HONcode Principles Research Articles

Health Information in Social Media: An Evaluation of YouTube Videos

New media hold the rapid dominance over the health information. People acquire the health information in different social media which includes YouTube, popular video sharing site. A systematic protocol was used to locate the 200 videos on YouTube in 20 different health topics. Blind coding was followed with two independent coders in the topics of authorship, channel types, information in video, elements shown in video, and the authenticity of the health information was analyzed using the eight standard HONCode principles. Profit organization took the major role of presenting the 109 (54.5%) health information videos on YouTube. Majority of the health information video produced by the profit organization lay in the field of medium (3-5) HONCode result, even the consumer authorship was the highly represented in the profit organization. The authenticated sources like educational institutions, Government organizations, Medical center, and Non-Profit organization do produces the highly authenticated (6-8 HONCode) health information; but their volume of producing the videos is quite low

Evaluating the Quality of Cancer-Related WeChat Public Accounts: Cross-Sectional Study.

WeChat (Tencent) is one of the most important information sources for Chinese people. Relevantly, various health-related data are constantly transmitted among WeChat users. WeChat public accounts (WPAs) for health are rapidly emerging. Health-related WeChat public accounts have a significant impact on public health. Because of the rise in web-based health-seeking behavior, the general public has grown accustomed to obtaining cancer information from WPAs. Although WPAs make it easy for people to obtain health information, the quality of the information is questionable. This study aims to assess the quality and suitability of cancer-related WeChat public accounts (CWPAs). The survey was conducted from February 1 to 28, 2023. Based on the WPA monthly list provided by Qingbo Big Data, 28 CWPAs in the WeChat communication index were selected as the survey sample. Quality assessment of the included CWPAs was performed using the HONcode instrument. Furthermore, suitability was measured by using the Suitability Assessment of Materials. A total of 2 researchers conducted the evaluations independently. Of the 28 CWPAs, 12 (43%) were academic and 16 (57%) were commercial. No statistical difference was found regarding the HONcode scores between the 2 groups (P=.96). The quality of the academic and commercial CWPAs evaluated using the HONcode instrument demonstrated mean scores of 5.58 (SD 2.02) and 5.63 (SD 2.16), respectively, corresponding to a moderate class. All CWPAs' compliance with the HONcode principles was unsatisfactory. A statistically significant difference between the 2 groups was observed in the Suitability Assessment of Materials scores (P=.04). The commercial WPAs reached an overall 55.1% (SD 5.5%) score versus the 50.2% (SD 6.4%) score reached by academic WPAs. The suitability of academic and commercial CWPAs was considered adequate. This study revealed that CWPAs are not sufficiently credible. WPA owners must endeavor to create reliable health websites using approved tools such as the HONcode criteria. However, it is necessary to educate the public about the evaluation tools of health websites to assess their credibility before using the provided content. In addition, improving readability will allow the public to read and understand the content.

Smartphone apps for point-of-care information summaries: systematic assessment of the quality and content

BackgroundClinicians need easy access to evidence-based information to inform their clinical practice. Point-of-care information summaries are increasingly available in the form of smartphone apps. However, the quality of information from...

Assessing the Quality of Direct-to-Consumer Teleconsultation Services in Canada.

The objective of this study was to describe and assess the quality of the direct-to-consumer medical teleconsultation landscape in three Canadian provinces. An environmental scan of primary care teleconsultation platforms was conducted in January 2022 to identify medical teleconsultation platforms in Quebec (Qc), Ontario, and British Columbia (BC). The quality of each teleconsultation platform was assessed using a modified version of the HONcode principles. Nineteen different direct-to-consumer medical teleconsultation platforms were identified across the three provinces. The quality of these teleconsultation platforms was very heterogeneous. The landscape of virtual primary care is changing rapidly in the Canadian ecosystem, and the transparency of current teleconsultation platforms could be improved.

Development, validation and international certification of a health portal for people with disabilities.

to develop, validate with specialists and internationally certify a virtual health portal, the D+Informação. a quantitative methodological study. Twenty-two expert judges validated the Portal in the health and computer science areas using the Content Validity Index and the Gwet test. International certification followed HONcode principles® to ensure the trust of information. judges of health and computer science validated the portal obtaining a minimum Content Validity Index in more than 75% of the topics, in addition to the evaluation of general agreement, 0.253; content evaluation, 0.193, and interface evaluation, 0.230. All presented the value of Gwet with p ≤ 0,001. the portal D+Informação was developed, validated, internationally certified and is hosted on this website: https://demaisinformacao.com.br.

Are health websites credible enough for elderly self-education in the most prevalent elderly diseases?

BackgroundThe Elderly and their caregivers need credible health information to manage elderly chronic diseases and help them to be involved in health decision making. In this regard, health websites are considered as a potential source of information for elderlies as well as their caregivers. Nevertheless, the credibility of these websites has not been identified yet. Thus, this study aimed to evaluate the credibility of the health websites on the most prevalent chronic diseases of the elderly.MethodsThe terms “Chronic obstructive pulmonary disease”, “Alzheimer's”, “Ischemic heart disease”, and “Stroke” were searched using the three popular search engines. A total of 216 unique websites were eligible for evaluation. The study was carried out using the HONcode of conduct. The chi-square test was carried out to determine the difference between conforming and nonconforming websites with HONcode principles and website categories.ResultsThe findings showed that half of the evaluated websites had fully considered the HONcode principles. Furthermore, there was a significant difference between websites category and compliance with HONcode principles (p value < .05).ConclusionRegarding the poor credibility of most prevalent elderly diseases’ websites, the potential online health information users should be aware of the low credibility of such websites, which may seriously threaten their health. Furthermore, educating the elderly and their caregivers to evaluate the credibility of websites by the use of popular tools such as HONcode of conducts before utilizing their information seems to be necessary.

How Users' Gaze Behavior Is Related to Their Quality Evaluation of a Health Website Based on HONcode Principles?

While the health website is an easily accessible source for patients to use when seeking health information, the quality of online health information has been a critical issue that concerns all stakeholders in healthcare. The aim of this research was to examine the relationship between users' evaluation of the health website quality and their gaze behavior on the web pages. Eye tracking and a self-report questionnaire based on the HONcode principles were used to address the objective. We found that (1) the evaluations of authority, privacy, financial disclosure, and advertising policy are positively correlated with the fixation count and total fixation duration toward corresponding page components, while the evaluations of complementarity and attribution are negatively correlated with the fixation count and total fixation duration to corresponding page components; and (2) the fixation count and total fixation duration toward health information sources are negatively related to the evaluation of health website quality, while the fixation count and total fixation duration to site owner are positively related to the quality evaluation. Users' attention to page components is closely related to the evaluation of principles, and also has a certain impact on the overall quality evaluation of a health website. Based on the findings, our research may serve to improve the health website design and be a foundation to develop an automatic evaluation approach of the health website quality.

Medication Management Apps for Diabetes: Systematic Assessment of the Transparency and Reliability of Health Information Dissemination

BackgroundSmartphone apps are increasingly used for diabetes self-management because of their ubiquity and ability to help users to personalize health care management. The number of diabetes apps has proliferated in recent years, but only a small subset of apps that pose a higher risk are regulated by governmental agencies. The transparency and reliability of information sources are unclear for apps that provide health care advice and are not regulated by governmental agencies.ObjectiveThis study aimed to assess the transparency and reliability of information disseminated via diabetes apps against 8 criteria adapted from the Health On the Net code of conduct (HONcode) principles.MethodsEnglish-language diabetes-related terms were searched on a market explorer (42matters) on June 12, 2018. Apps with medication and blood glucose management features were downloaded and evaluated against the App-HONcode criteria adapted from the 8 HONcode principles: authoritative, complementarity, privacy, attribution, justifiability, transparency, financial disclosure, and advertising policy. Apps were profiled by operating platforms (ie, Android and iOS) and the number of downloads (ie, Android only: ≥100,000 downloads and <100,000 downloads).ResultsA total of 143 apps (81 Android and 62 iOS) were downloaded and assessed against the adapted App-HONcode criteria. Most of the apps on the Android and iOS platforms fulfilled between 2 and 6 criteria, but few (20/143, 14.0%) apps mentioned the qualifications of individuals who contributed to app development. Less than half (59/143, 39.2%) of the apps disclaimed that the information provided or app functions do not replace the advice of the health care provider. A higher proportion of iOS apps fulfilled 5 or more App-HONcode criteria compared with Android apps. However, Android apps were more likely to have the developer’s email listed on the app store (Android: 75/81, 98%; and iOS: 52/62, 84%; P=.005) compared with iOS apps. Of the Android apps assessed, a significantly higher proportion of highly downloaded apps had a privacy and confidentiality clause (high downloads: 15/17, 88%; and low downloads: 33/64, 52%; P=.006) and were more likely to discuss their financial sources (high downloads: 14/17, 82%; and low downloads: 32/64, 50%; P=.03) compared with apps with a low number of downloads.ConclusionsGaps in the disclosure of the developer’s qualification, funding source, and the complementary role of the app in disease management were identified. App stores, developers, and medical providers should collaborate to close these gaps and provide more transparency and reliability to app users. Future work can further examine the consent-seeking process for data collection, data management policies, the appropriateness of advertising content, and clarity of privacy clause of these apps.

Suicide prevention and depression apps\u2019 suicide risk assessment and management: a systematic assessment of adherence to clinical guidelines

BackgroundThere are an estimated 800,000 suicides per year globally, and approximately 16,000,000 suicide attempts. Mobile apps may help address the unmet needs of people at risk. We assessed adherence of suicide prevention advice in depression management and suicide prevention apps to six evidence-based clinical guideline recommendations: mood and suicidal thought tracking, safety plan development, recommendation of activities to deter suicidal thoughts, information and education, access to support networks, and access to emergency counseling.MethodsA systematic assessment of depression and suicide prevention apps available in Google Play and Apple’s App Store was conducted. Apps were identified by searching 42matters in January 2019 for apps launched or updated since January 2017 using the terms “depression,” “depressed,” “depress,” “mood disorders,” “suicide,” and “self-harm.” General characteristics of apps, adherence with six suicide prevention strategies identified in evidence-based clinical guidelines using a 50-question checklist developed by the study team, and trustworthiness of the app based on HONcode principles were appraised and reported as a narrative review, using descriptive statistics.ResultsThe initial search yielded 2690 potentially relevant apps. Sixty-nine apps met inclusion criteria and were systematically assessed. There were 20 depression management apps (29%), 3 (4%) depression management and suicide prevention apps, and 46 (67%) suicide prevention apps. Eight (12%) depression management apps were chatbots. Only 5/69 apps (7%) incorporated all six suicide prevention strategies. Six apps (6/69, 9%), including two apps available in both app stores and downloaded more than one million times each, provided an erroneous crisis helpline number. Most apps included emergency contact information (65/69 apps, 94%) and direct access to a crisis helpline through the app (46/69 apps, 67%).ConclusionsNon-existent or inaccurate suicide crisis helpline phone numbers were provided by mental health apps downloaded more than 2 million times. Only five out of 69 depression and suicide prevention apps offered all six evidence-based suicide prevention strategies. This demonstrates a failure of Apple and Google app stores, and the health app industry in self-governance, and quality and safety assurance. Governance levels should be stratified by the risks and benefits to users of the app, such as when suicide prevention advice is provided.

Predicting the quality of health web documents using their characteristics

PurposeThe quality of consumer-oriented health information on the web has been defined and evaluated in several studies. Usually it is based on evaluation criteria identified by the researchers and, so far, there is no agreed standard for the quality indicators to use. Based on such indicators, tools have been developed to evaluate the quality of web information. The HONcode is one of such tools. The purpose of this paper is to investigate the influence of web document features on their quality, using HONcode as ground truth, with the aim of finding whether it is possible to predict the quality of a document using its characteristics.Design/methodology/approachThe present work uses a set of health documents and analyzes how their characteristics (e.g. web domain, last update, type, mention of places of treatment and prevention strategies) are associated with their quality. Based on these features, statistical models are built which predict whether health-related web documents have certification-level quality. Multivariate analysis is performed, using classification to estimate the probability of a document having quality given its characteristics. This approach tells us which predictors are important. Three types of full and reduced logistic regression models are built and evaluated. The first one includes every feature, without any exclusion, the second one disregards the Utilization Review Accreditation Commission variable, due to it being a quality indicator, and the third one excludes the variables related to the HONcode principles, which might also be indicators of quality. The reduced models were built with the aim to see whether they reach similar results with a smaller number of features.FindingsThe prediction models have high accuracy, even without including the characteristics of Health on the Net code principles in the models. The most informative prediction model considers characteristics that can be assessed automatically (e.g. split content, type, process of revision and place of treatment). It has an accuracy of 89 percent.Originality/valueThis paper proposes models that automatically predict whether a document has quality or not. Some of the used features (e.g. prevention, prognosis or treatment) have not yet been explicitly considered in this context. The findings of the present study may be used by search engines to promote high-quality documents. This will improve health information retrieval and may contribute to reduce the problems caused by inaccurate information.

Automated Detection of HONcode Website Conformity Compared to Manual Detection: An Evaluation.

BackgroundTo earn HONcode certification, a website must conform to the 8 principles of the HONcode of Conduct In the current manual process of certification, a HONcode expert assesses the candidate website using precise guidelines for each principle. In the scope of the European project KHRESMOI, the Health on the Net (HON) Foundation has developed an automated system to assist in detecting a website’s HONcode conformity. Automated assistance in conducting HONcode reviews can expedite the current time-consuming tasks of HONcode certification and ongoing surveillance. Additionally, an automated tool used as a plugin to a general search engine might help to detect health websites that respect HONcode principles but have not yet been certified.ObjectiveThe goal of this study was to determine whether the automated system is capable of performing as good as human experts for the task of identifying HONcode principles on health websites.MethodsUsing manual evaluation by HONcode senior experts as a baseline, this study compared the capability of the automated HONcode detection system to that of the HONcode senior experts. A set of 27 health-related websites were manually assessed for compliance to each of the 8 HONcode principles by senior HONcode experts. The same set of websites were processed by the automated system for HONcode compliance detection based on supervised machine learning. The results obtained by these two methods were then compared.ResultsFor the privacy criterion, the automated system obtained the same results as the human expert for 17 of 27 sites (14 true positives and 3 true negatives) without noise (0 false positives). The remaining 10 false negative instances for the privacy criterion represented tolerable behavior because it is important that all automatically detected principle conformities are accurate (ie, specificity [100%] is preferred over sensitivity [58%] for the privacy criterion). In addition, the automated system had precision of at least 75%, with a recall of more than 50% for contact details (100% precision, 69% recall), authority (85% precision, 52% recall), and reference (75% precision, 56% recall). The results also revealed issues for some criteria such as date. Changing the “document” definition (ie, using the sentence instead of whole document as a unit of classification) within the automated system resolved some but not all of them.ConclusionsStudy results indicate concordance between automated and expert manual compliance detection for authority, privacy, reference, and contact details. Results also indicate that using the same general parameters for automated detection of each criterion produces suboptimal results. Future work to configure optimal system parameters for each HONcode principle would improve results. The potential utility of integrating automated detection of HONcode conformity into future search engines is also discussed.

WEB TECHNOLOGY AND MEDICAL INFORMATION ACCESS

This analysis was conducted between December 2013 - January 2014. Concern for the reliability and credibility of information on health websites is widespread. Many institutions and organizations are developing various assessment tools, starting with lists of questions finishing with real assessment tools for evaluating sites for medical professionals. One of the most prestigious organization that has developed assessment tools for standardizing the reliability of medical and health information available on the World Wide Web, is the Health On the Net Foundation, which has developed the Code of Conduct (HONcode). Using the HONcode principles of evaluation, I conducted a brief analysis of the first five sites of medical/health information accessed by Internet users in Romania: www.sfatulmedicului.ro, www.pcfarm.ro, www.medipedia.ro, www .doctorulzilei.ro, www.efarma.ro. Rating sites using the 8 principles developed by the Health On the Net Foundation showed that none of the sites meet all 8 HONcode principles of evaluation: many of the materials from sites are not attributed to an author, the fact that content on site is complementary and is not meant to replace a physician’s visit is written under the heading Terms and Conditions, even though the fact that few people read this section. Also, date of the last update of materials is missing, the sites funding is not specified and none of the sites declare public policy. Keywords : Romanian medical sites, HONcode principles

Internet chemotherapy information is of good quality: assessment with the DISCERN tool

Sir, We read with interest Davies and Yeoh's (2012) paper about internet chemotherapy information (ICI). The pertinent points the authors make are the internet's potential as a source of information for patients, but also the concerns of health professionals (HP) that ICI is inaccurate and can cause harm to patients who use it. We performed a search of the term ‘chemotherapy' on google.com, and then sought to assess the quality of the first 10 websites for this search using the DISCERN instrument. Google.com was selected as the search engine of choice because it is the most commonly used search engine (Burns, 2012). Sponsored links and news articles were excluded. The DISCERN instrument is a validated rating tool of the quality of health information (Charnock et al, 1999). It is available for use by both HPs and the general public. Websites are given a score out of 80 based on 15 questions regarding the sites' content. The questions are rated on a 5-point scale from ‘no' (1 point) to ‘yes' (5 points). The 10 websites were independently evaluated with the DISCERN instrument by two of the authors of this letter (RS and NG). Discrepancies between the scores were discussed with a view to reaching a consensus. The mean DISCERN score was 56.1 (s.d.=8.76). The DISCERN handbook would therefore categorise these websites as being of ‘good quality' (excellent=63–75; good=51–62; fair=39–50; poor=27–38; very poor=15–26). The range of scores was 41–69, so all of the top 10 sites are of ‘fair quality' at least. Four of these sites are ‘excellent'. The websites scored highest for question 15 of the criteria – ‘Does it (the publication/website) provide support for shared decision making?' – with a mean score of 4.7, and question 13 – ‘Does it describe how the treatment choices affect quality of life?', with a mean score of 4.5. The websites scored lowest for questions 5, 8 and 12: ‘Is it clear when the information used or reported in the publication was produced?' ‘Does it refer to areas of uncertainty?' ‘Does it describe what would happen if no treatment is used?' The scores for these criteria are 2.5, 2.7 and 2.7, respectively. Our evaluation shows that the overall quality of ICI is good. However, Davies and Yeoh (2012) found that the majority of HPs do not routinely recommend ICI to their patients, and fear that it could cause harm to them, partly because HPs perceive it to be of poor quality. This suggests that HPs' mistrust of the ICI is misplaced, and that the patients might benefit from HPs openly recommending ICI. However, the concerns of HPs are not completely unfounded. There are several tools and methods for evaluating website quality, such as the HONcode principles (Boyer et al, 1998) and the JAMA benchmarks (Silberg et al, 1997), as well as the DISCERN criteria. Further systematic evaluations are warranted to explore the quality of ICI.

A content citizen health management system: a tele-health and tele-care prototype portal for the public

The main inspiration for the implementation of the Content Citizen Health Management System (CCHMS) is to provide a daily, convenient and easily accessible collaborative supportive environment, which will concern social and personal health and welfare matters, to computer literate citizens and those who desire to use information technology. It is a fact that Health services involving prevention and wellness are changing significantly towards a more citizen-centered, home care notion why not also mobile services via WEB and WAP technologies. In other words, the CCHMS as a portal is fundamentally an integration of health content and services in a functional and intelligent WEB environment via the development of communication channels among citizens and the public and private organizations. The design and the development of the CCHMS are based on open source software and follow the appropriate HITSP [1] and ISO/TR 22221 [2] standards along with HONcode principles [3]. In particular, the CCHM system relies on the creation of a customized portal based on the philosophy of the Knowledge Management and Content Management System (CMS). The CMS supports the creation, management, distribution and the publication of corporate information, used to organize and facilitate the collaborative document creation, and other types of content and powerful tools required to create the infrastructure upon which a dynamic website will be set up. The project’s objective is to create a modern, inexpensive, widespread tool to support access to a healthy lifestyle, by means of monitoring and consulting citizens on issues of prevention, diagnosis, treatment, shared information and collaborative education. Also, the development of a voluntary professional health network enables citizens to improve personalized health-related management according to national and European policies.

Improving the transparency of health information found on the internet through the honcode: a comparative study.

This study aims to show that health websites not asking for HONcode certification (Control sample websites A) do not respect elementary ethical standards such as the HONcode. The HONcode quality and ethical standards and the certification process have been developed by the Health on the Net Foundation to improve the transparency of the health and medical information found on the Internet. We compared the compliance with the 8 HONcode principles, and respectively the respect of principles 1 (authority), 4 (assignment), 5 (justification) and 8 (honesty in advertising and editorial policy) by certified websites (A) and by health websites which have not requested the certification (B). The assessment of the HONcode compliance was performed by HON evaluators by the same standards for all type of sites. Results shows that 0.6% of health websites not asking for HONcode certification does respect the eight HONcode ethical standards vs. 89% of certified websites. Regarding the principles 1, 4, 5 and 8, 1.2% of B respect these principles vs. 92% for A. The certification process led health websites to respect the ethical and quality standards such as the HONcode, and disclosing the production process of the health website.

Consumerism and its impact on robotic‐assisted radical prostatectomy

• Many experts consider that media coverage, marketing and/or direct-to-consumer advertising, particularly Internet-based forms, are fundamental to the widespread adoption of robotic-assisted prostatectomy (RARP). However, this has not been explored previously. • The primary objective of the present study was to delineate the role of media coverage and marketing of RARP on the Internet, whereas the secondary goal focused on website quality with respect to the presentation of prostatectomy. • Website content was evaluated for direct-to-consumer advertising after the retrieval of the first 50 websites using Google and Yahoo for each of the terms: 'robotic prostatectomy, laparoscopic prostatectomy (LP) and open radical prostatectomy (ORP)'. • A linear regression analysis was performed for the annual number of Internet news hits over the last decade for each procedure. Website quality assessment was performed using WHO Honesty on the Internet (HON) code principles. • Of the retrieved sites, the proportion containing direct-to-consumer advertising for RARP vs LP vs ORP using Google was 64% vs 14% vs 0%, respectively (P < 0.001) and, using Yahoo, 80% vs 16% vs 0%, respectively (P < 0.001). • In a linear regression analysis, the r(2) values for news hits for each year over the last 10 years were 0.89, 0.74 and 0.76 for RARP, LP and ORP, respectively. • Website quality assessment found that a minority of the websites were accredited with HONcode principles, with no difference between procedure types (P > 0.05). • Media coverage and marketing of RARP on the Internet is more widespread compared to LP and ORP. • Disturbingly, the quality of websites using any technique for prostatectomy was of poor quality when using principles of honest information presenting and such findings need to be discussed with respect to obtaining informed consent from patients.

An Evaluation of Web-based Information about Barrett's Esophagus in Korea

Internet has become an important source of medical information not only for doctors but also patients. However, information available in the Internet may provide wrong or even harmful knowledge to the public. The aim of this study was to evaluate the quality of Internet-based medical information about Barrett's esophagus in Korea. The first 50 Internet links were retrieved from the Google using the key word Barrett's esophagus. The quality of information from a total of 49 websites was evaluated using a checklist. Among total 49 sites related to Barrett's esophagus, only 4 sites (8.2%) were made by hospitals or clinics, and 11 sites (22.4%) were for patients. Of the 49 sites, only one web site (2.0%) had all HON CODE principles (authority, complementarity, confidentiality, attribution, justifiability, transparency of authorship, transparency of sponsorship, honesty in advertising and editorial policy). Sixteen Internet links (32.0%) had fair contents for the definition, and 24 links (48.0%) for the diagnosis, and 15 links (30.0%) for the treatment. Information about Barrett's esophagus was incomplete in the majority of medical web sites. It will bring about confusion in patients who want to get information about Barrett's esophagus from the Internet. There is a need for better evidence-based information about Barrett's esophagus on the web.

QOI6/416: The Health On the Net Code of Conduct for Medical and Health-related Web sites: Three years on

IntroductionThe explosive growth of the World Wide Web has made it more and more urgent to monitor and improve the quality of the information circulating through the Internet. But assessing medical and health information on the Web is a difficult challenge. In recent years, some organisations have been working on this issue. The Health On the Net Foundation (HON), for its part, administers an eight-point Code of Conduct called the HONcode, initiated in 1996. This solution is different from the others. The HONcode does not intend to rate or assess the quality of information provided by a Web site. This article gives a general presentation of the HONcode and its status in 1999, three years after it was launched.MethodsIt defines a set of voluntary rules designed to help a Web developer site practice responsible and to make sure a reader always knows the source and the purpose of the information he or she is reading. These guidelines encourage the authority, complimentarity, confidentiality, proper attribution, justifiability and validity of the medical advice and information provided. Furthermore, sites that subscribe to the HONcode commit themselves to providing transparent information on site sponsorship and clearly separating advertising and editorial content.ResultsIn 1998, the number of external links to the HONcode principles page grew by about 250% (e.g., from 2 to 5) . The rate of increase from January through April, 1999, suggests 300% this year. The growth in the number of links to the HONcode matches that of links to of the entire Web site, and is slightly higher than growth in links to HON's MedHunt search engine. Statistical analysis shows that approximately 50% of Web sites linked to the HONcode principles have a commercial domain name, 16% are from European countries, 15% are from non-profit organisations, and 7% are educational sites.DiscussionThis evolution shows a real need of guidelines for the developers of medical and health Web sites and their users. This conclusion is reinforced by the result of an international survey which HON conducted on the Internet in March and April 1999. The HONcode's scope of application is currently limited to publishing policy and ethical aspects. The HONcode does not address issues of quality and the relevance of the health and medical content of a Web page -- and this is a crucial issue for the further healthy development of the Internet in the medical domain. One way to assess and provide reliable medical and health content could be to review medical and health-related Web content by peers. Building on the system adopted by the scientific community decades ago for the paper medium, this Electronic peer review method could cover content as well as ethical and publishing aspects while retaining use of the HONcode display icon on registered sites as an additional reference.