Whose responsibility is it?
The interview started with asking people about their general health, followed by exploring their knee pain history. This then led to talking about the factors that contributed to their knee pain and their thoughts about preventing this, using the rainbow model as a guide. While nearly all respondents alluded to the issue of responsibility for maintaining health, eight people elaborated on this concept in greater depth. Each person emphasised that individuals are responsible for their own health using phrases such as:
"Well, it's nobody's responsibility but my own." (4575) or "I think you have to be prepared to help yourself." (5300)
These statements became more nuanced through considering the factors that allowed people to live responsibly, and professional advice was seen as important, or more broadly, organisations should take a pro-active approach to individuals:
"With the National Health, you know, the lessons I've learned is that, if it's a great expense for them to react to a condition that I've had, whereas it might have been cheaper had the resources been there to have taken the preventative." (6028)
"I suppose, in the first instance, it's the individual, but people, being individuals, are all different. So I think there should be some sort of 'gee-up' from authorities [...] somebody could come round from the [city] council or some gym or something. Just do a few basic exercises with residents." (6900)
The role of health and other statutory services with respect to prevention were explicitly recognised by these individuals: the NHS was seen as focusing on treating acute problems which may have been prevented if investments were aimed at prevention rather than cure. The importance of organisations outside of health was highlighted in the second quote where it was suggested that city councils could create the conditions that helped people to improve their health. As an extension of organisational facilitators the professionals working within health and social care were seen to be important in advising people on healthy lifestyles and who should act as educators and sources of information. At the same time, their influence was dependent on individual receptivity:
"I think it's got to come from within, hasn't it really? I mean, when we, you can listen to advice, but you've got to either put that advice into practice or be determined enough, in your own mind, that, you know, you will either lose the weight or stop smoking, or stop drinking, or whatever." (4713)
This person connected three factors: being given advice, accepting and implementing it, and maintaining new behaviour as dependent on motivation. He reinforced this with giving an example of individual will-power (resisting social pressure to smoke and drink) and returning to the theme of individual responsibility by concluding "the way you live your life is up to you". Having a sense of responsibility was considered to be learned behaviour, and people linked it directly to their social context such as coming from a "reasonably stable family background" (5228) or parenting which included encouraging children to eat healthily and take exercise (957). A broader role for education was also mentioned with teaching children how to look after their own health (5969).
Two people went further and discussed the role of the state in the face of people abdicating responsibility for themselves. One person gave the example of his son, an ambulance driver, who told him about being called out for trivial things:
"So, I'm aware that a lot of people, you know, feel that or choose to take the attitude "well, I'd rather somebody else take the responsibility for what I should be doing myself", but I just don't happen to believe that." (5228)
However, he realised that there will always be people who will not take responsibility for themselves and felt the community and the state will need to provide protection or coercion:
"Ought the state be sort of saying that you don't do this or you do something else and stopping people from doing things?" (5228)
Individual responsibility for health emerged as a strong theme, but structural factors were considered to affect individual behaviours. Thus, Blaxter's  finding that people tend to see healthy lifestyles and personal character and determination as key factors in maintenance of health is supported by the explanations given in our study. At the same time the argument by Hodgins et.al.  is reflected in the responses that argue that a sense of responsibility is shaped by social influences such as education, family context and pro-active interventions by public sector organisations, thus connecting agency and structure in specific ways. Taking responsibility is, therefore, not purely dependent on an individual's strength of character, but is fostered and supported over one's lifetime by factors outside of oneself. By interpreting those influences, individuals in turn, shape and reinforce the context within which they live, for example, by outlining how they should be supported by organisations and the state.
Barriers and facilitators to preventing knee pain and disability
Frohlich et.al.  developed the concept of collective lifestyles as "an expression of a shared way of relating and acting in a given environment" (p.791), but that can be observed through individuals' lifestyle practices. They further add a recursive aspect by stating that individuals are influenced by the context within which they live, but individuals also create and recreate the conditions that maintain structures. This line of thinking is helpful in making sense of how the people in our study reflected on the structural aspects of the rainbow model, and in particular, how they saw barriers and facilitators to health maintenance.
The majority of participants highlighted the importance of exercise to maintain musculoskeletal health. One person aptly termed it "use it or lose it", but this awareness was clearly tempered by contextual factors. The cultural perception of the word exercise tended to be equated with gyms, classes and specific regimes. A number of barriers were associated with this conceptualisation: first, gyms are for young people dressed in tight fitting clothes. One lady said that her husband did not want to entertain the idea of this type of exercise:
"He won't go to the gym. It's he doesn't want to go where the young 'dudes' are, you know, that's daft to him." (968)
Second, the issue of cost to either the individual or to the state when providing free exercise classes. The latter was illustrated by someone who saw the benefit of 'exercise on prescription' schemes, but that these could not be sustained indefinitely:
"After three months, you know, they've had the chance, you know. They can't keep saying: "well, I want to do, I want another three for free", you know. It can't go on forever. It's got to stop somewhere because it's going to cost too much." (5969)
This dilemma was particularly interesting as the collective understanding of the health benefits of exercise was supported by the state, but this support was time limited in the expectation that individuals would take over themselves. Two barriers might play a part: actual financial costs being judged by individuals as too high, or an expectation that it should be the state's rather than individual responsibility. Obviously, this participant felt that people should be given the opportunity to try out gyms, but that they should continue themselves without state support. The boundary between enacting a collective lifestyle with collective or individual resources has become fuzzy in this instance, and made it difficult to judge when and at what level costs would become a barrier.
The culture of work was mentioned by some people as a barrier, such as office jobs leading to a sedentary lifestyle, or the fact that work routines appeared to dominate everyday life:
"I mean, even at your age, you could look at some of the activities going on 'round you and you could think "well, I wished I could do, I wished I was doing that or not could do it, I wished I was doing it. Then you look at all your commitments. You say, I haven't got time." (6545)
This person saw work commitments determining how time was spent, and thereby reinforced the culture of work and its impact on people's choices. Yet, another person gave an example of how people could become empowered to challenge this:
"There's still people with busy lifestyles who build some exercise into it. Erm, like my daughter and her partner, her husband, go both out to work full time, but they do exercise. But they have a routine, they build it into their life." (5969)
Without explicitly referring to will power, the elements of personal choice and determination were implicit in this account, and the impact that individual behaviour might make on the environment was mentioned when concluding: "I think that people are slowly being made aware of it."
An important barrier to prevention was the actual image of knee pain itself as most people thought that "nothing could be done". As highlighted in previous studies [21, 22] this perception was associated with ageing and inevitable 'wear and tear' of joints. We will not repeat the arguments from the literature here, but suffice with stating that in our sample considering knee pain as part and parcel of becoming older was internalised, and thus created a barrier to prevention. The fact that the health service and health professionals tended not to offer active interventions (apart from knee replacements in extreme cases) could be perceived as a structural (organisational) problem.
When broadening out the concept of gym-based exercise to staying active in a variety of ways, more than half of the participants mentioned the benefits of swimming, walking, cycling or dancing. The main facilitating factor in taking up activities appeared to be the social aspect:
"We do a lot of dancing at parties and that sort of thing, you know. I mean, well, I don't dance particularly well, but I hold this girl while she does, you know, what I mean. I'm daft and that, like we do a lot, I do enjoy that, you know and she does, because she's a dancer." (6900)
This gentleman emphasised his enjoyment of dancing, and the pleasure he derived from the dance partnership. The contacts with others in the parties made the activity of dancing a shared experience. Similarly, the lady who joined in with an over-60s gym club emphasised the social interaction:
"They're all the same as me. They're overweight and they've all got health problems [...]. We giggle, yeah, we giggle, you know. You know, sort of, I don't know, you even, we just say, you know: "How's your leg today?" "Oh, it's been awful this weekend, how's yours?" (968)
The important additional factor for her was the fact that she identified with her fellow club members in terms of health and mobility. They could ask each other about problems, be supportive and at the same time downplay issues through the use of humour. Thus, participation was stimulated by a combination of factors, and not just by the knowledge that activity would help with reducing pain and disability. The contribution of social networks, trust and support in maintaining health and well-being have been highlighted in the literature on social capital [23–25]. Similar results  have been documented in relation to coping with pain and the above accounts reflect these findings.
A further important facilitator was the issue whether activity could be integrated within everyday life, such as using stairs rather than lifts, walking instead of taking the car or the daily walk with the dog:
"That's what my specialist once said to me when I went. He said: "Have you got a dog, Mr.S?" I said "yes". He said: "Make sure he gets plenty of exercise." Ha, I thought, that's a nice way of putting it." (6150)
The facilitating factors clearly underlined the importance of context, and that taking up and maintaining an active lifestyle was dependent on social networks, access to facilities (for walking, cycling etc) and finally whether health policy supported healthy behaviours:
"Smoking has changed. Now, what's the difference between allowing, or taking action, of advertising and everything else to do with smoking, and yet, on the other hand the same government will then extend the licensing laws and allow alcohol to be drunk 24 hours a day." (5228)
The participants in this study demonstrated that the contextual opportunities shaped their ability to put into practice their knowledge about health enhancing behaviours, in particular when the benefits were wider than pure physical health and encompassed psychological and social well-being. Thus, it was clear that they connected the different levels of the rainbow model and perceived their own decision-making as embedded within all the layers. In this way the model made sense as an explanatory and holistic model, even though in terms of action people emphasised individual responsibility and behaviour.