The quality of a website is considered over many domains. One of the arguments for this proposal is the number of attributes considered when ranking a website on a search engine results page [
19,
20,
21]. According to Rocha [
22], website quality can be considered in three domains: content, functionality, and technical aspects. A quality website is loaded quickly [
23]. It can be viewed both on desktop computers and mobile devices [
24]. The user experience on mobile devices depends on the size and layout of links so that they are spaced sufficiently. For textual links, it is the font color that is important inproviding contrast and readability [
25,
26]. Content legibility is also one of accessibility criteria, particularly for visually impaired and blind people [
27].
High-quality websites follow the World Wide Web Consortium (W3C) guidelines regarding code syntax (HyperText Markup Language, HTML and Cascading Style Sheets, CSS) [
32] and are loaded quickly [
23]. However, the design technique is not all. Quality websites have quality content: it must be valuable, must includemultimedia, and be unique (“content is king”). Texts on a web page should be plain and easy to understand. They should also be appropriately formatted, with headlines, bullet points, and text in bold to improve readability [
26]. A website’s address also affects its quality. It should be short and easy to remember [
33]. A website of high quality has a clear structure of internal links and a large number of backlinks from quality websites [
34]. Moreover, quality is affected by numerous design details. These can includea pre-loader with a system status report, images to facilitate social media use, map or audio components, and small details such as interactive graphics [
35].
2.1. Tools and Methods for Website Quality Assessment
Recent years have brought an abundance of methods and tools for assessing the quality of websites [
18]. Some of them are universal and can be applied to any website. Other ones have been adapted to attributes that are characteristic of specific industries [
36]. Website quality assessment methods can be algorithmic, expert-based, or user-based [
18]. Algorithmic assessment of website quality most often employs web applications (run in a browser window), browser extensions, such as Lighthouse [
37], or software installed on the machine, such as SEO SpyGlass, WebSite Auditor, or Screaming Frog SEO Spider [
38]. Emulators, such as Opera Mobile Emulator, are useful tools as well. Website quality is investigated through experiments, with surveys (such as computer-assisted telephone interviews, CATI), and comparative analyses (benchmarking) [
6,
7].
Website quality assessment employs indicators or indices expressed with numbers, letters, or images. The indices reflect test results in an unambiguous and lucid way [
18]. Other methods include checklists and the cognitive walkthrough [
39]. Quantitative and qualitative methods are used successfully [
5]. Other methods, such as multidimensional scaling and correspondence analysis, weighted scores, simulation, and the index method, have also been used in assessing and improving website quality [
5].
The quality of websites can be assessed using models and frameworks as well. One of such tools is WebQual. WebQual covers twelve dimensions: informational fit-to-task; tailored communications; trust; response time; ease of understanding; intuitive operations; visual appeal; innovativeness; emotional appeal; consistent image; online completeness; and relative advantage [
40]. Website quality assessment can be performed using the SERVQUAL (ServiceQuality) method proposed by Parasuraman et al. [
41] and its variants, HEALTHQUAL for example Lee [
42].
2.2. Hospital Website Quality and Quality of Medical Content Online
Models and frameworks are often employed to investigate the quality of hospital/medical websites. The criteria of accessibility, content, and apparent features of websites, the design procedure, the graphics applied on the website, and its attractivenesshave been mentioned in the majority of studies [
13]. Rafe and Monfaredzadeh [
8] proposed a framework for assessing the quality of hospital websites and websites with medical/health content. Their model assesses websites in seven dimensions: content quality, design quality, organization quality, user-friendly quality, performance quality, service quality, and technical points. A paper by Bilsel et al. [
5] also presents a model for assessing hospital website performance.
Dulaney et al. [
43] investigated the quality of prostate cancer treatment information on cancer center’s websites. They assessed websites of cancer clinics recommended by the National Cancer Institute of the United States of America using a validated decision quality instrument (DQI). They tested the compatibility with mobile devices using the Google mobile-friendly test tool. They demonstrated that websites of cancer centers failed to provide specific information on treatment and its results. The researchers recommended improving the mobile compatibility of the websites and provision of specialist texts in various language versions. They furthermore recommended publication of detailed information about the benefits, results, and toxicity of the presented therapies, also using tables and charts so that multiple therapies could be compared for decision-making. Choi and Lee’s [
44] research demonstrated that the usability and functionality of health information portals have increased over the last four years.
Meiyappan et al. [
3] investigated information available on websites of pediatric surgery hospitals in Australia and New Zealand. They verified the availability of patient information, including clinical procedural guidelines. They noted the availability of contact details and hospital activity in social media. Research by Meiyappan et al. [
3] indicated that the Internet presence of paediatric surgery in Australia and New Zealand was sparse. One-third of the centers did not have hospital web presence. The availability of clinical guidelines and patient information sheets on hospital websites was limited. Mira et al. [
45] assessed the quality of websites of Spanish public hospitals, focusing on content readability and accessibility. They investigated 73 attributes using the e-Information Quality Scale of Health Centers. The recommendations included content readability and website availability improvements.
Salarvand et al. [
2] evaluated the quality of 59 websites of public hospitals in Tehran. They used a localized checklist, Google page rank, and the Alexa traffic ranking. Their checklist included 112 items in five sections: technical characteristics, hospital information and facilities, medical services, interactive on-line services, and external activities. Data were analyzed using descriptive and analytical statistics. All the websites they investigated were assessed as having unsatisfactory quality (for the research design employed), which confirmed that they needed to be upgraded, and that further studies were necessary.
The purpose of a study by Gümüş and Sönmez [
39] was to determine the quality of online services provided by hospitals in Istanbul, Turkey. The first stage involved a survey with 442 residents of Istanbul. The survey focused on preferences for online healthcare services. Then, the authors used the results to build a checklist with four dimensions of attributes: ease of use, credentials of the institution, external activities, and technical features. The findings indicated that, among the top 100 private hospitals in İstanbul, 25% received an excellent rating, while 45% and 35% were ranked as good and fair, respectively. Emmert et al. [
46] concluded that online comments failed to reflect the quality of hospital care.
Thus, online ratings are of limited usefulness from a clinical point of view in guiding patients towards high-performing hospitals. Chi et al. [
10] assessed the quality and readability of websites with information about sleep apnea and tonsillectomy. They assessed information quality with DISCERN. DISCERN is a brief questionnaire, which offers a valid and reliable way of assessing the quality of written information on treatment choices. Text readability was evaluated with the Flesch-Kincaid Grade Level and Flesch Reading Ease Score. The research demonstrated that a significant portion of published information used excessively expert language and could be hard to understand. Chi et al. [
10] concluded that doctors could improve the way they explained therapies with the knowledge on information patients read online [
10]. DISCERN was employed also by Killip et al. [
47] in their study on the quality, readability, completeness, and accuracy of PTSD (post-traumatic stress disorder) websites for firefighters.
Research often touches upon the readability of websites with medical information [
11]. Many researchers have demonstrated that the quality of content on medical websites was below par [
48]. They often emphasized that websites lacked information about risks and rewards of therapies and texts were written in expert language, which made them difficult to understand [
1,
10,
49,
50]. MacLean et al. [
51] believed exhaustive information in plain language to be more readily understandable, which could make it easier for patients to prepare for a procedure, for example. Schreuders et al. [
1] investigated the variable quality and readability of patient-oriented websites on colorectal cancer screening. MacLean et al. [
51] looked into the readability of online information on colonoscopy preparation. Chi et al. [
10] investigated the quality and readability of websites with patient information on tonsillectomy and sleep apnea. Kocyigit et al. [
52] investigated the quality and readability of online information on ankylosing spondylitis. The goal of research by Azer et al. [
49] was to assess the accuracy of information and readability of websites on kidney and bladder cancer. The readability of the websites was calculated using the Flesch-Kincaid Grade Level Index and the Coleman-Liau Readability Index. Sixty-two websites were finally included in the study. The accuracy and quality of the websites on kidney and bladder cancers varied. In most websites, there were deficiencies in clarity of aims, presenting symptoms, investigations, and treatment options. The majority of them called for improvements.
Llinás et al. [
53] assessed the userorientation on hospital websites from Spain, the United States, and the United Kingdom. The study involved 32 websites. They looked into website readability with the Flesch Index, website accessibility with the Web Accessibility Test, and information quality with the e-Information Scale of Health Care Centers. Many websites were found to have accessibility and readability issues [
53]. Liu et al. [
54] evaluated the quality of websites of 23 hospitals in China. Their research demonstrated that most of the websites were of good quality. The functionality and design quality were satisfactory as well [
54]. Perçin [
6] investigated the quality of websites of selected Turkish hospitals. In his research, he applied the fuzzy decision-making trial and evaluation laboratory (DEMATEL) method and the generalized Choquet fuzzy integral (GCFI), i.e.,non-additive information fusion technique to aggregate the experts’ preferences and to calculate the overall website quality of hospitals [
6]. The purpose of research by Huert et al. [
55] was to assess hospital websites in five dimensions: accessibility, content quality, marketing potential, technology, and usability. In their paper, Huert et al. [
55] proposed guidelines and design standards to facilitate the use of websites and social media to streamline operations of healthcare providers.
Acosta-Vargas et al. [
56] assessed the accessibility of websites of 22 hospitals. Their evaluation was based on WCAG 2.0 guidelines. The research demonstrated the need to improve regulations for implementation of accessibility guidelines on websites of healthcare, public administration, and other institutions funded by the public, in particular.
The objective of the research by Adipridhana et al. [
57] was to identify expectations of medical staff of a hospital in Jakarta, Indonesia towards the Portal Hospital Indonesia (PHI) website. They considered such aspects as content quality, navigation structure, design architecture, scope of multimedia available, and unique character of the site. They employed the gap analysis method. It identified discrepancies between personnel expectations and the reality of PHI [
57].
The aim of a study conducted by Vetter et al. [
58] was to assess the quality of patient information on bariatric surgery available online using the modified Ensuring Quality Information for Patients (EQIP) tool. According to it, the general quality of online information on weight-loss surgery was relatively low. The frequency of complications and related treatment were rarely discussed, even on pages with high EQIP results [
58].
The United States Department of Health and Human Services’ Office of Disease Prevention and Health Promotion (ODPHP) conducted a nation-wide evaluation of Web-based health information. Its goal was to determine:(1) a standardized approach to defining and measuring the quality of health websites; (2) benchmarks for measurement; (3) baseline data points to capture the current status of website quality; and (4) targets to drive improvement. The ODPHP devised a tool, the National Quality Health Website Survey, to assess the quality of websites that provide health information [
11].