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).
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 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.