Towards an evidence‐based guideline for counselling of chronic hepatitis B virus infected patients

To the Editor: Annually thousands of patients with chronic hepatitis B virus infection (HBV) are diagnosed and referred for counselling with the aim to inform the patient on his disease, prognosis and (self) management. No evidence-based guideline exists for counselling. We therefore started a project with the objective to formulate counselling goals and to develop a theory and evidence-based guideline for counselling of chronic HBV patients. Since the introduction of the Precede Proceed model by Green and Kreuter (1) there has been an increased recognition that prevention interventions should be developed systematically and informed by evidence and theory, because such a planned procedure improves the chances of success substantially (2, 3). Recently the intervention mapping (IM) protocol was introduced as a six-step elaborate tool to guide the process of intervention development and implementation (4). In short IM guides the selection of specific intervention goals, the choice of intervention strategies and the development of programme parts. We used several data collection methods to inform our counselling protocol development. First a literature search was done on notification procedures concerning infectious diseases and guidelines for counselling HBV patients. We then conducted a focus group with seven chronic HBV patients. Information from the literature search and focus group discussion was used to design a questionnaire with 63 semi-structured questions regarding determinants of counselling goals. Data were collected at the Public Health Service (PHS) in Rotterdam. Interviews with 45 chronic HBV volunteer patients were verbally transcribed and analysed. Based on the information from literature, focus group discussion, and questionnaire performance objectives were defined. The performance objectives state exactly what the patient should do to reach the counselling goals and these therefore reflect the complexity of the desired protective behaviour. We combined information from evidence, theories and new data from the interviews and patient files to explore potential determinants of the performance objectives. We selected those theoretical methods from different behavioural change theories that are applicable to a counselling situation in general and translated the methods into a practical strategy. We then selected the most important and changeable determinants to be changed by the counselling. These steps resulted in a guideline which describes how to address different performance objectives during the counselling sessions for each of the six topics: general hygienic preventive measures, condom use, source and contact tracing, coping, vaccination of partner and household contacts and referral to medical care. The guideline consists of four parts: checklist, objectives and examples, background information, and tools. Public health nurses at the PHS in Rotterdam tested the guideline and 39 newly diagnosed patients were counselled with the new guideline. During this period a process evaluation was carried out in which different approaches were used to assess the structure and components of the counselling. As a result minor changers were made in style and formulation. This is a first systematic attempt in developing an evidence-based guideline for counselling of chronic HBV patients. The main advantage of this guideline is that users can focus their counselling on essential elements, and thus reduce the amount of redundant information, thereby improving cognitive processing. Knowing which elements are most essential is important when multiple targets need to be addressed in a short time. The guideline helps health care workers to systematically address all important topics related to chronic HBV while allowing tailoring contents of counselling to individual needs. As providing behavioural change information only is not likely to produce substantial changes in behaviour (5), the use of the guideline shifts focus from providing information to reaching preferred target behaviour and addressing relevant determinants of behaviour. We have made the complete guideline available in English at http://www.ggd. rotterdam.nl/smartsite 2122437.dws. It may be used in the public domain