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Comparative assessment of the information available on the treatment of depression over websites in English and Hindi language
Swarndeep Singh, Rahul Mathur, Rajesh Sagar
Department of Psychiatry, All India Institute of Medical Sciences, Delhi, India
|Date of Submission||14-Apr-2022|
|Date of Acceptance||03-May-2022|
|Date of Web Publication||02-Jun-2022|
Department of Psychiatry, All India Institute of Medical Sciences, Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The study aimed to perform a cross-sectional comparative assessment of the content and quality of information available on the treatment of depression over websites in English and Hindi language. Materials and Methods: We screened the first 50 links obtained on searching for depression treatment on Google, and selected 72 (44 in English; 28 in Hindi) websites. They were evaluated for coverage of different aspects of depression, quality of treatments mentioned, esthetics, and interactivity. Results: A significantly lesser number of Hindi websites discussed the minimum duration of treatment needed for a depressive episode (36% vs. 79%), possible side effects of treatment (18% vs. 77%), discussed suicidality in depression explicitly (25% vs. 57%), or recommended consultation with a mental health professional (11% vs. 43%). English websites more commonly mentioned psychotherapy (86% vs. 64%), electroconvulsive therapy (64% vs. 21%), and social support measures (59% vs. 32%) for depression treatment. Whereas, Hindi websites more commonly mentioned Ayurvedic/herbal medicines (46% vs. 16%), and yoga (29% vs. 4%) for treatment. Lastly, the esthetics score for English websites was significantly higher than for Hindi websites. A significantly greater number of Hindi websites were owned by commercial entities. Conclusion: This is the first study to systematically compare online information on depression treatment in English and Hindi language websites, and identify areas for further improvement in the overall quality of online information in Hindi. There is a need for the creation of credible and accessible online resources in regional languages like Hindi for the promotion of depression literacy among the general public by government and non-profit professional organizations.
Keywords: Esthetics, depression, internet, online information, treatment
Depression is one the most common mental health disorder, with about 5% of adults suffering from depression globally. Unfortunately, despite various effective treatment options available for the management of depression, the mental health treatment gap for depression is still more than 85% for most countries worldwide including India. Lack of awareness among general people about symptoms of depression and available treatment options, and high levels of stigma attached to mental health treatment seeking are some of the important reasons behind this huge treatment gap. The available literature also suggests that people with stigmatizing health conditions like depression are more likely to use the internet for seeking health-related information as compared to other health disorders. Further, people with depression have reported using the internet to seek information related to symptoms of depression, different medications, or treatment-related information, verify information already received by them from other sources, and prepare themselves for a visit to health professionals among other things., The Global Burden of Disease Study group reported that the maximum contribution to the overall burden of mental disorders in India (33.8% of total disability-adjusted lived-years by all mental disorders combined) was by depressive disorders. India has the second largest number of internet users in the world, with recent data released by the Telecom Regulatory Authority of India reporting more than 825 million internet users at the end of March 2021. Thus, there is a large proportion of the population, which could benefit from accessing health-related information online.
However, there have been concerns about the credibility and usability of mental health information available on the internet. A review of 31 studies assessing the quality of online information available on different mental disorders concluded it to be poor or unsatisfactory for the majority of websites analyzed. Some of the recent studies focusing on the quality of depression-related online information have reported improved content quality on the majority of websites analyzed., But, most of them did not assess the esthetics and interactivity-related attributes of these websites providing information about depression. Further, none of them evaluated websites providing content in languages other than English. This is a significant gap in the available literature, given the fact that only about 10% of Indians are English language speakers according to the latest population census data. At the same time, Hindi is the most widely used language with about 57% of Indians reporting Hindi as one of the languages they could speak. Thus, the present study was planned to address these important gaps in the available literature. This study aimed to perform a comparative assessment of the content and quality of information available on the treatment of depression over websites in English and Hindi language. Additionally, esthetics and interactivity-related attributes of the website were also examined.
| Material and Methods|| |
To identify websites providing information on the treatment of depression, a keyword search was performed on the most popular general internet search engine (www.google.com) on December 10, 2021. Additionally, the “incognito mode” mode was used to avoid biasing of google search results based on the user's search history. The first 50 search results were evaluated for inclusion, as most people are unlikely to go beyond this when looking for health-related information online. Results displayed as paid placements or paid ads, images, or videos were not considered while selecting the first 50 links. Subsequently, websites were excluded if they were inaccessible (invalid address, required an access fee or login), had already been reviewed in this study (i.e., duplicate), were not website/webpage (external links, books, academic journal articles, discussion groups), newspaper articles, contained no information on the treatment of depression, or only described a specific type of depression (e.g., post-partum depression, treatment-resistant depression, etc.). A total of 44 and 28 websites in English and Hindi language, respectively, were shortlisted for further quality assessment [see [Figure 1]].
|Figure 1: Flowchart for selection of websites in English and Hindi languages|
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Two researchers (both qualified psychiatrists) independently reviewed and extracted information using a pre-designed assessment tool (developed by authors based on the review of available literature and their own professional experience) for selected websites., Any disagreements between the two researchers were mutually discussed and resolved by consensus; and the third senior researcher was consulted if needed.
The completeness or comprehensiveness of information mentioned on the website was assessed based on their coverage of pre-decided themes/topics related to the treatment of depression (e.g., different treatment options for depression, duration of treatment required, a possible side effect of treatment, etc.). A quality indicator score (QIS) was calculated by counting the number of treatment options for depression that the website had mentioned out of the following five recommended treatments as per the current clinical practice guidelines for treating depression: antidepressants, psychotherapies (e.g., cognitive-behavioral therapy, inter-personal therapy), lifestyle modification/physical exercise, social support, and electroconvulsive treatment (ECT). The website could have a score ranging from zero to five depending upon the number of aforementioned five treatments included.
The trustworthiness of information available on the website was assessed by collecting information related to the ownership of the website (commercial vs. non-commercial), whether details about the author (s)/reviewer (s) and the last date of revision for online information were mentioned, and external references supporting the assertions made on the website were provided. Health On the Net (HON) is an international, non-profit foundation, which aims to promote transparency and credibility in health and medical information available on the internet. Thus, the presence of the HONcode badge on the website, which might be considered a proxy marker for transparency and trustworthiness, was also noted.
The esthetics of the website was evaluated using the Abbott esthetic criteria, which have also been used in a few previous studies., This included information being organized into headings and/or sub-headings; the use of relevant diagrams or graphics; the presence of functional hypertext links or hyperlinks for references; and the absence of advertisements from outside sources. A score of one point was given for meeting each of them.
The interactivity of the website was evaluated using selected questions of the Abbott scale, which have also been used in a few previous studies., This included availability of an internal site search engine option; the presence of audio or video support; satisfaction or knowledge questionnaires for users, supportive spaces (e.g., comments section); and the option of sending queries to webmasters or authors. A score of one point was given for meeting each of them.
The data were analyzed using SPSS version 17.0 (IBM Corp, Armonk, NY). Descriptive statistics using mean and standard deviation (SD), or frequency and percentage were used to describe the continuous or categorical attributes of websites, respectively. Alternatively, median and inter-quartile range (IQR) were used for describing skewed data. Since data for QIS, esthetics, and interactivity scores were significantly skewed, appropriate non-parametric tests were applied for inferential statistics. The Chi-square and Fisher's exact test (when the expected cell count was less than five) were used to compare proportions between two groups. The level of statistical significance was set at a two-tailed P value < 0.05 for all the tests.
| Results|| |
Content of information available on websites for treatment of depression
[Table 1] provides a comparison of general information relating to the symptoms and treatment of depression provided on websites in English and Hindi languages. While more than 90% of all the websites discussed common depressive symptoms and the minimum duration of two weeks required for diagnosing clinical depression, less than half of them discussed suicidality in depression or recommended consultation with mental health professionals for detailed assessment and treatment of depression. A significantly lesser number of Hindi language websites discussed the minimum duration of treatment needed for an episode of depression, described possible side effects of treatments mentioned, explicitly discussed suicidality in depression and provided information on help-seeking for the same, and recommended taking consultation with a mental health professional for detailed assessment and discussion about a treatment plan for depression in a given individual. [Table 2] compares the different depression treatment options suggested by websites in Hindi and English languages. The three most frequently mentioned treatments for depression on all websites were antidepressants, psychotherapy, and lifestyle modification/physical exercise. Whereas, the three least frequently mentioned treatments for depression on all websites were ketamine and psychedelics, yoga, and sunlight or light therapy. English language websites more commonly mentioned psychotherapy, ECT, and social support measures for the treatment of depression as compared to those in the Hindi language. Whereas, Hindi language websites more commonly mentioned Ayurvedic or herbal medicines, and yoga for the treatment of depression as compared to those in the English language.
|Table 1: General information about depression on websites in English and Hindi language|
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|Table 2: Treatment options for depression on websites in English and Hindi language|
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Quality of information available on websites for treatment of depression
The median number of treatment options suggested for depression by English and Hindi websites was 9.50 (IQR: 3.25–14.00) and 7.50 (IQR: 3.00–10.75), respectively. The number of treatment options suggested by English websites did not differ significantly from Hindi websites (U = 494.00, P = 0.15). The treatment strategies suggested by different websites were evaluated for their coverage of five recommended evidence-based treatment strategies as per the available clinical practice guidelines. The median QIS for English and Hindi websites was 4.00 (IQR: 2.25–5.00) and 2.00 (IQR: 1.00–3.00), respectively. The QIS for English websites was significantly higher than for Hindi websites (U = 338.50, P < 0.01). The trustworthiness and transparency of information provided by English and Hindi language websites have been shown in [Table 3]. About 41.7% (n = 30) of websites displayed the details of author (s)/reviewer (s) of the online content. Two-thirds (n = 48, 66.7%) of websites mentioned the last date for updating information. About 47.2% (n = 34) of websites had given external references for supporting the information mentioned online. A significantly greater number of English language websites provided external references as compared to Hindi language websites [see [Table 3]]. Three-fourths (n = 54, 75%) of all websites were affiliated with non-commercial sources. There was no significant association between the commercial status of websites and the number of treatments suggested or the QIS for treatments suggested by them. A significantly greater number of Hindi language websites were owned by commercial entities and were not HONcode certified as compared to English language websites [see [Table 3]]. Only one-eighth (n = 9, 12.5%) of all websites had displayed the HONcode label on their websites. The HONcode certified websites were more likely to provide greater number of treatment options (U = 113.00, P < 0.01) for depression and a higher QIS for treatments (U = 134.00, P < 0.01) mentioned on them.
|Table 3: Trustworthiness and transparency of information on websites in English and Hindi language|
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Esthetics and interactivity related attributes of websites
The relative distribution of different attributes related to the esthetics and interactivity of websites is described in [Table 4]. A significantly greater number of websites in the English language had information organized into headings and sub-headings, provided functional links to in-text references, did not have outside advertisements, and had the option of internal site search as compared to those in the Hindi language. The median esthetics score for English and Hindi websites was 3.00 (IQR: 2.00–3.00) and 1.00 (IQR: 1.00–2.00), respectively. The esthetics score for English websites was significantly higher than for Hindi websites (U = 197.00, P < 0.01). The median interactivity score for English and Hindi websites was 1.00 (IQR: 1.00–2.00) and 1.00 (IQR: 0.00–2.00), respectively. The interactivity score for English websites was not significantly different from Hindi websites (U = 497.00, P = 0.14).
|Table 4: Esthetics and interactivity related attributes of websites in English and Hindi language|
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| Discussion|| |
This is the first study to systematically evaluate and compare the information available on the treatment of depression over the World Wide Web in English and Hindi language. On the positive side, the majority of websites in both English and Hindi languages described common symptoms of depression and suggested evidence-based effective treatment options for depression. However, a significantly lesser number of websites in the Hindi language discussed the minimum duration of treatment recommended for an episode of depression, possible side effects of treatments mentioned, explicitly discussed suicidality in depression and provided information on help-seeking for the same, or recommended taking consultation with a mental health professional for detailed assessment and discussion about a treatment plan for depression in a given individual. This is in line with the findings of another study, which concluded that most depression websites (English) did not adequately cover the public's questions related to different treatment options available for depression. Further, a significantly lesser number of websites in Hindi provided external references supporting the information provided by them. Thus, online content creators or authors should be encouraged to include information on these aspects when discussing the treatment of depression. Also, references should be provided wherever possible to substantiate the claims/assertions made on the website. This would help general people to verify or read about them in detail if needed.
The websites on average mentioned about eight different treatment strategies for depression, with no significant difference between Hindi and English language websites. Though, the three most commonly mentioned treatments for depression on both English and Hindi language websites were antidepressants, psychotherapy, and lifestyle modification and exercises. The QIS calculated by summing the number of evidence-based treatments included on a website was higher for websites in the English language than Hindi. This might be because of the differences in the kind of treatment strategies suggested on Hindi and English language websites. The English language websites more frequently mentioned psychotherapy, ECT, and social support measures for the treatment of depression. Whereas, the use of Ayurvedic or herbal medicines and yoga for treatment of depression were more frequently mentioned on Hindi language websites. This might be due to differences in cultural understanding of causation and preferred treatment modalities for depression among the intended audience of Hindi and English language websites. This might also be partially due to the positive results supporting the use of Ayurveda and yoga for the treatment of depression in recent studies published from India., Another important finding was that ECT and social support measures were mentioned by less than half of all websites, and less than one-third of Hindi language websites. Though, both of them are evidence-based effective treatment strategies for alleviating depression., This might be because of the negative perception or stigma towards ECT among the general public and a group of health professionals. Similarly, a relative lack of interest in promoting cheaper social support-based measures for the management of depression by commercially owned websites could also explain this difference. This is also supported by the study finding that a greater number of websites in Hindi were affiliated with commercial entities. Lastly, the HONcode-certified websites were more likely to provide a higher number of evidence-based treatments for depression. However, none of the websites in the Hindi language were HONcode certified. This might be because these websites were not adherent to the ethical principles of authority, complementarity, confidentiality, attribution, justifiability, transparency of authorship, transparency of sponsorship, and honesty in advertising and editorial policy, laid down by the HON Foundation. This might also be because of the voluntary nature of HONcode certification, and the relative neglect or lack of awareness among managers of health and medical information websites about the need to apply for a HONcode certificate.
In this study, about one-fifth of all websites had used relevant graphics to supplant the text information, or audio-video support (e.g., slideshow presentations, recorded interviews with experts, etc.) to make them more interactive. Further, the median esthetics score for Hindi language websites was significantly lesser than English language websites. The esthetics and interactivity-related attributes of the website are also important for improving the ease of understanding and user engagement with online information on depression treatment among general people., This highlights the need for improving the esthetics and interactivity of websites, more so for Hindi language websites to facilitate the usability of online information.
The present study findings have several important implications. First, this study provides a systematic comparative assessment of online information available on different treatment-related aspects of depression over English and Hindi language websites. There were significant differences between English and Hindi language websites in terms of website ownership, and the content and presentation of information provided (e.g., type of treatments that were frequently mentioned for depression, providing external references, etc.). There is a need for the government (under the district mental health program), professionals (e.g., Indian Psychiatric Society), and other non-profit organizations to create credible and accessible online resources for the promotion of mental health literacy among the general public in regional languages like Hindi. Second, we identified certain important aspects associated with the treatment of depression that was under-represented on websites such as information related to suicidality in depression, and certain effective treatment options such as ECT or social support. Important shortcomings related to esthetics and interactivity of websites were highlighted, that could be addressed in the future to improve the usability of online information by general people. This would help guide website developers while making revisions or creating new online information on the treatment of depression. Also, healthcare professionals should be mindful of addressing some of these relatively under-covered areas while counseling patients with depression. For example, stress on the importance of social support measures in alleviating symptoms of depression. Lastly, though HONcode certification could be useful for identifying websites providing evidence-based information on the treatment of depression by the general public. It was currently not a practically feasible strategy for identifying Hindi language websites because of its low uptake or coverage for this category of websites.
The main limitations of the present study should be kept in mind while interpreting the study findings. This is a cross-sectional study with an assessment of websites selected at a single time point using a specific search query. However, given the rapidly changing nature of information available on the internet, findings might vary with time. Also, people might get different results with the use of other keywords, and caution is needed while interpreting the study findings. Secondly, readability assessment was not done in the present study because of the lack of standardized assessment tools available for the Hindi language, unlike English. Future studies should further confirm the present study findings with the use of a more exhaustive search strategy involving the use of multiple keywords and search engines for selecting websites.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]