L2 Public Health Socioeconomic Environment and Health

Overview

This lecture has three parts. Prof Dockerty sets out the framework of social determinants of health, the social gradient, and the classic evidence (Whitehall Study, Black Report, Acheson Report) for how socioeconomic position drives health inequalities, then applies this to child poverty, ethnic inequalities and food security in Aotearoa, closing with the WHO’s 2025 global equity report. Prof Norris then presents findings from the “Access to Medicines: Exploring Lived Experience” study, showing concretely why people living in poverty struggle to exercise, eat well, manage stress and access healthcare. Dr Wills closes with what clinicians and health services can actually do, framed around the UN Convention on the Rights of the Child (UNCROC) and finishing with a model of cultural competence and cultural humility.

Social Determinants of Health and the Social Gradient

• Health is not determined only by biology or health care; it is shaped by social determinants of health including income, education, housing, employment, social environment/neighbourhood conditions, and early childhood conditions. Social and economic factors are major drivers of both health outcomes and health inequalities.
• Illustrative case: two 55-year-old patients with identical hypertension. Maria is a lawyer with stable housing, high income and regular exercise; Anna is a casual worker in overcrowded rental housing with financial stress and limited access to healthy food. The teaching point is that despite an identical diagnosis, their socioeconomic circumstances put them at different risk of stroke or heart disease.
• Social gradient: health improves at every step up the socioeconomic ladder, not just rich versus poor; each step down brings worse health. It is influenced by socioeconomic position (e.g. education, income), access to resources (e.g. good food, safe living conditions, health care) and social support.
• Barton and Grant’s “health map” models determinants as concentric rings around the person: centre = people (age, sex, hereditary factors); then community/lifestyle; then local economy; then activities; then built environment; then natural environment; outer ring = global ecosystem. Unequal distribution of these determinants leads to inequalities in health outcomes.
• Definitions: inequality is an uneven distribution of resources or outcomes (seen in wealth, health, education); inequity is an unfair and avoidable difference in outcomes, indicating a lack of fairness or justice in distribution, often resulting from systemic issues such as poor governance or social exclusion.
• Marmot: “Social injustice is killing on a grand scale. Inequalities in power, money, and resources are the key drivers of inequities in health.”

Two diagrams in this section (the inset "Health Gradient" staircase graphic and the outer radiating labels of the Barton and Grant health map) were too low-resolution to transcribe in full; only the overall structure above is captured.

Evidence for Health Inequalities

• The Whitehall Study: a prospective cohort of over 17,000 British civil servants, begun in 1967. Found that lower employment grade was associated with higher mortality, even though all participants had jobs and universal health care (NHS) was available; mortality risk increased stepwise with lower job status. Key lesson: health inequalities exist even within relatively privileged populations with universal health care.
• Multifactorial mechanisms linking socioeconomic position to health: material factors (housing, nutrition, neighbourhood conditions), psychosocial stress (job insecurity, lack of control), behavioural pathways (smoking, alcohol, diet), and access to health care.
• The Black Report (UK government commissioned): found large health inequalities persisted despite the NHS, with mortality in the lowest social class about twice that of the highest. Conclusion: health inequalities were driven largely by economic and social conditions, not by health care access alone.
• Policy response, the Acheson Report (1998), recommended: reduce child poverty; improve housing; address income inequality; invest in early childhood. Its important message was that health policy alone cannot fix health inequalities; social policy matters too.
• Lecture summary of this section: health is shaped strongly by social and economic conditions; health follows a social gradient; evidence shows persistent health inequalities linked to the socioeconomic environment; early life conditions and cumulative disadvantage drive long-term health outcomes; addressing health inequalities requires policy, public health and clinical action.

Pathways from Socioeconomic Environment to Disease

• Four linked pathways: (1) material conditions, e.g. housing quality, food security; (2) behavioural factors, e.g. smoking, diet, physical activity; (3) stress biology, chronic stress leading via cortisol to inflammation; (4) access to quality health care.
• Example, smoking and deprivation: smoking prevalence is much higher in deprived populations, leading to cardiovascular disease, cancer and respiratory illness. This shows that behavioural risk factors are themselves socially patterned, not simply individual choices.
• Life-course perspective: early-life conditions shape health throughout life. Health inequalities often start in childhood via mechanisms such as fetal development, childhood nutrition, educational opportunities and chronic stress. Childhood deprivation continues to affect health decades later (evidence cited from the Dunedin Study).
• An accumulation chain given in the lecture: child poverty leads to lower education, which leads to lower pay, which leads to higher smoking, which leads to cardiovascular disease.
• COVID-19 as an example of the same pattern: in many countries poorer populations had higher mortality, some ethnic groups faced greater risk, and essential workers faced higher exposure; these disparities reflect underlying socioeconomic differences in housing, employment and health status.

Health Inequalities in Aotearoa New Zealand

• Socioeconomic gradients: poorer health is strongly related to deprivation, with income, housing, employment and neighbourhood environment identified as key determinants influencing outcomes and inequalities.
• Child poverty: about 1 in 9 NZ children live in poverty (Statistics NZ, 2022). Impacts include poorer health, lower educational outcomes, lower adult income and shorter life expectancy, showing clear life-course effects. The lecture frames addressing child poverty as “not a political question; it’s an ethical question, it’s a moral question” (Prof Marie Johansson).
• Ethnic inequalities: socioeconomic and historical factors intersect with ethnicity. Māori and Pacific populations have lower average incomes and higher exposure to deprivation; income disparities persist across ethnic groups. This contributes to higher chronic disease rates, lower life expectancy and higher hospitalisation rates.
• Neighbourhood effects: deprived communities often experience multiple stacked risks together, poorer housing and overcrowding, higher pollution, more alcohol outlets, fewer green spaces, and more fast-food outlets.
• Life expectancy by ethnicity, Counties Manukau (CM) vs NZ average, 2000-2018: Non-Māori Non-Pacific groups (CM and NZ) track highest, rising from roughly 79-80 to roughly 83-84 years; Pacific groups track in the middle, roughly 74-77 years with more fluctuation; Māori groups track lowest, roughly 69-77 years, with the most fluctuation and the lowest starting point (~69 in 2000). The gap between top and bottom groups narrows somewhat over the period but persists throughout.

Global Perspective: WHO World Report on Social Determinants of Health Equity (2025)

• Background: the WHO’s 2008 Commission on Social Determinants of Health highlighted the root causes of ill health, the conditions in which people are born, grow, live, work and age, and showed how inequities in these conditions lead to profound health differences between and within countries.
• The 2025 WHO “World Report on Social Determinants of Health Equity” found that the targets set by the 2008 Commission will be missed, and that, where data are available, life expectancy gaps within countries have often widened.
• Structural framework: a person’s socioeconomic position (income, education, race/ethnicity, class) sits above five categories of structural determinants: economic systems (e.g. income inequality, taxation, labour markets, trade policy, financial systems, commercial determinants); social infrastructure (universal social policies and public services); structural discrimination (racism, gender inequality, class privilege); conflict, forced migration and displacement; and mega-trends of climate change and digitalisation. These structural determinants shape the “conditions of daily life” (early child development, adolescent support, social connection, work and employment, food environments, housing and basic amenities, transport and mobility), which in turn determine health and health equity.
• Scale of inequity: people in the country with the highest life expectancy live, on average, 33 years longer than those born in the country with the lowest. Within countries, life expectancy varies by decades depending on area and social group.
• Four areas for action identified by the report: (1) address economic inequality and invest in social infrastructure and universal public services; (2) overcome structural discrimination; (3) manage the challenges and opportunities of climate change and digital transformation in a way that promotes health equity; (4) put in place governance arrangements that maximise the coherence and impact of action.
• War is highlighted as also “killing on a grand scale,” creating further injustice, poverty and ill health.
• Cross-country data: countries with a higher Gini index (more income inequality) tend to have lower life expectancy; countries with a bigger gap between the top 10% and bottom 10% of earners tend to have higher infant mortality. The United States is used as an example of comparatively high inequality with comparatively lower life expectancy and higher infant mortality; Iceland is used as a low-inequality, low-infant-mortality comparator.
• NZ wealth distribution (“Inequality Tower”): the share of building (wealth) ownership held by the top 1% rose from 16.4% to 22%, and the top 10% are thought to now own around 61% of total wealth (up from about half); the bottom 50%‘s ownership share fell from 5.4% to 2%.

Health inequalities are not confined to poor countries or historic evidence: the WHO's 2025 data show within-country life expectancy gaps have often widened, even as overall wealth has grown.

Food Security and Child Material Hardship in NZ

• Food security is defined as freedom from “limited or uncertain availability of nutritionally adequate and safe foods or limited ability to acquire personally acceptable foods that meet cultural needs in a socially acceptable way” (Anderson 1990; Holben 2010; Parnell et al 2001). For Māori, food security has a more integrative meaning, tied to cultural concepts and practices such as mana (authority), manaakitanga (reciprocity of kindness, respect and humanity), and mahinga kai (traditional food-gathering places and practices) (McKerchar et al 2015).
• In 2015/16 in NZ, an estimated 19.0% of children lived in households experiencing severe-to-moderate food insecurity (almost 1 in 5), of whom 1.6% of all children were in households with severe food insecurity. An estimated three in five children lived in households reporting no food insecurity at all.
• The DEP-17 material hardship index (Stats NZ; Child Poverty Monitor 2022) groups items into: enforced lack of essentials (e.g. no meal with meat/fish/chicken at least every second day, fewer than two pairs of good shoes, no suitable clothes for special occasions, no presents given for family/friends’ occasions, no home contents insurance, economised heavily on essentials, went without fresh fruit and vegetables, bought cheaper cuts of meat, postponed doctor or dentist visits, cut back on local trips, put up with being cold, delayed appliance repairs); restrictions (feeling “very limited” by money when buying clothes/shoes, unable to pay an unexpected $500 bill within a month without borrowing); and financial stress and vulnerability (arrears more than once in 12 months on rates/electricity/water or vehicle costs due to shortage of cash; borrowing from friends/family more than once in 12 months for everyday living expenses).
• Material hardship = enforced lack of 6 or more DEP-17 items; severe material hardship = enforced lack of 9 or more items.
• Trend 2012/13 to 2020/21: material hardship among 0-17 year-olds fell from around 18% to around 11% (with a dip to ~12% by 2015/16 and a plateau before further decline); severe material hardship stayed roughly flat to slightly declining, from around 7-8% to around 5%.
• Material hardship by group, 2020/21: Māori 20.2%, Pacific 24.0%, European 7.8%, Disabled children 20.5%, Non-disabled children 9.7%.
• Children in households experiencing material hardship report going without basic needs (DEP-17 items) at consistently and substantially higher rates than children not in material hardship, across essentially every item measured.

Lived Experience: Barriers Facing People in Poverty (Access to Medicines study)

• The study (“Access to Medicines: Exploring Lived Experience to Inform Policies and Programmes,” Norris et al, funded by the HRC) recruited 21 households (Māori, Pacific, refugee, Pākehā) living in poverty, followed for about 12 months with repeated interviews about their lives, health, health care and medicines. Household size ranged from 1 to 20 people; housing included private rental, Kāinga Ora housing, boarding houses, a halfway house, own homes, and (after the study) emergency housing. Income sources included the Supported Living Payment and other benefits, paid employment, and pensions.
• Why people might not exercise: disabilities (mental health, including social anxiety; physical, including injuries and waiting for surgery), disabilities made worse by lack of money (e.g. foot problems, unable to afford special shoes), care of children and others, and demanding work (long hours, physical exhaustion).
• Why people might not eat healthy food: insufficient income and rising prices, illustrated by a participant describing choosing cheaper saveloys or sausages over mince or steak because of cost; food is often the last item of expenditure, paid for only after everything else; shared kitchens in boarding houses are not conducive to cooking and food is observed by others; for refugees, foods they are used to (e.g. cucumbers, fresh dates, nuts, halal meat) can be expensive and hard to find in NZ; and there is a lack of storage and preparation space, especially in emergency housing.
• Why people might have too much stress: multiple simultaneous sources, e.g. poverty, poor physical health, waiting for and accessing health care, housing insecurity, mental health problems, past trauma, and worry about the future for themselves, their children and grandchildren.
• Why people might not seek health care: busy, stressful lives (large households in small houses; multiple illnesses/disabilities across the whānau meaning multiple appointments, medicines and instructions to manage; shift work, e.g. a carer working several consecutive 24-hour shifts for an understaffed employer who cannot give her time off; interactions with multiple agencies such as WINZ, the child protection system and the justice system; “the business of being poor,” meaning many support agencies, forms and eligibility criteria to navigate); limited knowledge of how the health system works (e.g. a refugee restricted to cheap medicines like paracetamol because other medication is too expensive; frustration with an unfamiliar system, such as GPs acting as gatekeepers to specialists and needing a prescription for antibiotics); and frustration and distrust arising from health system mistakes and poor past experiences.
• Practical barriers to arranging and attending appointments: sharing a phone with others, having no phone credit (so being unable to return calls or check voicemail), missing hospital letters or appointments after moving house frequently, and competing demands from work and caring responsibilities.
• Financial barriers to appointments and medicines: being unable to afford consultations (illustrated by a participant describing a $35 consultation fee as unaffordable even while partly employed) and medicines, being in debt to a medical practice or pharmacy, and shame or stigma.
• Conclusions: people’s lives can be busy and complex; participants in the study did care about their health, but faced multiple challenges that prevented them prioritising it, engaging in healthy behaviours, and being “good patients.” This should be borne in mind when giving patients recommendations, alongside advocacy to help people live healthy lives.

Clinical Relevance and What Clinicians Can Do

• Doctors often see the downstream consequences of social determinants, for example asthma from poor housing, diabetes from food insecurity, and mental illness linked to unemployment. Treating disease without addressing this context is often insufficient.
• Student question used in the lecture: a child with recurrent asthma living in cold, damp rental housing, what upstream factors are contributing?
• What clinicians can do: recognise social context in patient care and ask relevant questions; screen for social needs; advocate for patients; support public health policy; and work with community services, connecting patients to them.

The transcript includes an uncaptioned photo sequence (a weathered rental house, close-up black mould on a wall/ceiling, the same mould background overlaid with a photo of two children on a porch, an infant apparently receiving nebulizer/oxygen treatment, and a chest X-ray showing widespread patchy opacities). No caption, diagnosis or explicit link between these images is given on the slides; a housing-to-respiratory-illness pathway is visually suggested but not stated in the transcript, so no clinical conclusion is drawn from it here.

UNCROC and Health System Actions for Child Health Equity

• Core principles of the UN Convention on the Rights of the Child (UNCROC) covered: protect children from discrimination; make children’s interests paramount; ensure children’s right to be heard; ensure, to the maximum extent, the survival and development of the child; protect children from all forms of violence, injury and abuse; ensure appropriate prenatal and postnatal care for mothers; ensure children’s rights to rest, leisure and play; ensure disabled children’s active participation in their community; develop primary and preventive health care, guidance for parents, and family planning education and services; and provide services at standards agreed by experts.
• Applying UNCROC practically starts with agreeing values and what they mean for the project or issue at hand:
  • All children have these rights: no child left behind, no parent stands alone.
  • Discrimination: aim for equity of outcome.
  • Paramountcy: when adult and child interests conflict, children come first.
  • Survival and development: do the things that matter first.
  • Freedom from abuse: build skills for today, covering domestic violence, behaviour, drug and alcohol issues, and mental health.
  • Standards agreed by experts: decide what will actually be done and where not to compromise.
  • Value children’s views: use children’s voices to inform service design, delivery and evaluation.
• Practical actions health services can take (“our job”):
  • Enrol every child at birth: GP, National Immunisation Register, Well Child Tamariki Ora (WCTO), oral health.
  • Deliver the basics: immunisations on time, WCTO core visits, the B4 School Check at age 4.
  • Be opportunistic: opportunistic immunisations, asking the family-violence question, smokefree advice, healthy housing advice.
  • Ensure access to primary care: free care for under-13s (with discussion of extending this to under-18s).
  • Have everyone practise at the top of their scope: nurses managing throats, skin, contraception and STIs; GPs using eTreatment guidelines and eReferrals.
  • Build mechanisms to collaborate and share information: direct referrals from school, Occupational Therapy, NGOs or the Ministry of Education; multi-agency teams such as Maternal Wellbeing, High and Complex Needs, Strengthening Families, and the Intensive Wraparound Service.
  • Use a single plan for children across agencies, with joined-up purchasing.
  • Plan for quality and equity: clinical governance, the PDSA cycle (Plan, Do, Study, Act), and monitoring and publicly reporting outcomes by ethnicity, e.g. access and did-not-attend rates in children’s outpatients.
  • In practice: whakawhanaungatanga, manaakitanga, pronouncing people’s names properly (by asking), taking a good social history, asking about barriers to care, and giving medicines at school.

Cultural Competence and Cultural Humility

• Becoming culturally competent and practising cultural humility are ongoing processes that change with new situations, experiences and relationships. Cultural competence is described as a necessary foundation for cultural humility.
• Cultural competence (foundational tiers): gaining cultural knowledge (what other cultures are like, and what strengths they have) and developing cultural self-awareness (what is my own culture, and how does it influence how I view and interact with others).
• Cultural humility (upper tiers, built on that foundation): understanding and addressing power imbalances (using understanding of one’s own and others’ cultures to identify and disrupt inequitable systems) and holding systems accountable (working at an institutional level so that the systems one is part of move toward greater inclusion and equity).
• Closing message: health inequities can be reduced, and sometimes eliminated, through interventions in health, many of which cost nothing because they are simply about doing the job well. Start with a discussion about values, because they are why the work is done, and don’t forget to ask the children. Everyone is responsible for their own cultural competence and, as part of the health system, for holding the system accountable for equity.

Self-test

1. Define social determinants of health and list the categories given in the lecture.
2. Describe the social gradient in health, including what it means to say it is “not just rich vs poor.”
3. Distinguish inequality from inequity.
4. Describe the design and key finding of the Whitehall Study, and explain why the finding was significant given the study population.
5. What did the Black Report conclude about health inequalities under the NHS, and what quantitative disparity did it report between the highest and lowest social classes?
6. List the four key recommendations of the Acheson Report.
7. Describe the four pathways through which the socioeconomic environment influences disease.
8. Using the example of smoking, explain what it means for a behavioural risk factor to be “socially patterned.”
9. Describe the life-course chain of accumulating risk from child poverty to cardiovascular disease given in the lecture.
10. What proportion of NZ children live in poverty, and list three impacts of child poverty described in the lecture?
11. Describe the pattern of health inequalities by ethnicity in NZ, including the life expectancy trend shown for Māori, Pacific and non-Māori non-Pacific groups (Counties Manukau vs NZ, 2000-2018).
12. Describe the WHO 2025 framework linking structural determinants to health equity: what sits above the structural determinants, what are the five categories of structural determinants, and what do they shape before reaching “health and health equity”?
13. Define food security, including the additional cultural dimension described for Māori.
14. Distinguish material hardship from severe material hardship using the DEP-17 index, and state the 2020/21 material hardship rates for Māori, Pacific and European children.
15. From the Access to Medicines study, list three types of barriers that prevented participants from eating healthily.
16. From the same study, describe three reasons participants found it difficult to seek or attend health care.
17. List the core principles of UNCROC covered in the lecture.
18. Describe three practical actions health services can take to reduce inequities in child health, as outlined by Dr Wills.
19. Distinguish cultural competence from cultural humility, and explain how the lecture says they relate to one another.
20. Integrative: a child presents with recurrent asthma and lives in cold, damp rental housing. Drawing on material from across the lecture, describe the upstream socioeconomic factors that may be contributing and outline what a clinician could do about it.

Answers

Reveal answers

1. Social determinants of health are the non-biological, non-healthcare factors that shape health: income, education, housing, employment, social environment/neighbourhood conditions, and early childhood conditions. They are major drivers of both health outcomes and health inequalities.
2. The social gradient describes how health improves at every step up the socioeconomic ladder, with each step down bringing worse health, not just a difference between the very rich and very poor. It is influenced by socioeconomic position (e.g. education, income), access to resources (e.g. good food, safe housing, health care) and social support.
3. Inequality is an uneven distribution of resources or outcomes (e.g. in wealth, health, education). Inequity is an unfair and avoidable difference in outcomes, reflecting a lack of fairness or justice in distribution, often arising from systemic issues such as poor governance or social exclusion.
4. The Whitehall Study was a prospective cohort of over 17,000 British civil servants begun in 1967. It found that lower employment grade was associated with stepwise higher mortality. This was significant because all participants had jobs and access to universal health care (the NHS), showing that health inequalities exist even within a relatively privileged population with universal health care.
5. The Black Report found that large health inequalities persisted despite the NHS, and that mortality in the lowest social class was about twice that of the highest. It concluded these inequalities were driven largely by economic and social conditions rather than health care access.
6. Reduce child poverty; improve housing; address income inequality; invest in early childhood.
7. Material conditions (e.g. housing quality, food security); behavioural factors (e.g. smoking, diet, physical activity); stress biology (chronic stress leading via cortisol to inflammation); and access to quality health care.
8. Smoking prevalence is much higher in deprived populations, and this pattern (not just individual choice) drives higher rates of cardiovascular disease, cancer and respiratory illness in those populations, showing that behavioural risk factors follow the same social gradient as other determinants.
9. Child poverty leads to lower education, which leads to lower pay, which leads to higher smoking, which leads to cardiovascular disease.
10. About 1 in 9 NZ children live in poverty (Statistics NZ, 2022). Impacts include poorer health, lower educational outcomes, lower adult income, and shorter life expectancy (any three).
11. Māori and Pacific populations in NZ have lower average incomes and higher exposure to deprivation, contributing to higher chronic disease rates, lower life expectancy and higher hospitalisation rates. In the Counties Manukau/NZ data 2000-2018, non-Māori non-Pacific groups had the highest life expectancy (rising from ~79-80 to ~83-84), Pacific groups were in the middle (~74-77, more fluctuation), and Māori groups were lowest (~69-77, starting around 69 in 2000); the gap narrowed somewhat but persisted throughout the period.
12. Socioeconomic position (income, education, race/ethnicity, class) sits above the structural determinants. The five categories are: economic systems, social infrastructure, structural discrimination, conflict/forced migration/displacement, and mega-trends (climate change and digitalisation). These shape the “conditions of daily life” (early child development, adolescent support, social connection, work and employment, food environments, housing and basic amenities, transport and mobility), which in turn determine health and health equity.
13. Food security means having reliable availability of nutritionally adequate and safe food, and the ability to acquire personally acceptable food that meets cultural needs in a socially acceptable way. For Māori, food security also integrates cultural concepts and practices such as mana, manaakitanga and mahinga kai.
14. Material hardship is an enforced lack of 6 or more of the 17 DEP-17 items; severe material hardship is an enforced lack of 9 or more items. In 2020/21, material hardship rates were 20.2% for Māori, 24.0% for Pacific, and 7.8% for European children.
15. Any three of: insufficient income and rising prices forcing cheaper food choices; food being the last item of expenditure after other costs; shared kitchens (e.g. in boarding houses) not conducive to cooking and food being observed by others; unfamiliar/expensive foods for refugees; lack of storage and preparation space, especially in emergency housing.
16. Any three of: busy and stressful lives (large households in small houses, multiple appointments/medicines across the whānau, inflexible shift work, dealings with multiple agencies such as WINZ, child protection and justice); limited knowledge of, or frustration with, how the health system works (e.g. cost-restricted medicines for refugees, unfamiliar GP-gatekeeping); distrust from past health system mistakes and poor experiences; practical barriers such as shared phones, no phone credit, or missed letters after moving house; financial barriers such as unaffordable consultation fees, debt to providers, and shame/stigma.
17. Protect children from discrimination; make children’s interests paramount; ensure children’s right to be heard; ensure to the maximum extent the survival and development of the child; protect children from all forms of violence, injury and abuse; ensure appropriate prenatal and postnatal care for mothers; ensure children’s rights to rest, leisure and play; ensure disabled children’s active participation in their community; develop primary and preventive health care, parental guidance and family planning education/services; and provide services at standards agreed by experts.
18. Any three of: enrolling children at birth (GP, NIR, WCTO, oral health); delivering basics like on-time immunisations, WCTO core visits and the B4 School Check; being opportunistic (opportunistic immunisations, family-violence question, smokefree and healthy housing advice); ensuring free primary care access for under-13s; having staff work at the top of their scope; building multi-agency referral and collaboration mechanisms; using a single cross-agency plan for children; monitoring and publicly reporting outcomes by ethnicity via clinical governance and the PDSA cycle; and practising whakawhanaungatanga, manaakitanga and asking about barriers to care.
19. Cultural competence is about gaining cultural knowledge (of other cultures) and developing cultural self-awareness (of one’s own culture and its influence). Cultural humility is about understanding and addressing power imbalances and holding systems accountable at an institutional level. The lecture describes cultural competence as a necessary foundation for cultural humility, and both as ongoing processes that change with new situations, experiences and relationships.
20. Upstream socioeconomic factors may include poor-quality, cold or damp rental housing (a material-conditions pathway directly named in the lecture as a cause of asthma from poor housing), possible overcrowding, insufficient income to afford better housing or heating, and household stress. A clinician can recognise this social context and ask about it directly, screen for social needs (housing quality, financial stress), advocate for the family (e.g. referral toward healthy housing support), support public health policy on housing standards, and connect the family to relevant community services, consistent with the lecture’s “what clinicians can do” list.