inequalities may exist in the context of the health care system, or in broader social approaches. according to the who's commission on social determinants of health, access to health care is essential for equitable health, and it argued that health care should be a common good rather than a market commodity. however, there is substantial variation in health care systems and coverage from country to country. the commission also calls for government action on such things as access to clean water and safe, equitable working conditions, and it notes that dangerous working conditions exist even in some wealthy countries. in the rio political declaration on social determinants of health, several key areas of action were identified to address inequalities, including promotion of participatory policy-making processes, strengthening global governance and collaboration, and encouraging developed countries to reach a target of 0.7% of gross national product (gnp) for official development assistance. theoretical approaches the uk black and the health divide reports considered two primary mechanisms for understanding how social determinants influence health: cultural/behavioral and materialist/structuralist the cultural/behavioral explanation is that individuals' behavioral choices (e.g., tobacco and alcohol use, diet, physical activity, etc.) were responsible for their development and deaths from a variety of diseases. however, both the black and health divide reports found that behavioral choices are determined by one's material conditions of life, and these behavioral risk factors account for a relatively small proportion of variation in the incidence and death from various diseases. the materialist/structuralist explanation emphasizes the people's material living conditions. these conditions include availability of resources to access the amenities of life, working conditions, and quality of available food and housing among others. within this view, three frameworks have been developed to explain how social determinants influence health. these frameworks are: (a) materialist; (b) neo-materialist; and (c) psychosocial comparison. the materialist view explains how living conditions – and the social determinants of health that constitute these living conditions – shape health. the neo-materialist explanation extends the materialist analysis by asking how these living conditions occur. the psychosocial comparison explanation considers whether people compare themselves to others and how these comparisons affect health and wellbeing. a nation's wealth is a strong indicator of the health of its population. within nations, however, individual socio-economic position is a powerful predictor of health. material conditions of life determine health by influencing the quality of individual development, family life and interaction, and community environments. material conditions of life lead to differing likelihood of physical (infections, malnutrition, chronic disease, and injuries), developmental (delayed or impaired cognitive, personality, and social development), educational (learning disabilities, poor learning, early school leaving), and social (socialization, preparation for work, and family life) problems. material conditions of life also lead to differences in psychosocial stress. when the fight-or-flight reaction is chronically elicited in response to constant threats to income, housing, and food availability, the immune system is weakened, insulin resistance is increased, and lipid and clotting disorders appear more frequently. the effects of chronic fight-or-flight is described in the allostatic load model the materialist approach offers insight into the sources of health inequalities among individuals and nations. adoption of health-threatening behaviors is also influenced by material deprivation and stress. environments influence whether individuals take up tobacco, use alcohol, consume poor diets, and have low levels of physical activity. tobacco use, excessive alcohol consumption, and carbohydrate-dense diets are also used to cope with difficult circumstances. the materialist approach seeks to understand how these social determinants occur. the neo-materialist approach is concerned with how nations, regions, and cities differ on how economic and other resources are distributed among the population. this distribution of resources can vary widely from country to country. the neo-materialist view focuses on both the social determinants of health and the societal factors that determine the distribution of these social determinants, and especially emphasizes how resources are distributed among members of a society. the social comparison approach holds that the social determinants of health play their role through citizens' interpretations of their standings in the social hierarchy. there are two mechanisms by which this occurs. at the individual level, the perception and experience of one's status in unequal societies lead to stress and poor health. feelings of shame, worthlessness, and envy can lead to harmful effects upon neuro-endocrine, autonomic and metabolic, and immune systems. comparisons to those of a higher social class can also lead to attempts to alleviate such feelings by overspending, taking on additional employment that threaten health, and adopting health-threatening coping behaviors such as overeating and using alcohol and tobacco. at the communal level, widening and strengthening of hierarchy weakens social cohesion, which is a determinant of health. the social comparison approach directs attention to the psychosocial effects of public policies that weaken the social determinants of health. however, these effects may be secondary to how societies distribute material resources and provide security to its citizens, which are described in the materialist and neo-materialist approaches. life-course perspective life-course approaches emphasize the accumulated effects of experience across the life span in understanding the maintenance of health and the onset of disease. the economic and social conditions – the social determinants of health – under which individuals live their lives have a cumulative effect upon the probability of developing any number of diseases, including heart disease and stroke. studies into the childhood and adulthood antecedents of adult-onset diabetes show that adverse economic and social conditions across the life span predispose individuals to this disorder. hertzman outlines three health effects that have relevance for a life-course perspective. latent effects are biological or developmental early life experiences that influence health later in life. low birth weight, for instance, is a reliable predictor of incidence of cardiovascular disease and adult-onset diabetes in later life. nutritional deprivation during childhood has lasting health effects as well. pathway effects are experiences that set individuals onto trajectories that influence health, well-being, and competence over the life course. as one example, children who enter school with delayed vocabulary are set upon a path that leads to lower educational expectations, poor employment prospects, and greater likelihood of illness and disease across the lifespan. deprivation associated with poor-quality neighborhoods, schools, and housing sets children off on paths that are not conducive to health and well-being. cumulative effects are the accumulation of advantage or disadvantage over time that manifests itself in poor health, in particular between women and men. these involve the combination of latent and pathways effects. adopting a life-course perspective directs attention to how social determinants of health operate at every level of development – in utero, infancy, early childhood, childhood, adolescence, and adulthood – to both immediately influence health and influence it in the future. chronic stress and health stress is hypothesized to be a major influence in the social determinants of health. there is a relationship between experience of chronic stress and negative health outcomes. this relationship is explained through both direct and indirect effects of chronic stress on health outcomes. the direct relationship between stress and health outcomes is the effect of stress on human physiology. the long term stress hormone, cortisol, is believed to be the key driver in this relationship. chronic stress has been found to be significantly associated with chronic low-grade inflammation, slower wound healing, increased susceptibility to infections, and poorer responses to vaccines. meta-analysis of healing studies has found that there is a robust relationship between elevated stress levels and slower healing for many different acute and chronic conditions however, it is also important to note that certain factors, such as coping styles and social support, can mitigate the relationship between chronic stress and health outcomes. stress can also be seen to have an indirect effect on health status. one way this happens is due to the strain on the psychological resources of the stressed individual. chronic stress is common in those of a low socio-economic status, who are having to balance worries about financial security, how they will feed their families, housing status, and many other concerns. therefore, individuals with these kinds of worries may lack the emotional resources to adopt positive health behaviors. chronically stressed individuals may therefore be less likely to prioritize their health. in addition to this, the way that an individual responds to stress can influence their health status. often, individuals responding to chronic stress will develop potentially positive or negative coping behaviors. people who cope with stress through positive behaviors such as exercise or social connections may not be as affected by the relationship between stress and health, whereas those with a coping style more prone to over-consumption (i.e. emotional eating, drinking, smoking or drug use) are more likely to be see negative health effects of stress. vape shops are also found more in low socioeconomic status areas. the owners target these areas in particular to gain profit. since people with low-income status are not highly educated, they are more prone to make poor health behavior choices. socioeconomic status also has a huge impact in lives of people of color. according to kids count data center, children in poverty 2014, in the united states 39% of african american children and adolescents, and 33% of latino children and adolescents are living in poverty (kids count data center, children in poverty 2014). the stress these racial groups with low socioeconomic status face, is higher than the same race group from a high-income community. according to the research done on socioeconomic disparities in vape shop density and proximity to public schools, the researchers found that vape shops were located a lot more in the areas with schools where african-americans/latinos/hispanic students were in higher population than the areas with schools where white population was more. the detrimental effects of stress on health outcomes are hypothesized to partly explain why countries that have high levels of income inequality have poorer health outcomes compared to more equal countries. wilkinson and picket hypothesized in their book the spirit level that the stressors associated with low social status are amplified in societies where others are clearly far better off. a landmark study conducted by the world health organization and the international labour organization found that exposure to long working hours, operating through psychosocial stress, is the occupational risk factor with the largest attributable burden of disease, i.e. an estimated 745,000 fatalities from ischemic heart disease and stroke events in 2016. improving health conditions worldwide reducing the health gap requires that governments build systems that allow a healthy standard of living for every resident. interventions three common interventions for improving social determinant outcomes as identified by the who are education, social security and urban development. however, evaluation of interventions has been difficult due to the nature of the interventions, their impact and the fact that the interventions strongly affect children's health outcomes. education: many scientific studies have been conducted and strongly suggests that increased quantity and quality of education leads to benefits to both the individual and society (e.g. improved labor productivity). health and economic outcome improvements can be seen in health measures such as blood pressure, crime, and market participation trends. examples of interventions include decreasing size of classes and providing additional resources to low-income school districts. however, there is currently insufficient evidence to support education as a social determinants intervention with a cost-benefit analysis. social protection: interventions such as “health-related cash transfers”, maternal education, and nutrition-based social protections have been shown to have a positive impact on health outcomes. however, the full economic costs and impacts generated of social security interventions are difficult to evaluate, especially as many social protections primarily affect children of recipients. the landmark cochrane collaboration review of the health impact of unconditional cash transfers in low- and middle-income countries found a large body of evidence that these cash transfers clinically meaningfully reduce in the likelihood of being sick (by an estimated 27%), may also improve food security and dietary diversity, and may also reduce extreme poverty and improve school attendance, as well as increase healthcare spending. urban development: urban development interventions include a wide variety of potential targets such as housing, transportation, and infrastructure improvements. the health benefits are considerable (especially for children), because housing improvements such as smoke alarm installation, concrete flooring, removal of lead paint, etc. can have a direct impact on health. in addition, there is a fair amount of evidence to