Jinks et al. BMC Public Health 2010, 10:148 http://www.biomedcentral.com/1471-2458/10/148 The participants in this study demonstrated that the contextual opportunities shaped their ability to put into practice their knowledge about health enhancing beha- viours, 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 explana- tory and holistic model, even though in terms of action people emphasised individual responsibility and behaviour. Discussion The formulation of the rainbow model [3] was based upon the understanding that biological factors, social and physical environments, personal lifestyles, services and policy all influence the health status of individuals. These various factors are interrelated in complex ways, and determine the patterning of health inequalities. While this model has shaped public health thinking and policy with regard to populations, it has not been applied at the individual level. The purpose of our study was to use the model to help participants make sense of their own lives, and in particular when considering pre- vention of knee pain and disability. The participants considered the model as a common- sense framework for locating their personal life within a wider social, economic and policy context and made reference to a range of factors that have shaped their thinking about health and prevention. It appeared that the majority of people considered individual responsibil- ity for health maintenance as the key, but in the detailed discussions about the interaction between the layers within the model a more nuanced approach emerged. The relationship between agency, practices and structure [8] was drawn by a number of participants when they explained how their power to act was fed by feeling con- fident as a result of their upbringing or educational achievement. Their beliefs about appropriate health behaviour could be put into practice when stimulated or supported by professional advice, structural opportunities such as access and financial resources or in some cases by policy initiatives. While the words being used appeared to be individual-orientated - such as ‘deter- mined’, ‘help yourself’ or ‘it is down to you’ - they were not purely connected with moral fibre as defined in Blax- ter’s study [19]. In particular, when considering barriers and facilitators to preventive action the influence of social structure on individuals’ interpretation of their Page 8 of 9 everyday reality reflected how they took into account fac- tors beyond physical health and talked about well-being with regards to social and psychological aspects over the life course. This supports the notion that Williams [10] proposes, namely to develop a sociological and historical analysis of people and the places within which they live, and use this to contextualise patterns of health behaviour and outcomes. In our study people clearly engaged in such a fine-grained approach to their health behaviour by referring to their past, present and expectations of the future as embedded within their social context and the opportunities (or lack of) that these afforded. Conclusion The specific relevance of the rainbow model to knee pain relates to the NICE guidelines emphasising indivi- dual behaviours and self care, the evidence from epide- miology that identifies risk factors and opportunities for prevention, and the findings from qualitative studies that provide more complex and detailed understanding of living with knee pain. We conclude that the model does have relevance at the individual level and can help formulate more dynamic and contextualised approaches that resonate with individuals’ own interpretation of their lives, health and prospects for deliberate action that go beyond the duality of agency and structure. This is particularly important given the increased emphasis on partnership between patients and health care profes- sionals, whereby a better understanding of the life- world of patients allows for consultations to be respon- sive, targeted and more likely to lead to improved outcomes. Acknowledgements We would like to thank the patients who participated in this study. The study was funded by the North Staffordshire Primary Care Research and Development Consortium and National Co-ordinating Centre for Research Capacity Development (NCC RCD). Author details 1Arthritis Research Campaign National Primary Care Centre, Primary Care Sciences, Keele University, Keele ST5 5BG, UK. 2UKCRC Centre of Excellence for Public Health (NI), School of Medicine, Dentistry and Biomedical Sciences, Mullhouse Building, Grosvenor Rd, Belfast BT 12 6BJ, UK. Authors’ contributions CJ and BNO conceived the design of the study. TO coordinated the study and undertook the qualitative interviews. All authors contributed to interpretation of data and to the development of this manuscript. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests.