline
\textbf{Question 3: What are the personal determinant or factors with
greatest impact on mental well-being?} & \textbf{Question 3: What are
the personal determinant or factors with greatest impact on mental
well-being?} & \textbf{Question 3: What are the personal determinant or
factors with greatest impact on mental well-being?} & \textbf{Question
3: What are the personal determinant or factors with greatest impact on
mental well-being?} & \textbf{Question 3: What are the personal
determinant or factors with greatest impact on mental well-being?} &
\textbf{Question 3: What are the personal determinant or factors with
greatest impact on mental well-being?} & \textbf{Question 3: What are
the personal determinant or factors with greatest impact on mental
well-being?}\tabularnewline
\textbf{Determinants} & \textbf{Rank} & \textbf{Score} & \textbf{\%
agree} & \textbf{Rank} & \textbf{Score} & \textbf{\%
Agree}\tabularnewline
Personal self confidence & 1 & 173 & 46\% & 1 & 146 &
70\%\tabularnewline
Personal values & 2 & 135 & 40\% & 2 & 131 & 70\%\tabularnewline
Perception of competence & 4 & 115 & 27\% & 3 & 120 &
50\%\tabularnewline
Personal skills & 3 & 124 & 27\% & 4 & 113 & 70\%\tabularnewline
Cultural values & 5 & 114 & 36\% & 5 & 102 & 50\%\tabularnewline
\textbf{Question 4: Who at an interpersonal level are likely to
influence adolescent choices about what to do?} & \textbf{Question 4:
Who at an interpersonal level are likely to influence adolescent choices
about what to do?} & \textbf{Question 4: Who at an interpersonal level
are likely to influence adolescent choices about what to do?} &
\textbf{Question 4: Who at an interpersonal level are likely to
influence adolescent choices about what to do?} & \textbf{Question 4:
Who at an interpersonal level are likely to influence adolescent choices
about what to do?} & \textbf{Question 4: Who at an interpersonal level
are likely to influence adolescent choices about what to do?} &
\textbf{Question 4: Who at an interpersonal level are likely to
influence adolescent choices about what to do?}\tabularnewline
\textbf{Determinants} & \textbf{Determinants} & \textbf{Determinants} &
\textbf{Determinants} & \textbf{Rank} & \textbf{Score} & \textbf{\%
Agree}\tabularnewline
Peers & Peers & Peers & Peers & 1 & 119 & 90\%\tabularnewline
Siblings & Siblings & Siblings & Siblings & 1 & 119 &
30\%\tabularnewline
Parents & Parents & Parents & Parents & 2 & 96 & 50\%\tabularnewline
Teachers & Teachers & Teachers & Teachers & 3 & 80 & 30\%\tabularnewline
\textbf{Question 5: What are the community determinants that influence
what young people do in their daily lives?} & \textbf{Question 5: What
are the community determinants that influence what young people do in
their daily lives?} & \textbf{Question 5: What are the community
determinants that influence what young people do in their daily lives?}
& \textbf{Question 5: What are the community determinants that influence
what young people do in their daily lives?} & \textbf{Question 5: What
are the community determinants that influence what young people do in
their daily lives?} & \textbf{Question 5: What are the community
determinants that influence what young people do in their daily lives?}
& \textbf{Question 5: What are the community determinants that influence
what young people do in their daily lives?}\tabularnewline
\textbf{Determinants} & \textbf{Rank} & \textbf{Score} & \textbf{\%
Agree} & \textbf{Rank} & \textbf{Score} & \textbf{\%
Agree}\tabularnewline
Geography and locality. \emph{E.g. what facilities are available in the
local area or access to public transport.} & 1 & 145 & 25\% & 1 & 169 &
90\%\tabularnewline
Social determinants. \emph{E.g. wealth, and culture of the area} & 3 &
126 & 36\% & 2 & 151 & 50\%\tabularnewline
Nature and quality of relationships with family members. & 2 & 137 &
27\% & 2 & 151 & 50\%\tabularnewline
Quality of available support systems. \emph{E.g. mentors, guides,
counselling etc.} & 4 & 96 & 11\% & 3 & 124 & 30\%\tabularnewline
Local Resources to support activities. \emph{E.g. music lesson, local
bus network, sports facilities} & 4 & 96 & 22\% & 4 & 120 &
20\%\tabularnewline
Opportunity for exploring or developing interests in specific
occupations & 4 & 96 & 33\% & 5 & 118 & 40\%\tabularnewline
\textbf{Question 6: What are the organisational and societal factors
that affect what late adolescents do in their daily lives?} &
\textbf{Question 6: What are the organisational and societal factors
that affect what late adolescents do in their daily lives?} &
\textbf{Question 6: What are the organisational and societal factors
that affect what late adolescents do in their daily lives?} &
\textbf{Question 6: What are the organisational and societal factors
that affect what late adolescents do in their daily lives?} &
\textbf{Question 6: What are the organisational and societal factors
that affect what late adolescents do in their daily lives?} &
\textbf{Question 6: What are the organisational and societal factors
that affect what late adolescents do in their daily lives?} &
\textbf{Question 6: What are the organisational and societal factors
that affect what late adolescents do in their daily
lives?}\tabularnewline
\textbf{Determinants} & \textbf{Rank} & \textbf{Score} & \textbf{\%
agree} & \textbf{Rank} & \textbf{Score} & \textbf{\%
Agree}\tabularnewline
Local council investment in services & 1 & 101 & 45\% & 1 & 75 &
80\%\tabularnewline
Finance investment in schools for extracurricular activities & 2 & 95 &
50\% & 2 & 68 & 70\%\tabularnewline
National curriculum & 3 & 84 & 22\% & 3 & 51 & 40\%\tabularnewline
\bottomrule
\end{longtable}

\emph{Table 2}\textbf{: Levels of agreement between rounds}\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
& Question & Round & Kendal's W & Agree & Round & Kendal's W &
Agree\tabularnewline
\midrule
\endhead
1 & Doing determinants & 1 & 0.057 & Poor & 2 & 0.458 &
Moderate\tabularnewline
2 & Behavioural determinants & 1 & 0.289 & Poor & 2 & 0.42 &
Moderate\tabularnewline
3 & Personal determinants & 1 & 0.091 & Poor & 2 & 0.504 &
Moderate\tabularnewline
4 & Interpersonal determinants & 1 & N/A & N/A & 2 & 0.537 &
Moderate\tabularnewline
5 & Community determinants & 1 & 0.083 & Poor & 2 & 0.535 &
Moderate\tabularnewline
6 & Societal and organisational determinants & 1 & 0.078 & Poor & 2 &
0.468 & Moderate\tabularnewline
\bottomrule
\end{longtable}

\textbf{Figures legends}

\textbf{Figure 1.} \textbf{A descriptive outline of the Delphi process:}
The figure shows the questions asked, the number of determinants
identified before the start of the first round and later in the second
round.

\selectlanguage{english}
\FloatBarrier
\end{document}

