Social Determinants of Health (SDOH) and Three Delays Model

Social Determinants of Health (SDOH)

Definition

• Non-medical factors that influence health outcomes; conditions in which people are born, grow, live, work and age (WHO, 2008)
• Account for 30–55% of health outcomes; stronger predictors than genetics or healthcare access alone

Key Domains (WHO Framework)

• Economic stability (income, poverty, employment)
• Education (literacy, early childhood development)
• Healthcare access and quality
• Neighbourhood and built environment (housing, sanitation, pollution)
• Social and community context (discrimination, social cohesion, gender norms)

Relevance in Pediatric Context

• Major drivers of child morbidity, mortality, stunting, anemia and developmental delay in India
• Examples:
  • Poverty → undernutrition, poor immunization coverage
  • Low maternal education → delayed care-seeking, higher IMR/NMR
  • Unsafe water/sanitation → diarrheal diseases, stunting
  • Gender bias → female child neglect, higher female under-5 mortality
  • Urban slums/rural remoteness → higher injury, violence and pollution-related illness

Impact on Child Health Outcomes

• Inter-generational cycle: Poor SDOH in parents → adverse fetal programming → LBW, developmental disability
• Explains 60–70% of inequity in under-5 mortality across states (NFHS-5 data)
• Link with national programmes: POSHAN Abhiyaan, RBSK, RKSK target SDOH through convergence

Three Delays Model

Origin and Concept

• Proposed by Thaddeus and Maine (1994) to explain maternal mortality; now widely applied to neonatal, infant and child deaths
• Identifies three phases of delay that prevent timely life-saving care

The Three Delays

1. Delay in Decision to Seek Care (Phase I)

• Occurs at household/community level
• Contributing factors:
  • Lack of recognition of danger signs (e.g., neonatal sepsis, pneumonia)
  • Low health literacy, cultural beliefs, preference for traditional healers
  • Gender norms, financial constraints, decision-making by elders
• Pediatric examples: Delayed recognition of danger signs in pneumonia, diarrhea, fever

2. Delay in Reaching the Facility (Phase II)

• Transport and accessibility barriers
• Contributing factors:
  • Distance to health facility, poor roads, lack of transport
  • Cost of travel, lack of 108/102 ambulance awareness
  • Monsoon/floods in rural areas, night-time emergencies
• Pediatric examples: Delayed transport of sick neonate/infant leading to hypothermia, shock

3. Delay in Receiving Adequate Care (Phase III)

• Occurs after reaching facility
• Contributing factors:
  • Shortage of staff, drugs, blood, equipment
  • Inadequate referral linkages, long waiting time
  • Poor quality of care, lack of neonatal/pediatric intensive care
• Pediatric examples: Delayed surfactant/CPAP in preterm, delayed antibiotics in sepsis

Application in Indian Context

• Explains >50% of preventable neonatal and child deaths (Lancet series)
• Addressed through:
  • Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK) for free transport/drugs
  • Home-based newborn care (HBNC), ASHA training on danger signs
  • 108/102 ambulance services, DEIC/RBSK referral pathways

Strategies to Overcome Delays

• Community: Behaviour change communication, VHSNC, peer education (RKSK Saathiya)
• Facility: Strengthening FRUs, SNCUs, DEICs, LaQshya quality certification
• System: Real-time emergency transport, digital tracking (RCH portal), convergence with RBSK/RKSK