Jinks et al. BMC Public Health 2010, 10:148 http://www.biomedcentral.com/1471-2458/10/148 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 responsi- bility 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 educa- tion 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 pro- tection 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 [19] finding that people tend to see healthy lifestyles and personal character and determination as key factors in mainte- nance of health is supported by the explanations given in our study. At the same time the argument by Hod- gins et.al. [20] is reflected in the responses that argue that a sense of responsibility is shaped by social influ- ences such as education, family context and pro-active interventions by public sector organisations, thus con- necting 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 one- self. 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. Page 6 of 9 Barriers and facilitators to preventing knee pain and disability Frohlich et.al. [8] 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 impor- tance 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 conceptua- lisation: 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 ‘exer- cise 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 some- where because it’s going to cost too much.” (5969) This dilemma was particularly interesting as the col- lective 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