Last updated: Sep 21st, 2023
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Research Chronology 

Kooth is an evidence-based service with expertise in digital mental health, providing people with accessible and equitable support


This Research Chronology documents nearly 20 years' research into population-level mental health support delivery.


At Kooth, we believe everyone deserves access to effective, free-at-the-point-of-use, person-centred mental health support, whenever they need it.

We are pioneers of digital mental health, with over 20 years' experience innovating in the mental health tech space. Having spent many years researching the best possible model for delivering population-level mental health support which delivers positive outcomes for service users and commissioners alike, we are proud to share this Research Chronology, documenting the research, studies and findings that has helped us get to where we are today.

Navigating this Chronology

The Chronology is comprised of several sections containing collections of research.

To navigate to specific sections, please use the Contents menu below. Alternatively, you can use the dropdown menu in the "Chronology Contents" tab in the page header.

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Introduction from our CEO, Tim Barker

"Welcome to this Research Chronology. Kooth Digital Health is one of the world's leading digital mental health organisations.

We’ve been thoroughly researching and building on our findings to develop our innovative mental health platforms since 2006.
Our research has led to many groundbreaking developments in digital mental health, including the creation of the world's first validated single-session measure. Our research programs are developed with our own team of industry-leading researchers, alongside world-renowned experts and academics from institutions across the globe.

Kooth offers a range of benefits to its users, including free-at-the-point-of-use access to trained practitioners and therapists through chat sessions, self-help tools such as articles and activities, journaling, goal-setting and a vibrant community of peer support. Kooth strives to make its platforms accessible for whole populations, making it easy for individuals to access support from any internet-connected device when they need it most.

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This Chronology is a catalogue of our research, proudly grouped into themes such as economic evaluations, the impact of outcome measures, and the benefits of creating a positive virtual ecosystem. Alongside our peer-reviewed publications, we also appear as the featured data-source or case study for many other researchers and institutions. 

Kooth's extensive research into digital mental health has enabled us to develop platforms that have improved the lives of countless users in both Europe and North America. We are proud of our many academic accomplishments in this field and look forward to continuing our work in order to create even better solutions for those who need them most."

Tim Barker - CEO, Kooth PLC

A smart investment in mental health

Digital Mental Health services are a cost-effective solution to equitable wellbeing access


Measuring and tracking the financial impact of mental health services on healthcare, education, employment and judicial services has long-presented an operational challenge. 


An early evaluation that LSE conducted indicated that Kooth can be considered ‘Good’ value for money when reducing psychological distress and suicidal ideation and improving hope in young people. 


This early evaluation was then built on to produce a cost-benefit analysis and cost-effectiveness (QUALYs) for when Kooth was in commission. Kooth commissioned York Health Economics Consortium (YHEC) to produce this unbiased model. A cost-calculator is now available to use to calculate cost-benefits in existing commissioned areas, as well as prospective areas to predict cost-benefits to the healthcare, education, judicial and government systems.


Staff can easily access peer-to-peer, self-help, and one-on-one counselling with a professional. Via their mobile device.


The cost-benefit analysis demonstrates large cost-savings due to reductions in:

  • GP appointments and specialists referrals
  • Prescription of antidepressant medication
  • Hospital admissions due to suicidality and self-harm
  • Smoking and binge-drinking


Other cost savings that YHEC and other experts stated were highly important, but were not able to be modelled was the cost-savings associated with improvements in educational attendance and attainment. 


This cost-benefit model has been applied to the US market and projects significant cost savings in medical costs and societal outcomes.

Findings from economic evaluations


York Health Economic Forums, 2022

Cost-savings to UK public sectors

Coote L, Kelly L, Salhi L, de Ossorno Garcia S, Sefi A, & Holmes H

Kooth as a digital revolution in affordable youth support

The base case results followed a real cohort of 2,160 young people. The results of the cost calculator estimated that engagement with the Kooth platform is associated with a cost saving of £303,234 or £199 per engaged user, to the NHS and UK crime sector. These results are based on a typical Kooth contract in the UK.

London School of Economics - 2021

Preventative support for young people with mental health concerns

Stevens, M., Farías, J. C., Mindel, C., D’Amico, F., & Evans-Lacko, S

"Kooth cares: Unlocking pocket-friendly paths to CYP mental wellness"

The main aim of this research is to explore the potential benefits, and explore the economic case, for peer support in Kooth. The authors analysed whether participants obtained better outcomes over a 1 month period after having accessed Kooth, whether they attribute changes in part to use of Kooth, and at what cost.


The authors stated this their report that; “From an economic perspective, the Kooth intervention can be considered good “value for money” when used to target those outcomes that were found

to be significant (YP-CORE- reduced psychological distress, SIDAS, reduced suicidal ideation, HOPE - improved hope). This finding is also supported when comparing Kooth with similar interventions aimed at improving mental health in children and adolescents.”

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Kooth Digital Health, 2022

Estimated cost-savings to the US market

Kelly, L., Salhi, L., de Ossorno Garcia, S., Sefi, A

Koothonomics: Expanding the cost-calculator model to the US market

Kooth has produced a conversion of the UK Economic Evaluation model to be applicable to the US Market. The Kooth program has demonstrated success with children and young people and can project significant cost savings, both in terms of medical cost and societal impact.. 


Medical costs could be reduced by an estimated $790.72 per user while society could see an added $18.49 per user in benefits. 


For a population of 1,000 children and young people, 92% are expected to have an emerging mental health need (EMHN) and Kooth expects a 76.5% retention rate. Ultimately 704 are expected to engage with Kooth. The total population projected savings related to medical costs is $556,664 with a potential societal impact of $13,019.

Inclusive access to mental health and wellbeing solutions

Kooth, by design, has focussed on improving access.

Kooth characteristics such as anonymity first, no-thresholds or waiting lists to speak to a practitioner, and no referrals, meaning we aim to reduce the burden on other services to refer in but also to enable individuals to be autonomous in their mental health journey. 

Access to mental health and wellbeing services is critical to improve outcomes and wider systemic impact. Whether that be access to early intervention and prevention services, or timely and rapid access at the point of need or crisis. Access to wellbeing and mental health services, however, has traditionally been difficult, with the need for referrals and formal signposting to services, as well as long waiting lists and thresholds to meet. This, along with physical barriers, such as attending appointments at a set time and in a set location, usually in working hours, meant there are lots of physical barriers to accessing support. These barriers are sadly still coupled with social barriers such as stigma and prejudice around seeking wellbeing and mental health support. Kooth’s theory of system change improves downstream access for young people by providing a streamlined pathway to appropriate referrals. 


At Kooth we understand that improving access is the first step to driving change and being able to provide effective international and prevention services. Our model is that of a whole population or whole-school approach to access, with everyone getting access, meaning that everyone can access when needed for whatever reason or issue. Young people in the US indicated they want support that is free and immediately accessible - without the need for payment or wait-lists. 

When providing access to all, we have to acknowledge the shortage of practitioners and resources, so scalable digital interventions are needed. Kooth specialises in providing the therapeutic bundle, with single-sessions and peer-support making up a large proportion of Kooth’s engagement from service users. This became evermore evident during the COVID-19 pandemic and lockdowns, where at Kooth we had a privileged position to be able to provide access and care as normal whilst other services needed to change their delivery model. We were able to utilise our data to inform and report to the UK government to support decision making.

Findings from accessibility evaluations

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Kooth, 2023

“Meeting young people's needs within a single session”

Roberts,A., Wohi,G., Wilson, H., Hanley, T., & Salhi,L.

One and done - scaling mental health support with single sessions

The “one at a time” approach assumes the young person may not return for further sessions and focuses on providing an effective, solution-focused therapeutic contact to address the young person’s wants and needs. 


With the increase in demand for mental health services for children and young people, digital single-session interventions have been found effective and useful for addressing barriers and challenges. There are substantial opportunities for single-session interventions to meaningfully impact future policy-making and service delivery such as waiting list management. 


We have also acknowledged how single-session interventions address the wants and needs of underserved communities by providing support without the common barriers to accessing traditional therapeutic services. The online, free, and inclusive nature of single-session interventions appeals to youths facing significant barriers to mental healthcare, even without cultural-specific tailoring. Moreover, innovative tools such as the SWAN-OM (Session Wants and Needs Outcome Measure; De Ossorno Garcia, 2021) combine young people’s wants and needs into an outcome measure to improve the therapeutic experience for young people and practitioners.

Pennsylvania State, 2023

"Filling the gap in Pennsylvania: Impacts on an individual and systemic level"

Hedges, E., Roberts,A., Wohi,G., Fitzsimmons-Craft, E., Schleider, J., & Salhi,L.


A Report of the Pilot’s First Five Months

This report utilised data from the first five months of this pioneering pilot demonstrates the value, as well as the need, in having Kooth available as a digital mental health and wellbeing service across whole-school districts in Pennsylvania. Key education-based stakeholders in school districts involved in this pilot program have reiterated the increasing mental health needs of their students, which outstrip the current resource in many of their schools, and alongside leading academics, have shown support for Kooth as a digital platform to provide mental health and wellbeing support to their students. This report provides early evidence around how Kooth can (1) improve access to mental health and wellbeing services, (2) reduce the need for downstream intervention with early help, (3) enable the use of other services, and (4) impact the school system, at a student and organisational level.

The theoretical impact of Pennsylvania’s whole-school approach

The early Kooth Theory of System Change outlines the predicted long-term change as a result of the Kooth whole-school approach to mental health and well-being. The framework describes sequential events within the Kooth service (inputs, activities, outputs, and outcomes) and theorises the potential impacts on wider systems. By providing the Kooth service and enabling mechanisms of change, Kooth can contribute to improved literacy and agency; social, emotional, and mental wellbeing; downstream service access; school and economic outcomes. Therefore, it is theorised that Kooth meaningfully impacts wider systems in Pennsylvania, such as the education, healthcare, government, judicial, and economic systems, leading to positive systemic change.

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Kooth, under review

"Changes to digital mental health use during COVID-19"

Knipe D, de Ossorno S, Salhi L, Mainstone-Cotton L, Sefi A and John A.

Kooth acting as a lockdown lifeline - navigating equitable care during the UK's COVID challenges

Using Kooth’s data, this paper explores the impact of the pandemic on service access and presenting concerns and whether differences were observed by sociodemographic characteristics in terms of access (gender, ethnicity and deprivation). 


Activity and contact with digital web-based therapy increased in the first few months of the pandemic. Significant changes were observed in referral routes to the service, unsurprisedly a drop in referrals from educational settings was observed due to school-based lockdowns. 

Changes were observed in presenting concerns for service users before and during the pandemic, reflecting some of the immediate mental health impacts, including a significant increase in risk, abuse, and safeguarding issues for young peole but also mental health concerns, suicidality and, self-harm demonstrating the enhancing vulnerability for young peole during the pandemic.

Pulse Report, 2021

“The State of the Nation's Mental Health”

Hedges, E., Roberts,A., Wohi,G., Fitzsimmons-Craft, E., Schleider, J., & Salhi,L.

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The needs of the UK nation during COVID-19 lockdowns

As the UK’s leading digital mental health service provider, we provided anonymised mental health insights to support the NHS and Local Authorities, Public Health England, policymakers, charities, and businesses since the UK’s first lockdown in March 2020.


This report provides a unique analysis of access, severity and needs during the Covid-19 lockdowns in the UK.


Kooth & University of Swansea, 2023

“Engagement of individuals aged 14–25 years with a digital mental health service during the COVID-19 pandemic in the UK: a cohort study of service usage data”

Bernard A, Salhi L, de Ossorno Garcia S, John A, del Pozo-Baños M.

Community is key - facilitating changing priorities of young people during COVID-19

This study examines changes in user engagement with Kooth during the COVID-19 pandemic. The cohort study, based on usage data, included 18,889 users aged 14-25, split into pre-COVID and COVID cohorts. Results show a notable shift in primary engagement clusters, with a greater proportion of users in the COVID cohort engaging primarily with community-based interventions. 


The study identified significant changes in how users engaged with digital mental health services during the COVID-19 pandemic.  While users were generally less engaged during the pandemic, there was a notable increase in users seeking community-based interventions. The findings emphasised that continuous monitoring of user engagement patterns is crucial to develop informed designs and personalised interventions, since patterns within digital mental health services may be susceptible to change in response to external events such as a pandemic.

Pioneering mental health trends with groundbreaking single session measurement

Kooth is innovating to create outcomes that respond to trends in mental health and have created a novel measurement of single-sessions. 

It is important to provide services that users want, enabling them to have a more meaningful interaction, therefore as a service we have been responding to trends in what users want.  Research suggests 46% of young people accessing specialist mental health services attended only a single session.

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The majority of Kooth service users choose to engage in single-session therapy, which is also seen in other digital services as well as face-to-face and specialist mental health services. Diagnostic outcome measures that track symptom improvements, however, are not well-aligned to provide single-session outcomes. Therefore, Kooth took it on to develop the Session Wants and Needs Outcome Measure (SWAN-OM), a tool and outcome measure to support single-sessions and measure the outcome of these in real-time. 

The SWAN-OM plays an important role in supporting adolescent mental health here at Kooth. More specifically, the instrument identifies and explores changes in ‘in-session goals’ that represent service users' wants and needs for the session. It does not only provide outcomes, but also helps to provide a solution-focused framework for single-sessions. Developed in conjunction with young people and clinicians, the SWAN-OM is aligned to Kooth’s values and service model. Over the last two years, the Research team have published two peer-reviewed papers that outline the development and explore the validity of the SWAN-OM. There is evidence for good face, content and concurrent validity of the SWAN-OM. Ongoing research will examine the acceptability of the measure and look at how demographic information predicts item-selections. This can be informative to what different cohorts want and need from solution focussed single-sessions or coaching sessions.

Findings from innovation evaluations

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CORC, 2021

“The Session Wants and Need Outcome Measure: The Development of a Brief Outcome Measure for Single-Sessions of Web-Based Support”

de Ossorno Garcia S, Salhi L, Sefi A and Hanley T

Developing a bespoke measurement tool for single-sessions with young people and clinical experts: The SWAN-OM

This paper develops a measure to assess brief therapeutic interventions to be used in a web-based digital therapy setting. No measure before this captured the benefit and/or ‘change’ directly related to these brief sessions. This study included a pre- and post-questionnaire for users to identify what they wanted to get from their session, and how well they thought it was achieved. 


This paper provided a new measure, as well as helped young people  generalise their thoughts and feelings into achievable goals. it helped focus the chat and provided a framework 

CORC, 2021

“Examining concurrent validity and item selection of the Wants and Needs Outcome Measure (SWAN-OM) in a web-based therapy service"

de Ossorno Garcia S, Edbrooke-Childs J, Salhi L, Ruby F, Sefi A and Jacob J


Validating the SWAN-OM single-session measure

This paper focuses on testing the validity of the previously created SWAN-OM measure (see below). More specifically, it measured concurrent validity against other frequently used outcome and experience measures, at a web-based service. 


Findings show that the SWAN-OM demonstrates good concurrent validity with common measures of outcome and experience.

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Publication coming, 2024

“The Development of Adult SWAN-OM using novel data-science approaches”


Applying the SWAN-OM to non-digital settings

This study outlines the development of a measure for single session wants and needs in adults using contemporary machine learning methods and textual data analysis of transcript data from Qwell's counselling sessions. The study solicited feedback from clinical experts and Qwell service users  to refine the measure. 


The aim of the study is to provide insights into the wants and needs of users and improve mental health support. The study focuses on developing outcome measures in the context of 'single sessions' and refining automated methods through collaboration with clinicians and individuals with lived experience.


The aim of the study is to provide insights into the wants and needs of users and improve mental health support. The study focuses on developing outcome measures in the context of 'single sessions' and refining automated methods through collaboration with clinicians and individuals with lived experience.

Publication coming, 2024




Acceptability and suitability of the SWAN-OM in non-digital settings - using digital innovation to inform in-person mental health services

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Publication coming, 2024

"Exploring free-text responses in the SWAN-OM, examining single-session wants and needs of young people."


Empowering young people to set their own objectives for single session support

Peer-Powered Success of an Evidence-Backed Online Peer Community

Online peer communities can play an important role in supporting adolescent mental health. 


From the Theory of Change for Kooth, the desired impact of our community is increased safety in the user, increased connections, a more hopeful perspective, and greater ability to make changes in their life.

Overall, young people find the web-based peer support helpful, indicating that peer support can provide an important strand of care within a supportive mental health ecosystem, particularly during time periods when in-person support is typically closed. We see clinical benefits on young people’s mental health, with reduced psychological distress, suicidal ideation and loneliness to name a few, even after only 1 month of using the community aspects of Kooth. Typically young people used online forums for both informational and emotional support. 

Kooth’s peer community is designed to provide a safe and inclusive virtual space to share and connect with peers. It is fully moderated, safe and preserves anonymity. We have published various peer-reviewed papers that provide evidence and demonstrate the value  for the peer support component of Kooth’s ‘Positive Virtual Ecosystem’.

Findings from peer support evaluations

London School of Economics, 2023

“Pilot evaluation to assess the effectiveness of youth peer community support via the Kooth online mental wellbeing website”

Stevens, M., Farías, J.C., Mindel, C. et al

An Evaluation of Kooth’s clinical effectiveness - with positive effects of Kooth’s community as well as chat based support

This paper assessed changes in the wellbeing and mental health of Kooth users over one month, specifically focussing on the platform’s community features. Young people completed a survey when they first accessed Kooth and again one month later. In addition, a few qualitative interviews were completed to explore perceptions of the Kooth community. 

The findings suggest improvements across psychological distress, suicidal ideation, loneliness and more. This was similar for users who utilised only the community features of Kooth, as well as those who engaged with counsellors


The aim of the study is to provide insights into the wants and needs of users and improve mental health support. The study focuses on developing outcome measures in the context of 'single sessions' and refining automated methods through collaboration with clinicians and individuals with lived experience.

Collaborating across industry and academic: Kooth & Exeter, Kent, Manchester Universities, 2022

“The design and development of an experience measure for a peer community moderated forum in a digital mental health service”

Mindel, C., Mainstone-Cotton, L., De Ossorno Garcia, S., Sefi, A., Sugarman, G., Salhi, L., & Hanley, T.

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A way to measure outcomes from community engagement - introducing the POCEM

In this paper we demonstrate the development of an online experience measure for a specific children and young people's community forum inside a digital mental health service. The development of the Peer Online Community Experience Measure (POCEM) is informed by a multi-phased design.


Findings showed that Young People who participated in the community as writers found it more helpful than those who consume the community as viewers. young service users( 10 - 14 years ) have a more positive experience within the community. Outcomes frequently selected show the importance of certain aspects of the community, such as safety, connection, and non-judgment previously highlighted in the literature.

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Kooth & Universities: Exeter, Manchester, 2022

“The helpfulness of web-based mental health and wellbeing forums for providing peer support for young people: A cross-sectional exploration”

Banwell E, Hanley T, De Ossorno Garcia S, Mindel C, Kayll T, Sefi A

‘Important to me’ - Using the POCEM to understand how young people make use of peer support at Kooth

Kooth created the POCEM (Peer Online Community Experience Measure) to explore experiences with online content. This study provides novel insight into how children and young people interact with the POCEM measure.

The results appear to demonstrate that overall, the young people found web-based peer support helpful. They indicate that peer support can provide an important strand of care within a supportive mental health ecosystem, particularly during time periods when in-person support is typically closed.

Universities: Liverpool, Bolton, Manchester, 2019

“Why do young people use online forums for mental health and emotional support? Benefits and challenges”

Prescott, J., Hanley, T., & Ujhelyi Gomez, K.

‘It wasn’t just me’ - Kooth’s peer community tackles loneliness, psychological distress, and more

Individuals suggested the forums were supportive environments where they felt able to interact to share helpful advice and ask questions, making them feel less alone and more connected to others.


Analysis indicated that forums do not replace the role of a counsellor, but they provide a valuable place for young people to gain additional, lower level support requirements.

Universities: Bolton, Manchester, 2017

“Peer Communication in Online Mental Health Forums for Young People: Directional and Nondirectional Support”

Prescott, J., Hanley, T., & Ujhelyi Gomez, K.

Benefits of peer communities in forums to young people

The aim of the research was to gain an understanding of how young people use an online forum on Kooth for emotional and mental health issues. There was an investigation into what young people discuss and how they seek support on the forum and how the young service users responded to posts to gain an understanding of how young people provided each other with peer-to-peer support.


Online forums provide young people with both informational and emotional support around a wide array of topics. Informational/emotional support can be seen as either directive or non-directive.

Innovative Goal Setting for Transformative Change

Kooth helps people achieve their goals, leading to meaningful change in their lives

Goals and the Goal-Based Outcome Measure are a well-established tool and related outcome measure that provide a framework for practitioners and users to set and monitor their individual goals. Goals are very aligned to the person-centred and holistic service model that Kooth aligns, and are very widely accepted and utilised by practitioners, counsellors and coaches. A useful tool for both adults and children and adolescents.


At Kooth, we have explored what types of goals are set by or with service users and determined which of these are achieved more commonly. Goals for young people clustered into; intra-personal goals, inter-personal goals and goals on ‘self’ relating to others. Work across adults and young people showed that goals that were collaboratively set were achieved more, suggesting the importance of a trained practitioner in supporting goal setting and meaningful improvement of goals. 

Work alongside the Anna Freud Center in the UK determined that Most young people made significant movements towards achieving their goals, which is a good indication that Kooth is helping to address important areas of change. Goals are a good way to measure impact and person-centred change, without focussing on symptom reduction alone.


Findings from goal-based outcomes evaluations

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Kooth & University of Manchester, 2022

“The use of goal-based outcome measures in digital therapy with adults: What goals are set, and are they achieved?”

Banwell, E., Salhi, L., Hanley, T., & Facey‐Campbell, N.

Adults benefit from goal based outcomes - especially when collaboratively set with practitioners

This paper identified patterns of goal-based outcome (GBO) engagement in digital therapy for adults. Goals were examined for level of progress on goal, pattern of engagement with self-set vs. collaboratively-set goals and the influence of key presenting issues on goal progress. 


Results showed that goals set collaboratively with a practitioner were successfully achieved more than those set independently, as well as those with a practitioner-recorded presenting issue. 


These insights suggest that goals are useful for monitoring therapeutic progress with adults within the digital context.

Kooth & Universities: Bolton, Manchester, 2022

“The Therapeutic Goals Set by University Students in an Anonymous Web-Based Therapy and Support Setting”

Hanley, T., Prescott, J., & Sefi, A

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Exploring the types of therapeutic goals set by university students

Utilising data from Kooth, this paper examined how university students use web-based therapy, specifically focusing on goal setting. The results suggest better engagement with goals from younger individuals (18–22). Additionally, males were less likely to set goals and less likely to move towards achieving them , whereas females showed increased movement and achievement.

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Kooth & Anna Freud, 2020

“Online counselling and goal achievement: Exploring meaningful change and the types of goals progressed by young people”

Jaco J et al

Meaningful change in goal-based outcomes (GBOs)

Most young people made significant movement towards their collaboratively agreed goals in Kooth, which is a good indication that the service is helping to address important areas of change. 


The findings indicated that those who report improvements in goals may engage with services more. The high proportion of ‘getting help’ goals may be attributable to the online setting, which young people may use as a first point of contact for help seeking, to gather information to access further support.

University of Manchester, 2015

“Therapeutic Goals in Online Youth Therapy:What Goals Do Young People Identify and How Do Counsellors Work with Them?”

Ersahin, Z

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Therapeutic Goals in Online Youth Therapy

This project explored the types of goals that young people want to achieve from online services. The challenges and opportunities that online counsellors have experienced when working with these goals were also explored. 


The findings suggest that three different types of goals were typically identified by young people: 

1) intra-personal goals

2) interpersonal goals

3) goals on self-relating to others

Commitment to Empowerment of Seldom-Heard Communities

Kooth supports seldom-heard communities


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Specific communities also are at higher risk of mental health needs coupled with reduced likelihood of accessing support. At Kooth we have started exploring the needs and wants of these groups, as well as barriers to support, and preferences for support. This is only the start of this important work, but so far we have interesting findings. 


Seldom heard groups often do not access traditional face-to-face services as much as white, middle-class, famales. This may be for a range of reasons, however we must as service providers shed light on this systemic issue and provide insight and solutions to provide more equitable access. Acknowledging that when providing a whole-population approach, not all communities will see or feel comfortable accessing services advertised in the same way. We saw in Kooth that there were differences in where individuals from seldom-heard communities heard about Kooth, for example young people from Asian and Black ethnicities reached out through informal sources such as Google as opposed to health professionals such as GPs. 


When working with vulnerable young people during the covid-19 pandemic in the UK, practitioners saw that children who had experienced adverse childhood trauma, as well as other vulnerabilities or risk factors, experienced a very separate experience during the lockdowns. The findings highlight the importance of the consistency and availability of care during periods of uncertainty and restricted face-to-face care access, with digital provision being well suited to provide consistent support.


For adults experiencing stressful life events, individuals who were in absolute poverty were more likely to experience numerous stressful life events, and yet at the same time, least likely to access or seek support. Similarly when exploring how parents utilise mental health services, no-one in the <£20,000 income bracket said they were likely to seek face-to-face counselling as an alternative to Kooth, compared to 67% of those in the £50,000-75,000 bracket. Alongside this, 63% of young parents (aged 20-30 years) in particular said they wanted to reduce their feeling of isolation from using Kooth. This reiterates the importance of free mental health support, and raises questions on how a counselling service can support the financial hardship experienced by people struggling with a stressful life event or significant life events, i.e. becoming a parent or caregiver,  in both the short-term and in the long-term.

Findings from community outreach evaluations


Kooth & University of Bolton, 2022

“An exploration into how young-people from ethnic-minority backgrounds interact with online counselling”

Patel, A., Sefi, A., Hanley, T., Conn, C. and Prescott, J.

Kooth & Culture: Navigating digital interactions amongst young people from ethnic minorities

Literature suggests young people from ethnic minority backgrounds face barriers in accessing mental health support due to discrimination and stigma and so this study aims to explore how young people from ethnic minority backgrounds interact with online counselling. 


Findings from this study reveal school-based services are the most popular source of referral for all young people; however, a higher number of young people from Asian and Black ethnicities reached out through informal sources such as Google as opposed to health professionals such as GPs. From the data, young people who identified as Indian, Chinese and African present to online counselling at a lower level of distress compared to their White British counterparts, contradictory to findings investigating measures of need in face-to-face settings.


It is important to provide access routes for individuals from different ethnic and cultural backgrounds who are less likely to access through Kooth’s traditional referral routes, such as via schools.

Kooth & University of Nottingham, 2022

“Alienated and unsafe: Experiences of the first national UK COVID-19 lockdown for vulnerable young people (aged 11–24 years) as revealed in Web-based therapeutic sessions with mental health professionals”

Mindel, C., Salhi, L, Lockwood, J


Alienated & unsafe, empowering vulnerable young people to speak out and be heard

Focus groups with professionals from Kooth were conducted to understand the experiences of vulnerable youth during the pandemic lockdowns in the UK. Four main themes were identified: 1) escalation of risk; 2) the experience and consequence of loss; 3) feeling supported and empowered; and 4) feeling separate and isolated.


Findings suggest that those with existing vulnerability, for example having experienced adverse childhood trauma, face an increased risk of poor outcomes through the pandemic and restrictions of lockdown. There needs to be acknowledgement that, as life returns to ‘normal’, vulnerable young people are not being met with the support they need at the time they need it, particularly for those who feel alienated.


The findings highlight the importance of the consistency and availability of care during periods of uncertainty and restricted face-to-face care access, with digital provision being well suited to provide consistent support. We recognise the critical role that schools play, not only in the early identification of risk and provision of mental health support but also in providing access to a safe and predictable space and respite away from an abusive or precarious environment, or where young people may experience alienation within the family home.


Kooth & University of Kent, 2022

“Supporting adults who have experienced Stressful Life Events through Kooth”

Salhi, L., de Ossorno Garcia, G., Mainstone-Cotton,L., Facey-Campbell,N., & Mindel, C.,

Guiding adults through stressful life events with care

This report explores how providing a digital mental health support service - Kooth for Adults (Qwell) - for free, with flexible access and anonymity can help adults dealing with stressful life events, and contribute to their personal growth. A survey was released across the service, and four interviews were conducted with Qwell users who had experienced stressful events.


Headlines from  the report were; 

->84% said it was important that they were in charge of their own mental health journey and 90% said it was important that they were supported in accepting that their problems and emotions are real and valid. 


-> Adults in ’absolute poverty’ experienced significantly more Stressful Life Events and these had a significantly higher negative impact on their lives and wellbeing. 


->Anonymity on Qwell reduces inhibitions and promotes disclosure talking about mental health.


Results indicate that Qwell, as a digital service, was well-placed to support individuals who experience stressful life events. Financial hardship, as well as experiencing absolute poverty was a major contributor to the impact of stressful life events on an individual's mental health and wellbeing, as well as likelihood to seek support.


This reiterates the importance of free access, and raises questions on how a counselling service can support the financial hardship experienced by people struggling with a stressful life event in both the short-term and in the long-term.


Online forums provide young people with both informational and emotional support around a wide array of topics. Informational/emotional support can be seen as either directive or non-directive.

Kooth, 2021

“Supporting Parents: a personalised approach to mental health”

Mindel, C., Salhi, L., & de Ossorno Garcia, G.,


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How Kooth supports parents and caregivers

This report is a snapshot view of how parents interact with online therapeutic support, including an insight into their needs and their wants from a digital mental health platform. 


Headlines from the report showed; 

->67% of parents accessed Kooth for support with their own mental health and 71% of parents who use Kooth for parenting support want to discuss challenges with their child’s mental health or behaviour.


->Increased goal setting was associated with improvements in routine outcome measure scores, with the largest association to improved GAD-7 scores measuring generalised anxiety. 


->63% of parents aged 20-30 years want to experience reduced isolation from using Kooth, compared to 20% aged 50+ years. 


->No-one in the <£20,000 income bracket is likely to seek face-to-face counselling as an alternative to Kooth, compared to 67% of those in the £50,000-75,000 bracket.


Whether using Kooth for support with their own needs or for help related to parenting, parents want reliable information from professionals or their peers, to support them in making informed choices within their lives. Using a digital platform to get these needs met not only helps to reduce some of the barriers that adults face as a result of social inequalities, but also enables autonomy and independence in how the individual engages with support.

Safety first: Kooth as a Fully Moderated, Safe Digital Environment where Risk can be managed

One of Kooth’s values is ‘safety’, and Kooth has been exploring this to ensure the users of Kooth are safe at all stages of using Kooth. Kooth has very strong governance and policies in place to ensure the users are safe. 

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Key aspects of risk management in kooth is the moderation of user generated or submitted content, this can span from a journal entry or goal submitted in their ‘private’ space on Kooth, to content submitted in the live forums, discussion boards or articles. Moderation both keeps the user safe themselves as Kooth practitioners can intervene and escalate where needed, but also ensures the other users are not exposed to anything harmful in the community spaces on Kooth. One recent paper explores how AI tools can support moderators, the paper uses Kooth as a case study to explore the challenges and makes recommendations to support the development of responsible AI assisted tools for practitioners/ moderators. The use of AI can speed up the discovery of risky behaviour online, meaning practitioners can reach out quicker, leading to a safer online environment for users.  




As there are no thresholds to using Kooth, there is a large variability in psychological distress levels of users who start using Kooth. Collaborations with academics have explored how digital interventions can support the management of self-harming behaviours as well as how users perceive receiving support from digital versus face to face support services. Common themes in support preferences for seeking online support for suicidal ideation were ‘anonymity’ with sub-themes of ‘safety and freedom’, ‘confidentiality’ and 'control’. 

Kooth will continue to investigate and explore how to support users online in a safe and effective way, through conducting research it provides knowledge about a relatively unexplored area of anonymous digital support.

Findings from risk management evaluations


Manchester Metropolitan University, 2023

“Experience of online, text-based, anonymous mental health support during COVID-19 for young women previously at risk of suicide”

Leece, Wilson & Andriopoulou

Exploring the experience of online, text-based support during the Covid-19 pandemic for  individuals previously at risk of suicide.

The present study aims to explore the experience of online, anonymous, text-based services provided by Kooth, an online MH platform, to YP previously at risk of suicide during the COVID-19 pandemic. 


Results discuss three superordinate themes: a safe space to share; control; and need for connection. Thematic results highlight the desire for anonymity and control of therapeutic conversations due to concerns regarding confidentiality, and the perceived consequences of seeking help. Participants were successfully able to build connections through chats with online MH support staff. Themes suggest that anonymous, online services can overcome access barriers and enable YP to share and process their experiences.


“Identifying key challenges and needs in digital mental health moderation practices supporting users exhibiting risk behaviours to develop responsible AI tools: the case study of Kooth.”

Nichele, Lavorna & Middleton

Identifying key challenges and needs in digital mental health moderation practices supporting users exhibiting risk behaviours to develop responsible AI tools: a case study of Kooth

This research aims to better understand the challenges and needs of moderators and digital counsellors. Moderation can be defined as the ‘governance mechanisms that structure participation in a community to facilitate cooperation and prevent abuse’. Moderators and digital counsellors need both intellectual and social capital, as they require both specialised subject knowledge and the ability to navigate online support in effective ways. Through this case study, the authors intend to contribute to the development of responsible AI tools that are fit for purpose and better understand the challenges. If AI is delivered in a responsible way, with safeguards in place as part of a wider and evidenced governance framework, coupled with opportunities for stakeholder trust to be built via mechanisms such as co-design, then it can potentially empower moderators and lead the field of digital community moderation into an exciting future.

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Kooth, Pennine Care Trust & Universities: Cambridge, York St John, Manchester, Bristol 2020 

“Shaping the Design of Smartphone-Based Interventions for Self-Harm”

Honorary, Bell, Clinch, Vega, Kroll, Sefi & McNaney

Digital Interventions for Self-Harm

Self-harm is a prevalent issue amongst young people, yet it is thought around 40% will never seek professional help due to stigma surrounding it. It is generally a way of coping with emotional distress and can have a range of triggers. This paper explores perceptions of mobile sensing, and current and future uses for smartphone-based interventions. This paper also contributes to the understanding of how triggers for self-harm might be identified and subsequently predicted and prevented using mobile-sensing technology.

Manchester Metropolitan University, University of Ioannina, 2023

A Thematic Analysis of Preferences of Young People using Online Support to Discuss Suicide.

Leece, Wilson & Andriopoulou

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"Anonymous, online services can overcome access barriers and enable YP to share and process their experiences."

The present study aims to explore the experience of online, anonymous, text-based services provided by Kooth, an online MH platform, to YP previously at risk of suicide during the COVID-19 pandemic. 

Results discuss three superordinate themes: a safe space to share; control; and need for connection. Thematic results highlight the desire for anonymity and control of therapeutic conversations due to concerns regarding confidentiality, and the perceived consequences of seeking help. Participants were successfully able to build connections through chats with online MH support staff. Themes suggest that anonymous, online services can overcome access barriers and enable YP to share and process their experiences.

The Theory of Change

Kooth’s Theory of Change sets out the theoretical underpinnings of Kooth for young people and separately for adults. This theory can then be used to guide evaluations and test the assumptions in the theory.

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Kooth, 2021

“How adults use the Kooth ‘positive virtual ecosystem'"

de Ossorno Garcia S, Salhi L, Sefi A and Hanley T

The Theory of Change for Adults on Kooth in the UK

This report provides an outcome-based framework based on the theory of change methodology for Kooth adult services. This research explores the different pathways of engagement in the platform through a collaborative multimethod approach using qualitative and quantitative data to inform the intended impacts, outcomes, mechanisms and inputs of the service.


The defining features to date of Kooth for adults are described as a positive virtual ecosystem, humanistic, anonymous and accessible, used by people in need of mental health support. It provides an integrative view of the service as an ecosystem with shared impacts across self-directed, reactive, structured and ongoing pathways of engagement.

Kooth & Universities; Bolton, Manchester, 2021

“A positive virtual ecosystem. The theory of change for Kooth. Comprehensive Report 2020”

Hanley.T, Sefi.A et al

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The Theory of Change for Young People on Kooth in the UK


This paper signals the beginning of an important, ground-breaking journey to define the role and the impact of Kooth. We have explored, mapped and categorised activity within the service with a specific goal in mind: to define our Theory of Change. This describes the Kooth experience and the many routes in and out of the service, each reliant on our understanding of an individual’s unique building blocks for wellness. 

The Theory of Change (ToC) is not a clinical model and nor does it seek to be. It is not there to show how we can address specific standalone symptoms. Instead it is a characterisation of the broad, person-centred, holistic work Kooth does every day. It is also the foundation for a future set of mental health outcome measures, which will represent each child or young person’s journey.

The Voice of Young People and Practitioners in developing Kooth

The considerations involved with developing Kooth, involving key stakeholders in decision making and leading with best practice.

Kooth’s development and innovation is centred around evidence-based practise, which focuses on (1) the user's needs and wants, determining how acceptable and accessible Kooth is, (2) the clinical best practices, brining in internal and external clinical experts, and finally (3) using best research practices and evidence, both internally and externally. 

Kooth prioritised the user voice and user’s preferences, lots of work that goes on behind the scenes ensures that users get the features they want and the usability of these are tested by an experienced usability team. Asking young people what they want from services, as well as what blockers and barriers we can help overcome is important to providing services that young people want to use. 

Importantly outcome measures are commonly designed and tested in the face-to-face space, with structured interventions in mind. In the digital space, outcome measures are less explored, especially when considering self-guided interventions, like Kooth's. Looking at the acceptability of outcome measures is therefore important when deciding which measures to implement. Here we present some of the research into using standardised outcome measures on Kooth. Earlier you would have read about our bespoke measures, the SWAN-OM and the POCEM, designed when we saw that standardised outcome measures were not applicable to our setting. 

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Learning from clinical experts is critical, as is involving practitioners in the design and evaluations of Kooth, this helps shape and direct the services and provide unique insights into how the service can improve. Supporting practitioners to transition from working face-to-face to the online setting is important to be able to provide practitioners with the best opportunities to support service users.

Findings from development evaluations

Kooth - 2023

Giving Young People a Voice to Inform Digital Services.

Salhi et al

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“How Kooth is responding to feedback and remaining at the forefront of innovation in digital mental health.”

This report provides a timely look at Kooth, bridging insights from young people, from professionals who signpost or refer to Kooth, and from the routinely collected data from the service as a whole. The integration between commissioned, digital services alongside on-the-ground services is now more important than ever, and this report highlights Kooth’s mechanisms to enhance reach and engagement from young people and professionals.

There is strong evidence that service users highly value the ability to be autonomous and make choices in their mental health journey on Kooth, whilst, importantly, remaining anonymous. Removing barriers to support is critical to improving early access and prevention of mental health deterioration. Kooth has multiple mechanisms and features that can support a diverse set of users accessing the service and is seen as a digital front door for many due to no thresholds, referrals or waiting lists. Service users reported that Kooth helped them feel heard and listened to, and there were strong indicators that service users promoted the platform to their peers. Both service users and professionals outside of Kooth highly value the out-of-hours support as well as the ability to access the platform without a referral and no waiting lists to have a chat with a professional.

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Kooth & Anna Freud, 2021

“Assessing the need of young people using online counselling services: how useful are standardised measures?”

Mindel, C., Oppong, C., Rothwell, E., Sefi, A., Jacob, J

Using standardised measures to assess the need of young people using online counselling services

This study explores the reliability of using a standardised measure to detect clinical need in an online therapeutic environment, focusing on three specific measures. A deep-dive approach is used to inform practitioner assessment of young people, validating it along with the individuals’ self-rated outcome.


The findings demonstrate a fair to moderate reliability when assessing concordance between service users and practitioners, which suggests standardised measures are a reliable indicator of need. Higher levels of need were present than those seen previously in general or face-to-face clinical populations, which suggests using such measures in an online therapeutic environment influences the way in which assessments are responded to.

Kooth & Anna Freud, 2021

“Exploring the experiences of young people completing the YP-CORE to capture clinical need on a digital counselling platform ”

Mindel, C., Oppong, C., & Jacob, J

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Beyond the Numbers: Diving into young people's minds and their experience with standard measures

The aim of this research is to contribute to the knowledge base of young people's motivation to complete voluntary standardised mental health assessment measures and how the accuracy of the information derived may be improved.


The findings demonstrate the need for transparency online, to instil trust in those completing standardised mental health assessment measures. This may be implemented through co-designed visual materials which contribute to the young people's understanding of how the data collected through assessment will be used and what the response of the service will be following assessment.

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Kooth & University of Roehampton, 2021

“Helpful and unhelpful elements of synchronous text-based therapy: A thematic analysis”

Dhesi M, Sefi A, Donati M, Hayes J, Cooper M

Exploring Helpful Aspects of Text-Based Therapy

There has been a growth of services delivering online therapy to young people and this study identifies the factors that young people find helpful and unhelpful in chats that were synchronous text-based therapy (STBT), and the processes by which these factors may be of value. Young people, aged between 14 and 18, were interviewed synchronously online. All participants had a minimum of four chat sessions. Data were analysed thematically.

Four main domains of helpful and unhelpful factors were identified: 1) anonymity, 2) access, 3) communication, and 4) control. Control was a particularly important element for young people and was an underlying aspect across all themes.

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Kooth & University of Manchester, 2021

“Exploring the development and maintenance of therapeutic relationships through e-Health support: A narrative analysis of therapist experiences”

Wood, M., Wilson, H., &  Parry, S.

Practitioner experiences of the development and maintenance of therapeutic relationships online and best practise to support practitioners transition to online therapy.

Challenges to digital therapeutic care exist, mainly how to develop and maintain a supportive, collaborative therapeutic relationship, built upon mutual trust and respect; intrinsic values of relationships that are often implied through complex non-verbal cues. Challenges identified were; learning experience of translating existing therapeutic skills to online working, rapidly building therapeutic relationships, managing risk in the online therapeutic relationship, and techniques for maintaining a digital therapeutic relationship.


It was seen here that online practitioners are eager to learn how to adapt to online delivery, although platform-specific training is limited. The study provides novel insights into the flexibility and adjustments therapists can make to improve online interventions and delivery through the development and maintenance of positive therapeutic relationships. Recommendations are also made in relation to platform-specific training, communicative adaptations, risk management and practitioner support. Clinical staff from Kooth informed these recommendations to evidence best practise to support practitioners moving from physical to digital therapy provision.

Kooth & University of Exeter, 2020

“Testing, testing, one, two, three: Service user evaluation of three standard measures of mental health and well‐being in an online counselling and support service for children and young people”

Sefi.A & Frampton.I


Are online assessments suitable for today's CYP? - Acceptability, applicability and appropriateness

This study assesses the relative merits of acceptability, applicability and appropriateness of assessment measures online for children and young people. Acceptability was determined by whether users elected to complete the measure, applicability by whether they understood the questions, and appropriateness by their experience of completing the measure. 


Focusing on three specific measures, the findings suggest a high level of acceptability of all three measures in an online setting,  indicating that any of these measures would be acceptable in an online setting.

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Kooth & University of Manchester, 2012

“Examining the complexities of measuring effectiveness of online counselling for young people using routine evaluation data”

Sefi.A & Hanley.T

Measures of psychological distress present much higher in digital settings

An existing routine evaluation and outcome measure (Young Person’s Clinical Outcome Measures in Routine Evaluation - YP CORE) was incorporated within other routine evaluation systems within Kooth. 

Initial data suggests that young people who seek out online counselling and support have a significantly higher level of distress than those within face-to-face services.

University of Manchester, 2012

“Understanding the online therapeutic alliance through the eyes of adolescent service users.”

Hanley, T.

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The therapeutic alliance in digital support for adolescents 

This study examines the therapeutic alliance when counselling services are offered online to young people. Three subcategories were identified:

(1) initial engagement,

(2) developing rapport, and

(3) establishing control.


The themes elicited are all relevant to the matching process and viewed as a chronological process similar to face-to-face counselling. However, unlike face-to-face work, specific nuances related to the online work arise that counsellors should be mindful of, including the rationale behind each individual's choice to approach services online, their own computer-mediated communication skills, technical hurdles, and the perceived ‘power’ of the counsellor.

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University of Manchester, 2006

“Developing youth-friendly online counselling services in the United Kingdom: A small scale investigation into the views of practitioners.”

Hanley, T

Developing youth friendly online counselling in the UK - investigating views of practitioners

 This study focused upon the development of online counselling services for young people in the UK. It used online forums to host an asynchronous focus group with the intention of bringing together the views of a small sample of counsellors and counsellors in training regarding the subject matter. The focus group lasted a one-month period and initiated 10 threads of discussion and received 41 message postings. These dialogues were analysed using a Grounded Theory approach. Findings suggested that although there is a great potential for offering therapy in this medium, services need to be appropriately regulated and good practice promoted.

Kooth, 2014

“A Thematic Analysis of Preferences of Young People using Online Support to Discuss Suicide.”

Evans S

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Preferences for online support vs face to face support for young people

Young people (mainly 15-17 years) using an online counselling, support and advice website were asked about their preferences for online versus face-to-face discussion of suicidal feelings. Thematic analysis of results (n = 24) yielded a main theme of ‘anonymity’ with sub-themes of ‘safety and freedom’, ‘confidentiality’ and 'control’. Issues of safeguarding distressed young people who have chosen to remain anonymous are raised.

Data & AI with integrity: Kooth's Responsible Approach

Being an online platform we collect and hold a lot of information and data. This is very insightful but we also need to ensure we are not only being legal in our compliance but also ethical in our use of data.

As seen here we are striking to be a thought leader in how digital mental health platforms can be transparent and responsible in their use of data, in particular the use of AI with data.

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Findings from ethical data & AI evaluations

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Kooth, 2023

“Responsible Innovation in Digital Mental Healthcare: Case Study on Artificial Intelligence for Safeguarding Assistance”



Pioneering responsible digital mental health through the use of AI

Artificial intelligence (AI) is increasingly utilised to scale digital mental health services. To do this safely and effectively responsible innovation is the only option. This study explores the applicability of the Alan Turing Institute (ATI) AI ethics and safety guide in developing a safeguarding assistance tool for Kooth, the UK’s leading digital mental healthcare platform


Applying the framework enables structured and transparent development of AI for digital mental health services. The SUM values guide ethical reflection, while the FAST track principles ensure fairness, accountability, sustainability, and transparency. Challenges include need for data for bias monitoring and mitigation. The study demonstrates the framework's usefulness in AI development for digital mental health services. Integration of an AI ethics council and further measurement of user circumstances to enhance bias mitigation are suggested to build on the framework, contributing to the advancement of evidence-based digital mental healthcare delivery.

Universities: Nottingham, Chester, Manchester Metropolitan, 2019

“Accessing Online Data for Youth Mental Health Research: Meeting the Ethical Challenges”

Perez Vallejos, E., Koene, A., Carter, C.J. Hunt, D., woodard, C., Urquhart, L, Bergin, A., & Statche, R.

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Ethical Challenges of Online Data  - Kooth as a case study to support recommendations for best practise

This article addresses the general ethical issues of accessing online personal data for research purposes. The authors discuss the practical aspects of online research with a specific case study that illustrates the ethical challenges encountered when accessing data from Kooth, an online youth web-counselling service. It presents solutions that aim to protect young DMH service users as well as the DMH providers and researchers mining such data. Special consideration is given to service users’ expectations of what their data might be used for, as well as their perceptions of whether the data they post is public, private or open. We provide recommendations for planning and designing online research that includes vulnerable young people as research participants in an ethical manner. We emphasise the distinction between public, private and open data, which is crucial to comprehend the ethical challenges in accessing DMH data. Among our key recommendations, we foreground the need to consider a collaborative approach with the DMH providers while respecting service users’ control over personal data, and we propose the implementation of digital solutions embedded within the platform for explicit opt-out/opt-in recruitment strategies and ‘read more’ options.

Kooth Plc London

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Kooth Plc Manchester

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United Kingdom


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