Social Factors: A Sometimes-overlooked Opportunity

By Anna-Marie Schmidt, MM, DC, and Robert Vining, DC, DHSc

The biopsychosocial model is a widely recommended method of clinical evaluation and management.1–5  The model identifies three important areas. “Bio” refers to evaluating/treating biological problems (e.g., pathology), “psych” refers to psychological health, and “social” refers to a person’s relationships with others and the environment.5–7

Biomedically-based training naturally orients practitioners toward evaluating and managing biological/pathological aspects of health. Reimbursement structures also reinforce this approach.2 Important relationships between psychological and physical health are now better understood, compelling practitioners to incorporate mental health screening into regular clinical assessment.1,8,9 However, some evidence suggests that practitioners, as a group, may not be addressing “social” components of health as much as they could.2,5 This potentially overlooked part of clinical evaluation is likely due to one or more factors such as:

  • Lack of clarity: Clinical guidelines generally include less emphasis on addressing specific social components of health compared with biological and psychological aspects.2,5,10
  • Knowledge gap: Psychological and social factors are often related and sometimes thought of as a single element (“psychosocial”). However, they are distinct.

The table below displays examples of social factors that can influence important aspects of health.3,7,9–12 Several factors can relate to multiple categories. For example, poor access to care can be related to low socioeconomic status, living in an area with few providers, and/or difficulty attending visits during normal business hours.

Table. 1 Examples of negative social factors and their potential implications.3,7,9–12

Negative Social Factor
Potential Negative Implications
Social Disadvantage  

Low Socioeconomic status

 Reduced access to health insurance, poor food quality

Low educational status

 Reduced health literacy, low socioeconomic status

Low Literacy

 Decreased access to health information, low socioeconomic status

Language barrier

 Reduced access to care, reduces ability to participate in social groups

Lack of community resources

 Negatively influences food quality and quantity, availability of informal  help, access to care, and a social support system

High occupational demands

 Decreases return to work expectations

Low expectations for returning to work

 Reduces likelihood of returning to work

Return to work policies

 Negatively influences clinician decisions regarding treatment plan

Perception of heavy work

 Negative opinions of ability and reduced expectations for returning to work

Job inflexibility

 Impacts return to work timing, decreases return to work expectations
Personal Relationships  

Poor Social Relationships

 Negatively impacts sense of social connection and support

Lack of Informal help

 Limited social relationships, social pain of isolation

Family caregiver

 Reduces time for self-care, increased stress
Clinical Setting  

Lack of clinician empathy

 Negatively influences perceived support from clinician

Lack of clinician reassurance

 Reduces return to work expectations, negatively influences pain catastrophizing and coping

Not meeting patient preferences

 Leads to increased patient anxiety, decreased treatment adherence


Why care about social factors?

Neurophysiological research has demonstrated that both social pain (actual or potential damage to a sense of social connection) and physical pain are processed on shared neural pathways within the cerebral cortex.13–15 Other research evidence suggests several clinically important implications are associated with positive and negative social experiences.

Negative social experiences may result in:

  • Increased circulation of proinflammatory cytokines15
  • Increased perceived pain intensity13–15
  • Reduced ability to cope with pain15
  • Increased vulnerability for developing chronic pain15

Positive social experiences such as meaningful social support can:

  • Reduce pain intensity1,15,16
  • Lead to greater pain tolerance15,16
  • Diminish physiological stress reactions1,16

Influencing social factors

In practice settings, clinically evaluating and addressing every possible social factor for every person is likely unrealistic. But, it is sometimes possible to positively influence some social factors. For example, recovery expectations can be directly addressed by helping patients better understand a condition as part of an ongoing educational process.10 Practitioners can also help foster social support for treatment through encouraging patients to invite their spouse, child or close friend to an office visit.12 Other factors, such as job satisfaction, loneliness or socioeconomic status are more difficult to address directly.10 However, these factors can sometimes be addressed indirectly by referring patients to social groups (reading club, senior community group), food banks, shelters, social workers or other healthcare professionals.

Therapeutic alliance

Perhaps the greatest opportunity to influence social aspects of health is through fostering a strong therapeutic alliance with patients. Research has shown that strong alliances can support important clinical outcomes.10,15,17 Therapeutic alliance is a concept based on positive rapport between patient and practitioner. It reflects practitioner technical skills, communication capacity and the ability to respond to patient needs in the moment.17 As the ability to recognize and respond to patient needs grows and technical and communication skills improve, the therapeutic alliance is theoretically strengthened.

One way to foster positive rapport is to express both empathy and sympathy. Empathetic interactions show an interest in how a health concern impacts a person’s life.18 Empathy is expressed through statements that acknowledge what a person is going through, such as, “That must be difficult.” In contrast, sympathy expresses the feelings of the doctor, for example “I’m sorry you are going through this.” Both empathy and sympathy can be appropriate mechanisms to show emotional support and encouragement.18 Alternatively, being judgmental of patients’ thoughts, attitudes, and/or beliefs can impede positive rapport and negatively affect clinical outcomes.9


Identifying specific social needs is a key part of a balanced biopsychosocial approach.  There are many opportunities to assess and potentially influence social factors in clinical settings. Though addressing all social factors is not likely feasible, enhancing the therapeutic alliance is something on which all providers can focus. In some cases, addressing a social need(s) may be the most important element in moving toward improved health.

Anna-Marie Schmidt, MM, DC, is a post-doctoral research scholar at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic.
Robert Vining, DC, DHSc, is associate dean of clinical research at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic.


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