Dental Websites as New Media Tools for Patients in Dental Health Tourism.

INTRODUCTION: Nowadays, potential patients surf the internet to check the websites of health care organizations to select the most suitable health organization for their needs within the perspective of health tourism. To this effect, dental health tourism as a subset of health tourism is considered to be a developing sector. AIM: The aim of the study was to assess whether websites are effectively used as media tools by dental health care organizations, which serve as currently active as well as promising components of health tourism in Turkey.
METHODS: In this cross-sectional study, 555 websites of dental health care organizations were examined. Web pages were evaluated by using E-Information Quality Scale of the Health Centre. A low score indicates well-designed websites.
RESULTS: Scores related to "contact information" and "website layout" were lower in the private ones (n:146) than the public institutions (n:409)(p=0.000, p=0.011). It was observed that 80.8% (n:122) of the websites with foreign language options (n:151), were private institutions); whereas, public institutions only constitute 19.2% (n:29) of the total. All sub-group scores in the scale were lower in the organizations offering foreign language alternatives in contrast to the ones without foreign language options (p<0.05).
CONCLUSION: In private dental health care organizations," contact information" and "website layout" of websites were observed to be the most prominent features in the conduct of public relations activities. Websites with foreign language alternatives were well-designed due to the fact that language options were considered to be an incentive for the health tourists.

INTRODUCTION

Healthcare is one of the most important motives for traveling. ‘Health tourism’, refers to a growing market for patients searching treatment options (1, 2). This type of tourism has emerged from increased medical needs for chronic diseases, difficulties in accessing the required healthcare in the vicinity, high cost of healthcare in the home country and alternative treatment options abroad (3). Dental health tourism, a subset of health tourism, is identified as the search for options in dental care by many patient-tourists worldwide (4, 5). The main reasons for dental patient mobility can be classified in four main categories: Availability, affordability, familiarity and perceived quality of care (6, 7). Dental health tourism, a recently developing sector, is also impacted by other factors besides the alternative costs of the treatment, namely, delays in access to the relevant care locally, the reports of high patient satisfaction with the treatments provided abroad and the competitive fares of air travel (4, 8-10).

Oral health problems limit the oral functions and lead to communication difficulties by hampering the general well-being of the patients (11).Dental care standards relate to having qualified and competent dental professionals as required by licensing and accreditation, regulations of dental clinics, quality of dental care education, training of assistants, selection of equipment and supplies, and treating patients based on specific needs or personalized care (5). Therefore, millions of affluent patient-tourists are traveling across the borders for more timely and affordable dental care services (4, 5, 12). In addition to all,the role of networks and on line information, critical to understanding the choices of treatment options, providers and destinations are important in this activity (7).

Patients select the most convenient institution for their treatments via several means, the most common of which is the internet; therefore, it is essential that dental healthcare institutions use websites effectively. The information and communication technologies foster health tourism. Patients can reach information about healthcare organizations in the remote regions of the world easily and conveniently by using network channels which play a crucial role in the competition at the international and regional levels for healthcare managers (13-15).

Although Turkey is an outstanding destination for health tourism (16), there is limited published information available regarding the properties of web sites of dental care organizations through the perspective of health tourism. Therefore, this study aimed to assess whether websites are effectively used for health tourism by dental health care organizations in Turkey.

AIM

The aim of the study was to assess whether websites are effectively used as media tools by dental health care organizations, which serve as currently active as well as promising components of health tourism in Turkey.

METHODS

In this cross-sectional study, 555 websites of dental health care organizations located in seven big cities, İstanbul, Ankara, Samsun, Antalya, İzmir, Gaziantep and Malatya were examined (17). Surveys were conducted according to the lists of the Ministry of Health. Dental healthcare institutions were categorized as “private clinic”, “dental clinic in hospital”, “oral and dental healthcare center”, “faculty of dentistry”and “dental hospital”. All websites accessed during the 6-month study period were included in the study. The main criterion for the inclusion was that, in each geographic region of the country, the city with the highest number of dentists (n=7) was selected to represent the country’s profile. All the dental care organizations in the selected seven cities were included in the study. Due to technical problems resulting in denied access to their web sites, a few dental clinics in the selected cities were excluded from the study.

Data were collected by E-Information Quality Scale of the Health Center, developed by Llinas et al (18). Each item in the scale was coded as “Yes” (1 point) or “No” (2 points). Low scores indicate well-designed websites (18). Prior to this study, two authors (BK, GM) evaluated 5 % of the websites. Since the scores of the websites were found to be similar (p>0.05), one of the authors (BK) analyzed all websites during the study.

Eleven subgroups of the scale were calculated, as a result of which a low score indicates well-designed websites. The subgroups included in the research were examined according to , (website map, website search engine, accessibility for disabled people, links to other websites), (letter or font type, size, colour and contrast), (date of page creation, last page update, etc.), (organization location, how to get to the hospital, etc.), (organization’s chart, name and position of the staff, telephone and/or fax for each department, access to webpage in foreign languages), (information related to patient rights and obligations, EFQM reports, quality commitment, suggestions forms), (hospitalization guidelines: information and regulations to be followed during admission, during the hospitalization, at the time of discharge, to be followed by visitors, to get examination appointments via internet), (national or international medical news, graduate, postgraduate courses, etc., provided by the hospital, scientific studies supported by the organization), (organization news; courses, workshops, conferences and announcements)

The study was approved by the Ethics Committee of Health Sciences Institute of Marmara University (22.05.2015-10)

Statistical analysis

The data were analyzed by SPSS 25.0package program (Illinois, USA). ANOVA, Unpaired T- test and Pearson correlation tests were used in the analysis.

RESULTS

In the examined web pages, 73.7% of the group (n=409) were private institutions and the rest were public ones (n=146, 26.3%). More than half of the studied institutions were located in Istanbul (57.3%). Institutions were categorized as follows: private clinics (56.22%) which had the highest number of websites. Dental clinics in hospitals (34.95%) ranked the second; whereas, the lowest numbers of websites were detected among dental hospitals (1.26%), faculties of dentistry (3.60%) and oral and dental healthcare centers (3.96%) (Table 1).

Table 1.

The Profile of Organisations and Foreign Language Alternatives in the Study Group

	All Organisations			Organisations with Foreign Language Alternatives
		n	%	n	%
Type	Private Organisations	409	73.7	122	80.8
	Public Organisations	146	26.3	29	19.2
	Total	555	100	151	100
Institution Category	Private Dental Clinic	312	56.2	74	49.0
	Private Dental Clinic in Hospital	194	34.9	61	40.4
	Oral and Dental Healthcare Center	22	3.9	3	1.9
	Faculty of Dentistry	20	3.6	9	5.9
	Dental Hospital	7	1.3	4	2.6
	Total	555	100	151	100

Scores of “contact information” (5.91±0.74) and “website layout” (6.31±1.28) in public institutions rated higher than those of private ones, respectively (p=0.000, p=0.011). However, the scores of other subgroups of the following criteria such as, website specifications, updates, in access path, technical specifications general information, patient services, patient information, public relations, staff training, and research facilities were observed to be higher in private institutions than in the public ones (p<0.05) (Table 2).

Table 2.

Subgroup Scores* of Websites According to Organisation Types and Foreign Language Alternatives. *Low score indicated well designed websites. **Unpaired T Test was used in the analyses.

	Public Organisations		Private Organisations		p**	Foreign Language Alternatives (+)		Foreign Language Alternatives (-)		p**
	Mean	SD	Mean	SD		Mean	SD	Mean	SD
Contact information (5-10 points)	5.91	0.74	5.35	0.66	0.000	5.39	0.57	5.54	0.77	0.012
Website Specifications (4-8 points)	6.53	0.83	7.40	0.79	0.000	6.89	0.98	7.28	0.81	0.000
Website Layout (5-10 points)	6.31	1.28	6.01	1.00	0.011	5.80	0.71	6.19	1.17	0.000
Updates (3-6 points)	4.72	0.72	5.27	0.64	0.000	8.17	1.32	8.67	1.29	0.000
Access path (6-12 points)	9.97	0.88	10.41	0.88	0.000	10.06	0.90	10.39	0.88	0.000
General Information (9-18 points)	15.21	1.19	15.81	0.96	0.000	14.70	0.93	16.00	0.86	0.000
Patient Services (11-22 points)	17.34	2.00	19.42	1.73	0.000	18.45	1.95	19.02	2.02	0.003
Patient Information (7-14 points)	11.29	1.47	13.05	1.04	0.000	12.22	1.47	12.72	1.34	0.000
Staff training and Research Facilities (7-14 points)	12.68	1.39	13.75	0.60	0.000	13.31	1.17	13.52	0.91	0.024
Public Relations Activities (5-10 points)	7.38	1.08	8.83	1.52	0.000	7.89	1.65	8.65	1.46	0.000
Technical Specifications (4-8 points)	4.24	0.47	4.91	0.53	0.000	4.64	0.53	4.76	0.61	0.027

Among the websites with foreign language options, 80.8% were private institutions (n: 122); whereas, public institutions constituted only 19.2% (n: 29). Their distribution was as follows: private dental clinics (49.0%) and dental divisions in hospitals (40.4%), faculty of dentistry (5.9%), dental hospitals (2.6%), oral and dental healthcare centers (1.9). Furthermore, sub-group scale scores of websites rated lower in organizations with foreign language alternatives compared to the ones without foreign language options (p<0.05)(Table 2).

When websites with foreign language options were examined according to cities, different rates were observed according to the location and population of the cities. The highest rates were seen in İstanbul (54.3%) and Antalya (29.8%); whereas, in other cities the rates were less than 10%.

DISCUSSION

Health tourism is a particularly concentrated area in the correlation between the internet and increased number of patient- tourists (19). It is also heavily reliant on web-based information nowadays (20). Websites have become the most significant means of providing medical information for the patients throughout the globe in reaching the dental service providers. Since health tourists use websites to select target countries and institutions, well-designed websites should contain sufficient and qualified information and increase the preference for addressing the institutions. Language options, proper graphics, structural stability, loading speed, updating and the content of the website should be considered while designing a web page (19).

Designing proper health tourism websites provides a good opportunity to attract health tourists to the host country. Marketing features via well-designed websites significantly contribute to the effective delivery of messages, quality of products and services reflecting effectively the brand images in hospitality and tourism, including health tourism (21, 22). Websites in a virtual space act as a gateway where patients can conveniently select their destination and/or touristic purposes with high quality, low price and proper services (19, 23). In the light of the fact that well-designed-informative web pages are crucial to attract potential patients for dental tourism, the majority of accessed websites, which were studied comprised those of private organizations, mainly dental clinics and dental clinics in hospitals.

Foreign language alternatives make websites more qualified and informative for health patient-tourists. If the website is well designed and user-friendly, the user will spend more time on this website instead of its alternatives (24). Keeping this fact in mind, the most critical result obtained from the study was that websites with foreign language options were better-designed with better technical characteristics than the others. The global reality requires that all healthcare organizations in Turkey develop their websites to take part in the international marketing of dental care through well-designed and easily accessed websites.

As health tourists are not familiar with the health systems and options available to them abroad and rely on the internet for information to facilitate decision making, reliable information availability is important. In becoming a global industry, dental tourism is being driven by the increasing costs of dentistry, long waiting-lists and dental work force issues at home, in contrast to the increasing availability of competent care abroad, competitive air travel fares and easy internet access, which connect travelers with dental providers abroad (24). Therefore, health managers should pay attention to the completeness of dental care service programs, information about dental clinics and the services they provide (12). Turkey is no exception to this rule.

In our study, it was observed that the websites of the public sector were designed much better and more conveniently than the websites of the private sector. This is considered to be related to the preparation of public websites according to a standard format.

Since most internet users spend only a few seconds viewing a site on average, the first impression of a site determines whether users will decide to continue interacting with it or browse another (23, 25). In health tourism, the communication between patients and health professionals is as important an issue as the quality of the treatment itself (6). Institutions, taking into consideration the trend for easy access to information, design web pages containing texts and graphics to provide information about physicians, treatment options, special care services, organizational structure and communication channels of healthcare organizations to influence the patients’ decision-making process in choosing a hospital or a health care center (19).

As our study suggests, İstanbul and Antalya had the highest number of institutions with websites offering foreign language alternatives because of their location, historical and cultural lure and transportation facilities enabling easy access. Language options can be an incentive to the health tourists (6). It is one of the reasons for preferring the health institutions’ website which use the patient’s own language and to have the personnel communicate with the patients in their mother tongue for verbal communication.

A shortcoming of the websites noted during this study was that the disabled people had not been considered while designing any of the websites examined. The audible information or visual information while browsing dental care providers’ websites with good reviews from previous patients, may help disabled potential patients to decide on and plan their trip to a destination country or dental care center (26). This feature may play an important role in influencing patients to decide on a dental service provider, after which the internet becomes an important source of detailed information for customers in reaching providers for dental care services overseas (5). Especially, healthcare organizations, should take into consideration all of the target groups. Therefore, collaborative design and determining requirements for websites could be important for efficient websites (27, 28).

Private clinics constitute nearly half of the study group in categorizing the institutions. This pattern was in accordance with the structure of dental health services in the country (17). However, more than half of these institutions are located in İstanbul, the most crowded city of Turkey, which suggests that Istanbul is a popular health care and tourist-patient destination (29). Therefore, our study focused mainly on the institutions in Istanbul.

Through the health manager’s perspective, communication in health tourism industry must be available and updated 24/7 a week. This suggests that website information update must be given priority and be performed regularly by health organizations. Taking into consideration the crucial role of websites in dental health care organizations, this study provides vital information for health tourism facilities.

On the other hand, the study proves to have some limitations. Firstly, the health patients’ assessments related to the websites were not contained in the results. Secondly, some websites of organizations could not be accessed due to technical failures. Finally, this study only includes data about a single country, namely Turkey. Future studies focusing on this issue may help to understand the patients’ perspective more thoroughly.

CONCLUSION

The most prominent characteristics observed during the study were “contact information” and “website layout” in the websites of private organizations. The private organizations which were examined had well-designed web pages with foreign language alternatives. Language options can be an incentive to the health tourists since the websites are efficient communication tools used in the conduct of public relations practices of the health institutions against their alternatives.