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Preventing Chronic Disease: Public Health Research, Practice and Policy

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Emerging Infectious Diseases Journal


Volume 4: No. 4, October 2007

About This Image

Cover of the July 2007 issue

The relationship between health and other social conditions is so complicated that even designing a visual model to represent it poses a significant challenge. In this issue of Preventing Chronic Disease (PCD), we explore social determinants of health in the broad context in which communities operate, and the editorial from our editor in chief describes various models that have been used to encompass these interactions. Models ranging from concentric circles to inverted pyramids to causal webs define linear, two-dimensional modes of operation. But the interactions among early childhood development, globalization, health systems, urban settings, women and gender equity, social exclusion, employment conditions, priority public health conditions, and measurement and evidence — the nine areas of concentration established by the World Health Organization Commission on Social Determinants of Health (1) — suggest a visual model more closely approximating the three dimensions in which these elements exist and interact.

The cover image for this issue of PCD presents such a model, a cluster of bubbles representing various factors affecting health and designed using computer imaging software. As Wilcox writes in her editorial, “A single bubble interfaces with many others, and if one bubble pops, the surface tension and connectivity of the others change throughout the cascade” (2). Represented as influences, the bubbles in this model affect individuals both directly and indirectly, not only through the companion bubble’s interface but also through the companion bubble’s connections to other surfaces. Additionally, catastrophic natural or political events can impact the cascade so that all systems will change, and the individual will be caught up in these forces rather than be their focus. The cascade properties illustrate the dynamic consequences, both intended and unintended, that may result from social policy interventions.


  1. Commission on social determinants of health. London (UK): Commission on Social Determinants of Health, World Health Organization; 2006.
  2. Wilcox LS. Onions and bubbles: models of the social determinants of health. Prev Chronic Dis 2007;4(4).

Cover artist: Dan J. Higgins
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The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.


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