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Objective. To evaluate the reliability of a new tool, the LIV-MAAS, in assessing consultation competence in UK generalpractice.Design. These were pilot studies, with small numbers of participants. Videoed general practitioner (GP) consultations wereanalysed by trained lay and professional raters, using the LIV-MAAS. The inter-rater reliabilities were assessed. Four videoswere assessed by Wve raters in a pilot study. After this, 71 consultations from eight doctors were assessed by sets of three raters.Main measures. Inter-rater reliabilities and inter-consultation reliabilities.Results. For the pilot study, the estimated inter-rater reliability ranged from 0.69 (one rater) to 0.91 (Wve raters). For the mainstudy, the estimated inter-rater reliability for the LIV-MAAS checklist using two raters was 0.71, and using three raters it was0.78. Mean differences in reliability within each series of nine consultations were 0.20 (three raters) and 0.42 (two raters).Conclusions. As a measure of ‘consultation competence’, administered by trained raters (medical or lay) to real GP consult-ations, the LIV-MAAS instrument shows adequate reliability and stability but would beneWt from considerable shortening.Further development of the LIV-MAAS and testing with larger samples are required.Keywords: consultation competence, general practitioner assessment, inter-rater reliability, LIV-MAAS, MAAS-GPInterviewing and consultation skills are key in the clinicalpractice of medicine [1]. In recent years, there have beenattempts to make use of psychometric techniques and thedevelopment of speci Wc instruments to measure the attributesof the consultation, both in the UK and internationally [2–7].The expression ‘consultation competence’ is used in the UKliterature to describe the range of skills a medical practitionerneeds in a meeting with a patient [8–11].Medical interviewing involves content and process [1,4].The process requires communication skills to promoteinformation Xow and interpersonal skills to establish rapportwith the patient. A recent ‘functional’ approach has threeaspects: to collect information, to respond to the patient’semotions, and to educate and inXuence behaviour andimplement treatment plans [3,12].As part of a wider study of general practitioner (GP, familypractitioner) consultation skills, we wished to use a reliableinstrument to measure competence in the process of con-sultation. A literature search found one systematic review ofsuch instruments [5], which recommended two ‘as best Wttingthe criteria of reliability, validity and practicality’: the ArizonaClinical Interview Rating Scale [7] (developed in the USA)and the MAAS-GP [4] (developed in The Netherlands, undera medical system much closer to that of the UK). Other toolsalso exist, including the recent UK Leicester AssessmentPackage (LAP) [8], but neither the MAAS-GP nor the LAPhad been adequately tested with samples of real patients; forinstance the MAAS-GP [4] was tested with simulated patientsand medical student raters.The MAAS-GP is based on the presence or absence ofspeciWed behaviours. A technical review identiWed severalproblems: MAAS-GP used an old scaling model with a verysmall group for item analysis, had a mixed item format, hadsome very low subscale reliabilities, and had limited normdata. Despite these shortcomings, the 68-item MAAS-GP hasbeen claimed to best Wt the criteria of reliability, validity, andpracticality for evaluation instruments for medical interviewingskills [4,5]. We therefore chose to develop it with an additional27 items added to include a patient perspective and UK focus.The new 95-item scale, the LIV-MAAS, is divided into sixsubscales and the full instrument can be reviewed on a web-site [13]. The content validity of this new tool has been dem-onstrated for the UK [14]. Like the MAAS-GP scale, itdepends on a rater recording the presence or absence ofAddress reprint requests to Professor T. Walley, Prescribing Research Group, Depart ment of Pharmacology and Therapeutics, University of Liverpool, L69 3GF, UK. E-mail: twalley@liv.ac.uk

The systems of support for people with a visual impairment in the United Kingdom are complex and can be difficult to access, involving input from a range of health and social care services. In this article, we report qualitative findings from research looking at people’s experiences of accessing health and social care services. These highlight the inconsistencies and variability in existing systems of support for people with a visual impairment, and show that access to services is largely dependent on the agency and initiative of individual service users in establishing networks of support for themselves. This means that those who are less able to do this may find themselves without the support necessary to maintain or improve their quality of life. We argue that health and social care agencies need to be more proactive in addressing the support needs of people with a visual impairment beyond the point of initial diagnosis or registration.

There has been increasing pressure for anthropologists to communicate their ideas and thinking to new publics and so actively engage in national and international debates relating to their field. However, this is not an unproblematic practice and the politics of representation requires anthropologists to consider the sometimes conflicting dimensions of the moral, ethical, political, social, personal and academic. My fieldwork with families linked to In Harmony Liverpool, a children's music project in England, involved inviting participants variously to take part in interviews, draw maps of musical sites in their homes, construct playlists of favourite songs and take photographs of sites in their homes where music 'happens'. As my aim is to produce a visual and audio display to communicate with wider audiences, I consider the issues of representation, authenticity, potential damage and 'othering' in the planning of the research and how this shaped data collection and the plans for dissemination.

To assess the feasibility and effectiveness of a new service using referral liaison advisers to increase the number of referrals of parents/carers at selected Children's Centres to National Health Service (NHS) Stop Smoking Services (SSS) and/or smoke-free families schemes (SFS).This mixed-methods pilot study collected numerical data on indicators of smoking behaviours and carried out face-to-face and telephone interviews.Thirteen Children's Centres in Liverpool and Nottingham using local providers of smoking cessation services, from September 2010 to April 2011.Parents and carers registered with, and staff working for, Children's Centres.Number of smokers referred to smoking cessation services and/or smoke-free family schemes and the views of service providers and users on the new service.In Liverpool, 181 referrals to NHS SSS were made from 331 identified smokers (54.7%); extrapolated to 12 months, this represents a 182% increase in referrals from baseline and a similar extrapolation indicates a 643% increase from baseline of referrals to smoke-free families schemes. There were no reliable baseline data for Nottingham; 31 referrals were made (30.7% of smokers) to SSS and 44 referrals to SFS from 52 contacts (84.6%). The interviews highlighted the need for sustained personal contact with parents/carers to discuss smoking behaviours and concerns and their willingness to be referred to SFS as part of caring for their child.Routine recording of smoking status and appropriate follow-up by trained staff in Children's Centres can lead to significant numbers of clients attending stop-smoking services, although relatively few stop smoking.

Intimate relationships influence family members' health practices. Although cigarette smoking in China is predominantly a male behavior, (non-smoking) women's roles should be taken into account for the development of home-smoking interventions. Drawing on ethnographic interviews with 22 families in a rural area of China, this article explores non-smoking women's attitudes towards male smoking. The findings suggest that women's ability to influence male behavior is largely determined by culturally defined gender roles, underpinned by ideologies of familism and collectivism. Despite concerns about the adverse results of smoking to their family members and households, non-smoking women ultimately maintain the (male) smokers' argument that smoking plays an important role in construction and maintenance of intra- and extra-family relationships. By accepting male smoking and men's engagement in the social practice of smoking and cigarette exchanges, women maintain their identities as supportive wives, filial daughters/in-law and responsible family members who pursue family collective interests at the expense of their own personal beliefs. Future smoking control initiatives that target non-smoking women to influence male smoking should take into account the women's overarching need to maintain the status and harmony of their families.

Planning and delivering an effective and enjoyable focus group discussion requires researchers to consider not only issues of sampling and group composition, but group ethics and dynamics as well as the comfort and convenience of the research participants. The success of a focus group relates to the stimulation and engagement of the participants, and moderators need to work hard to develop topic guides and to introduce topics appropriately to ensure that participants are able to contribute to the discussions as fully as possible. Through a careful consideration of the research literature on the good practice of face-to-face and online focus groups, in this chapter I identify issues relating to their planning and delivery, and highlight some of the technical, methodological and analytical challenges researchers are likely to encounter.

There is increasing evidence for the efficacy of non-medical strategies to improve mental health and well-being. Get into Reading is a shared reading intervention which has demonstrable acceptability and feasibility. This paper explores potential catalysts for change resulting from Get into Reading. Two weekly reading groups ran for 12 months, in a GP surgery and a mental health drop-in centre, for people with a GP diagnosis of depression and a validated severity measure. Data collection included quantitative measures at the outset and end of the study, digital recording of sessions, observation and reflective diaries. Qualitative data were analysed thematically and critically compared with digital recordings. The evidence suggested a reduction in depressive symptoms for Get into Reading group participants. Three potential catalysts for change were identified: literary form and content, including the balance between prose and poetry; group facilitation, including social awareness and communicative skills; and group processes, including reflective and syntactic mirroring. This study has generated hypotheses about potential change processes of Get into Reading groups. Evidence of clinical efficacy was limited by small sample size, participant attrition and lack of controls. The focus on depression limited the generalisability of findings to other clinical groups or in non-clinical settings. Further research is needed, including assessment of the social and economic impact and substantial trials of the clinical effectiveness and cost-effectiveness of this intervention.

The protection of children from secondhand smoke in their homes remains a key objective for health agencies worldwide. While research has explored how parents can influence the introduction of home smoking restrictions, less attention has been paid to the role of wider familial and social networks as conduits for positive behaviour changes. In this article we explore how people living in Scotland have introduced various home smoking restrictions to reduce or eliminate children's exposure to tobacco smoke, and how some have gone on to influence people in their wider familial and social networks. The results suggest that many parents are willing to act on messages on the need to protect children from smoke, leading to the creation of patterns of smoking behaviour that are passed on to their parents and siblings and, more widely, to friends and visitors. However, while some parents and grandparents apparently voluntarily changed their smoking behaviour, other parents found that they had to make direct requests to family members and some needed to negotiate more forcefully to protect children, albeit often with positive results.

The production of an ethnographic film offers a ‘way of seeing’ for researchers exploring the lives of others, and one that remains open to further interpretation. The film Home, directed by Jeff Togman, documents a momentous 10 weeks in the lives of Sheree Farmer and Mary Abernathy, as they participate in a project designed to move selected families out of the Newark slums to new houses in a ‘better area’. Home also includes interviews with others concerned in the project, and images of the local area where the old and the new houses are located. What the film reveals is the complexity of the emotional and social, rather than simply the legal and economic, decision-making process surrounding the proposed move. It also shows how two people, depending on whether or not they are part of the dominant social group, can perceive an apparently golden and life-changing opportunity very differently. Ultimately, Home gives an insight into the lived experience of a lone mother's participation in a neighbourhood regeneration project, and powerfully calls into question the values that underpin much of our thinking about how problems of poverty and neighbourhood could, and should, be resolved.

Smoking in the home is, potentially, the next frontier in tobacco control in the developed world. As smoking regulations in public space are extended, attention is turning to private spaces and the contribution of parental, particularly maternal, smoking to children's health and socio-economic inequalities in family health. Yet relatively little is known about mothers' smoking practices within the home and the social meanings of smoking that are constructed by these practices. In this paper we explore how mothers who smoke construct moralities of their smoking behaviour, particularly in relation to where and with whom they smoke. Drawing on in-depth Biographic Narrative Interpretative Method, in interviews with 12 smoking mothers, and their partners, we consider how these moral tales involve comparisons with other smokers and the importance of community endorsement of smoking practices, particularly around children. We also consider the role of children in the home and how children are actively involved in the regulation of smoking behaviours. Finally, we consider the implications of these moral tales for interventions around smoke-free homes.

Breathing tobacco smoke is linked to poor health in young children, with their homes identified as the primary place of exposure. This UK study uses focus group discussions to explore how mothers living in disadvantaged areas use space within their homes to smoke while looking after children aged 0–4 years, and critically examines how they define non-smoking or smoking homes. Many women imposed temporary and ad hoc restrictions, and this research highlights how the mothers’ desire to create a smoke-free environment for their children competes with their caring responsibilities, and how their efforts are restricted by the limitations of the physical environment of their homes.

Objectives To explore the views of clinicians and lay people about the minimum benefit needed to justify drug treatment to prevent heart attacks, and to explore the rationale behind treatment decisions. Design Qualitative study using semi-structured interviews. Participants 4 general practitioners, 4 practice nurses, and 18 lay people. Setting 8 general practices and 6 community settings across Liverpool. Results Participants varied widely in the minimum acceptable benefits chosen. Most people found the concepts difficult initially, and few appreciated that increased length of treatment should increase absolute benefits. Lay people usually wanted to make decisions for themselves, and clinicians supported this. Participants wanted to consider adverse effects and costs of treatment. Dislike of drug taking was common, and many people preferred lifestyle change to an imperfect treatment. Quality of life and personal views were more important than an individual's age. Conclusions Evidence based guidelines make assumptions about people's preferences, and, by using 10 year estimates of risk, inflate the apparent benefits of treatment. It is unlikely that guidelines could incorporate the wide range of people's preferences, and true dialogue is necessary between clinicians and patients before starting long term preventive treatment.

The fort at Birdoswald is situated on the line of Hadrian's Wall, some 25 km (15½ miles) east of Carlisle (FIG. 1). The site lies between the forts of Great Chesters 10 km (6⅓ miles) to the east, and Castlesteads 12 km (7⅓ miles) to the west.

Climate change means that many more people find themselves living in areas of environmental disadvantage, with water insecurity recognized as a major health issue. Local ecologies shape everyday hygiene practices in households as people respond to diurnal and seasonal changes in their external environment. Periods of water shortage paradoxically increase the risk of waterborne diseases such as cholera, exacerbated by reduced washing to conserve limited supplies. Unpredictable periods of drought and/or flooding compromise household income, and families cannot afford the basic resources they need to keep themselves and others clean. The risks of water borne diseases, such as typhoid, giardia and cholera, are reduced by strategies that improve the sourcing, storage, and treatment of drinking water in areas of environmental disadvantage. In this chapter we first outline global water insecurity in the context of climate change and the negative effects on people’s physical and mental health. We develop our ideas by drawing on our fieldwork, specifically depth interviews with over 50 people living in Kware, Ongata Rongai outside Nairobi, Kenya, to consider how people negotiate persistent water insecurity in resource-limited settings. We conclude the chapter with reflections on the barriers and opportunities to improve water security and hygiene practices.

Introduction: More than half of the world’s population now live in cities, including over 70% in Europe. Cities bring opportunities but can be unhealthy places to live. The poorest urban dwellers live in the worst environments and are at the greatest risk of poor health outcomes. EURO-URHIS 1 set out to compile a cross-EU inventory of member states use of measures of urban health in order to support policymakers and improve public health policy. Methods: Following a literature review to define terms and find an appropriate model to guide urban health research, EURO-URHIS Urban Areas in all EU member states except Luxembourg, as well as Croatia, Turkey, Macedonia, Iceland and Norway, were defined and selected in collaboration with project partners. Following piloting of the survey tool, a the EURO-URHIS 45 data collection tool was sent out to contacts in all countries with identified EUA’s, asking for data on 45 Urban Health Indicators (UHI) and 10 other indicators. Results: 60 questionnaires were received from 30 countries, giving information on local health indicator availability, definitions and sources. Telephone interviews were also conducted with 14 respondents about their knowledge of sources of urban health data and barriers or problems experienced when collecting the data. Discussion: Most participants had little problem identifying the sources of data, though some found that data was not always routinely recorded and was held by diverse sources or not at local level. Some participants found the data collection instrument to not be user-friendly and with UHI definitions that were sometimes unclear. However, the work has demonstrated that urban health and its measurement is of major relevance and importance for Public Health across Europe. The current study has constructed an initial system of European UHIs to meet the objectives of the project, but has also clearly demonstrated that further development work is required. The importance and value of examining UHIs has been confirmed, and the scene has been set for further studies on this topic.

OBJECTIVES: Electronic cigarettes (e-cigarettes) are promoted as smoking cessation tools, yet they remain unavailable from Stop Smoking Services in England; the debate over their safety and efficacy is ongoing. This study was designed to explore perceptions and reasons for use or non-use of electronic cigarettes as smoking cessation tools, among individuals engaged in Stop Smoking Services. METHODS: Semi-structured telephone interviews were undertaken with twenty participants engaged in Stop Smoking Services in the north-west of England. Participants comprised of both individuals who had tried e-cigarettes (n = 6) and those who had not (n = 14). Interviews were digitally recorded and transcribed verbatim. The transcripts were subject to thematic analysis, which explored participants' beliefs and experiences of e-cigarettes. RESULTS: A thematic analysis of transcripts suggested that the following three superordinate themes were prominent: (1) self-efficacy and beliefs in e-cigarettes; (2) e-cigarettes as a smoking cessation aid; and (3) cues for e-cigarette use. Participants, particularly never users, were especially concerned regarding e-cigarette efficacy and safety. Overall, participants largely expressed uncertainty regarding e-cigarette safety and efficacy, with some evidence of misunderstanding. CONCLUSIONS: Evidence of uncertainty and misunderstanding regarding information on e-cigarettes highlights the importance of providing smokers with concise, up-to-date information regarding e-cigarettes, enabling smokers to make informed treatment decisions. Furthermore, identification of potential predictors of e-cigarette use can be used to inform Stop Smoking Services provision and future research. Statement of contribution What is already known on this subject? Research suggests that e-cigarettes may help smokers quit smoking, but further studies are needed. Electronic cigarette use in Stop Smoking Services has increased substantially in recent years, although e-cigarettes are currently not regulated. There is debate within the academic community regarding e-cigarette efficacy and safety. What does this study add? Service users interviewed in the current study felt uncertain regarding e-cigarette efficacy and safety. E-cigarette ever users viewed e-cigarettes as effective and safe, more often than never users. Accurate and up-to-date education will enable service users to make informed treatment decisions.

Introduction: Electronic cigarette (e-cigarette) use rose substantially within the UK in recent years but currently, Stop Smoking Services in England do not prescribe them due to a lack of regulation. Previous research has examined e-cigarette use and attitudes within English Stop Smoking Services using samples of practitioners and managers; the current study recruited a sample of service users. Methods: Participants (N¼319) aged 18–60 years old were recruited from Roy Castle FagEnds, Liverpool, England (Stop Smoking Service). A cross-sectional questionnaire was completed, which recorded demographic variables, e-cigarette use alongside risk perception, and lastly, smoking behaviour i.e. smoking duration, cigarettes per day, and nicotine dependence. Results: Most participants were female (57.1%), current smokers (53.0%), and current or former e-cigarette users (51.7%). Participants who perceived e-cigarettes as less harmful than smoked tobacco were more likely to have smoked fewer cigarettes per day (p¼0.008). Furthermore, those who felt uncertain whether e-cigarettes were safer than smoked tobacco, were less likely to have tried them (p50.001). Conclusion: This study suggests that e-cigarette use is becoming common among users of Stop Smoking Services (despite e-cigarettes being unavailable from such services) and that e-cigarette risk perception is related to e-cigarette status. The results highlight the importance of providing smokers intending to quit smoking with current and accurate e-cigarette information. Findings may inform future Stop Smoking Services provision and the results demonstrate that further research is warranted.

Aims: To explore depression in people treated for chronic venous leg ulceration, and to assess the impact of excessive exudate, leading to leakage and odour, on their daily lives, overall health and quality of life. Methods: Completion of a questionnaire and Hospital Anxiety and Depression Scale to determine the prevalence of anxiety and depression in people with chronic leg ulceration (n=196), and interviews with 20 people living with chronic leg ulceration. Findings: Odour and excessive exudate leading to leakage had an adverse effect on patients’ psychological state, leading to feelings of disgust, self-loathing and low self-esteem. Conclusion: Chronic leg ulcers disrupt patients’ lives and restrict their social lives, leading to social isolation and depression. Healthcare professionals should better understand the impact of symptoms such as odour and exudate leakage on patients’ mental health, physical health and healing.