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The biopsychosocial model in medical research: The evolution of the health

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 Patient Education and Counseling 53 (2004) 239–244

Short communication
The biopsychosocial model in medical research: the evolution of the
health concept over the last two decades
Yolanda Alonso∗
Department of Personality, Psychological Assessment and Treatment, University of Almerı́a, 04120 La Cañada, Almerı́a, Spain
Received 5 April 2002; received in revised form 10 March 2003; accepted 7 April 2003

Abstract

The object of this study was to assess the change towards a biopsychosocial health concept among medical researchers in the last two
decades, after the explicit criticism of the biomedical model in the late 1970s because of its somatic reductionism. The concepts of ‘health’
or ‘healthy status of an individual’ as reported as variable in empirical articles published in the journal The Lancet over the years 1978–1982
(period a) and 1996–2000 (period b) were searched by means of Medline and compared for their definition of these variables. None of
the 52 examined papers set out a positive and replicable definition of ‘health’ (seven papers) or ‘healthy status’ (45). No difference was
found between the two periods studied except for the failure of reports to describe ‘healthy status’ at all (65.5% in a, 19% in b). Most
articles do it in an indirect way, namely through exclusion conditions of subjects taking part in treatment or control groups. Only three
studies include psychological dimensions in their measures of ‘healthy status’ (two in a, one in b). Concerning ‘health’, all seven examined
papers include psychological or both psychological and social dimensions. Although a change towards a more holistic concept of health
has occurred in academic and institutional contexts over the last few decades, there does not appear to have been a parallel change in the
practical domains of medicine. Possible reasons are discussed, specially the difficulty of applying the biopsychosocial model in medical
care and the difficulty of competing with the traditional biomedical concept of health, which has proved fruitful and dominant in medicine
over the past three centuries.
© 2003 Elsevier Ireland Ltd. All rights reserved.

Keywords: Biopsychosocial model; Biomedical model; Measuring health

1. Introduction In his classic papers, Engel [1,5] explicitly warned of

The traditional biomedical paradigm has its roots in the
Cartesian division between mind and body, and considers
disease primarily as a failure within the soma, resulting
from injury, infection, inheritance and the like. Although
this model has been extraordinarily productive for medicine,
its reductionistic character prevents it from adequately ac-
counting for all relevant medical aspects of health and illness
[1,2]. One of the most criticised consequences of adopting
the biomedical model is a partial definition of the concept
of health. If disease consists only of somatic pathology—
or, more strictly and according to the influential work of
Virchow [3], cellular pathology—health must be the state
in which somatic signs and symptoms are not present. Ac-
cording to this view, the World Health Organization defined
health simply as the “absence of disease” [4].
∗ Tel.: +34-950-015993; fax: +34-950-015471.
E-mail address: yalonso@ual.es (Y. Alonso).
a crisis in the biomedical paradigm and conceptualised a
new model which regards social and psychological aspects
as giving a better understanding of the illness process [6].
In recent years, the so-called biopsychosocial model has
found broad acceptance in some academic and institutional
domains, such as health education, health psychology, public
health or preventive medicine, and even in public opinion.
It is now generally accepted that illness and health are the
result of an interaction between biological, psychological
and social factors [7–9]. Many authors now include mental
and social aspects in their definitions of health [10–13].
It might be expected that, in the two decades since Engel’s
call for a biopsychosocial framework, the concept of health
implying social and psychological components would also
have extended to practical contexts. The purpose of the
present study is to find out whether and to what extent the
biopsychosocial concept of health has spread among medi-
cal researchers. With this aim, I reviewed articles published
in The Lancet between 1978 and 1982 and between 1996
and 2000 and compared the concept of health employed.

0738-3991/$ – see front matter © 2003 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/S0738-3991(03)00146-0
240 Y. Alonso / Patient Education and Counseling 53 (2004) 239–244
This journal was chosen because of its world-wide circula-
tion and because it publishes research articles in every field
of medicine. Generally, the study consisted of using Med-
line to select those empirical studies in which ‘health’ or
‘healthy status’ were reported as variables and identifying
how these terms were defined or measured. For a similar
study concerning nursing research, see Reynolds [14], and
Hwu et al. [15]. The expected result was a greater use of
the social and/or psychological dimensions of health in the
second revised period.
2. Materials and methods
By means of the database Medline, articles published
in The Lancet over the years 1978–1982 (period a) and
1996–2000 (period b) were examined. The first period cov-
ers the 5 years around the publication of Engel’s ideas and
the second one covers the last 5 years before the beginning
of the study, so an interval of 13 years, in which the biopsy-
chosocial model extended among health scientists, separates
the two studied periods. Search parameters comprised ei-
ther the word ‘health’ or ‘healthy’ appearing in the fields
abstract or title. From this first search, all empirical articles
using human adults as subjects were chosen, excluding stud-
ies carried out in less industrially-developed countries. The
reason for this exclusion was the different pattern of disease
in such populations (infectious disease, malnutrition), which
has not developed into the so-called civilisation disease pat-
tern. This change in the health of populations in modern
societies has been one of the most important factors chal-
lenging the biomedical paradigm [16]. Next, two types of
reports were selected: (a) those using ‘health’ as a depen-
dent or independent variable; and (b) those using subjects
characterised as ‘healthy’ or ‘having good health’ as partic-
ipants in controlled studies. From the latter, the following
were excluded:
• Studies whose healthy subjects were blood donors, since
health conditions for giving blood are specifically-deter-
mined by immunological and hematological criteria.
• Studies whose healthy subjects were assigned to control
groups to be compared with treatment groups of patients
suffering a specific illness. Since, in this case, the main
goal is to compare possible signs and symptoms of the
specific illness in both groups, it could be supposed that
the authors, in such a methodological context, understand
‘healthy’ as the absence of these specific signs and symp-
toms. Control groups that were compared to treatment
groups containing more than one clinical diagnosis, were
taken into account.
Finally, the resulting reports were carefully checked for
their operational definition of ‘health’ as a major variable or
‘healthy’ as a condition to take part in the studies. Possibil-
ities were that the definition:
• was present or absent;
• was direct, explicit and clear or, on the contrary, negative
or indirectly suggested;
• included parameters other than medical and/or physi-
cal (namely psychiatric, psychological, behavioural or
social).
3. Results
Three reports in period a and four in b assessed health as
a dependent variable (‘health’ studies). Reports considering
‘to be healthy’ or ‘having good health’ as a condition for
subjects to take part in studies numbered 29 in period a
and 16 in period b (‘healthy’ studies). Detailed information
about the 52 papers included in the study can be seen in
Tables 1 and 2.
3.1. Studies using ‘to be healthy’ or ‘having good health’
as condition (‘healthy’ studies)
None of the 45 reports considered defines this concept
in a clear form. Only one report (study 5 of Table 1) of-
fers an explicit, but unfortunately too vague, definition of
‘stable good health’, namely: ‘. . . a constant clinical state
acceptable to both patient and doctor’. Many papers (19 in
a, 65.5%; 3 in b, 19%) do not mention any characteristic of
people considered to be healthy. Ten studies in a and 11 in b
characterise healthy in an indirect way, namely by inclusion
or exclusion criteria for taking part in the control or treat-
ment groups. Of these, six in a (20.5%; studies 2, 5, 12, 16,
19 and 22 of Table 1) and 10 in b (62.5%; 30, 31, 32, 34,
36, 37, 39, 40, 44 and 45 of Table 1) use general medical
criteria (e.g. not having relevant serious illness); and four
reports in a (14%; 17, 23, 28 and 29 of Table 1) and three
in b (19%; 33, 41 and 43 of Table 1) use specific criteria re-
lated to the specific disease they were researching (e.g. not
having gastrointestinal disease) (Fig. 1).
Some studies (five in a, 17%, five in b, 31%; 7, 8, 10, 19,
21, 30, 33, 37, 43 and 44 of Table 1) include behavioural fac-
tors such as taking alcohol or drugs or smoking cigarettes,
and two reports in b (12.5%; 30 and 40 of Table 1) even in-
clude functional data (doing exercise). However, these mea-
sures are related to the direct influence of such substances
or activity on the treatment in question, in the same way
as taking any medication, and cannot be understood as be-
havioural criteria for considering someone healthy.
Only three studies (two in a, 7%, one in b, 6%; studies
2, 22 and 45 of Table 1) consider also psychological cri-
teria. In addition to several medical, chemical and physical
tests, the first study includes psychological examination, al-
though the authors do not specify what kind. Study 22 con-
siders psychopathological disease and alcoholism as exclu-
sion criteria. This paper deserves special comment, since
the authors consider people with high coronary health risk
(e.g. ischæmic exercise ECG) as healthy. Study 45 (period
 Y. Alonso / Patient Education and Counseling 53 (2004) 239–244
Table 1
Studies including ‘healthy’ subjects as participants in controlled studies published in The Lancet within 1978–1982 (period a) and 1996–2000 (period b)
Study
Period a
1. Cummings et al. 1978 Jan 7; 1(8054): 5–9
2. Levine et al. 1978 May 27; 1(8074): 1119–22
3. Hsueh et al. 1978 Jun 17; 1(8077): 1281–4
4. Mahley et al. 1978 Oct 14; 2(8094): 807–9
5. O’Donoghe et al. 1978 Nov 4; 2(8097): 955–7
6. Low-Beer & Nutter 1978 Nov 18; 2(8099): 1063–5
7. Vermylen et al. 1979 Mar 10; 1(8115): 518–20
8. Holt et al. 1979 Mar 24; 1(8117): 636–9
9. Jenkins et al. 1979 Nov 3; 2(8149): 924–7
10. Peters et al. 1979 Nov 3; 2(8149): 933–6
11. Abramsky et al. 1979 Dec 22; 2(8156): 1333–5
12. Horowitz et al. 1980 Jan 12; 1(8159): 60–1
13. Rem et al. 1980 Feb 9; 1(8163): 283–4
14. Siess et al. 1980 Mar 1; 1(8166): 441–4
15. Blackburn et al. 1980 May 10; 1(8176): 987–9
16. Keen et al. 1980 Aug 23; 2(8191): 398–40
17. Hoftiezer et al. 1980 Sep 20; 2(8195): 609–12
18. Harron et al. 1981 Feb 14; 1(8216); 351–3
19. Tyler et al. 1981 Mar 21; 1(8221): 629–32
20. Nicholson et al. 1981 Oct 24; 2(8252): 915–8
21. Thorngren & Gustafson 1981 Nov 28; 2(8257): 1190–3 Eicosapentaenoic acid/platelet aggregation
22. Hjermann et al. 1981 Dec 12; 2(8259): 1303–10
23. Milton-Thompson et al. 1982 May 15; 1(8281): 1091–5 Cimetidine/intragastric bacteria & others
24. Hintz et al. 1982 Jun 5; 1(9294): 1276–9
25. Morris et al. 1982 Jun 5; 1(8284): 1294–7
26. Shearer et al. 1982 Aug 28; 2(8296): 460–3
27. Mannucci & Vigano 1982 Aug 28; 2(8296): 463–7
28. McMahon et al. 1982 Nov 13; 2(8307): 1059–61
29. Khaw & Thom 1982 Nov 20; 2(8308): 1127–9
Period b
30. Heinonen et al. 1996 Nov 16; 348(9038): 1343–7
31. Churchill et al. 1997 Jan 4; 349(9044): 7–10
32. Ridker et al. 1997 Feb 8; 349(9049): 385–8
33. Jansen et al. 1997 Feb 22; 349(9051): 528–32
34. Tingle et al. 1997 May 3; 349(9061): 1277–81
35. Molloy et al. 1997 May 31; 349(9065): 1591–3
Measured variables
Dietary fibre/faecal weight
Administration of E. Coli/enterotoxin production Medical history, physical
Sodium intake/big renin in plasma
Cholesterol intake/HDL-binding activity
Azathioprine/Crohn’s disease
Bacterial activity/biliary cholesterol saturation Not defined
Antithrombotic drug/prostacyclin release
Gel fibre/gastric emptying & others
Guar and acarbose intake/postprandial glycaemia Not defined
Oral contraceptives/platelet aggregation
Amniotic fluid extraction
Phenilpropanolamine/hypertension
Epidural analgesia/posoperative lymphopenia
Mackerel diet/platelet aggregation & others
Neurotensin/gastric function
Reactions to human insulin
Aspirin/gastroduodenal mucosa
Alinidine/heart-rate
UK-37,248-01/thromboxane concentrations
Rabies vaccine/antibody production
Diet and smoking/coronary heart-disease
Synthetic growth hormone/triglycerides & others Not defined
Illness caused by V. damsela & others
Vitamin K1 in mothers and babies
Protein C levels
Potassium chloride/gastrointestinal lesions
Potassium/blood pressure
High-impact exercise/osteoporosis
Blood presure in pregnancy/fetal growth
PIA1-A2 polymorphism/cardiovascular risks
Hydroquinine/muscle cramps
Rubella-virus vaccine/arthralgia & others
C677T genotype/red-cell folate
241
Inclusion criteria for healthy
participants
Not defined
examination, blood and urin analysis
& others. Psychological examination
Not defined
Not defined
Having good health: constant
clinical state acceptable to both
patient and doctor
Not defined. No taking drugs 2
weeks before
Not defined. No drugs nor smoking
during test
Not defined. No drugs, non-smokers
Not defined
No heart-disease, asthma & others,
no treatment with antidepressant or
sympathomimetic drugs
Not defined
Not defined
Not defined
No history of major metabolic
illnes, allergy & others
No history of gastrointestinal
illness, physical examination,
laboratory tests
Not defined
No clinically relevant disease, no
history of asthma, allergy & others,
non-smokers
Not defined
Not defined. Non-smokers, no
taking drugs
Cardiovascular measures, no
diabetes, cancer and others. No
psychopathological disease
No history of peptic ulcer disease
Not defined
Not defined
Not defined
No gastrointestinal disease
No hypertension
No cardiovascular & other cronic
disease, mestrual irregularities, no
smoking, no obesity
No hipertension, diabetes, renal
disease & others
No history of cardiovascular disease
or cancer
No history of alcohol or drugs, no
allergy to hydroquinine & others
No contraindications for rubella
vaccine, no serious illnes or inmune
deficiency
Not defined
242 Y. Alonso / Patient Education and Counseling 53 (2004) 239–244

Table 1 (Continued )
Study Measured variables Inclusion criteria for healthy
participants
36. Ridker et al. 1998 Jan 10; 351(9096): 88–92 ICAM-1 concentration/myocardial infarction No history of cardiovascular disease
or cancer
37. Suhara et al. 1998 Jan 31; 351(9099): 332–5 Lung as reservoir for antidepressants No relevant medical history, no
history of drugs or alcohol
38. Kerrigan et al. 1998 May 9; 351(9113): 1399–401 High-heeled shoes/knee osteoarthritis Not defined
39. Powles et al. 1998 Jul 11; 352(9122): 98–101 Tamoxifen/incidence of breast cancer No history of cancer, thrombosis or
embolism, no evidence of breast
cancer
40. Eriksen et al. 1998 Sep 5; 352(9130): 759–62 Physical fitness/mortality No heart or metabolic disease, no
other serious disorders
41. Anonymous 1999 Feb 27; 353(9154): 679–702 Doses of mifepristone contraceptive Regular menstrual cycles
42. Street et al. 1999 Oct 2; 354(9185): 1178–9 Tropheryma whippelli DNA in saliva Not defined
43. Gamero et al. 2000 Mar 11; 355(9207): 898–9 Insulin-like growth factor 1/osteoporosis No disease or treatment influencing
in bone metabolism
44. Maccarrone et al. 2000 Apr 15; 355(9212): 1326–9 Anandamine hydrolase/miscarriage No chronic disease, no history of
miscarriage, no smoking more than
20 per day & others
45. Garde et al. 2000 Aug 19; 356(9230): 628–34 White-matter hyperintensities/decline in Medical and psychological
intelligence assessment

Table 2
Studies using ‘health’ as dependent variable published in The Lancet within 1978–1982 (period a) and 1996–2000 (period b)
Study Independent variable Measured health

Period a
1. Coakley & Woodford-W. 1979 Nov 17; 2(8151): 1066–7 Have being victim of vandalism Includes psychological aspects
2. Cockburn et al. 1982 Mar 20; 1(8273): 647–9 Hypertension during pregnancy Includes psychological and behavioral aspects
3. Cook et al. 1982 Jun 5; 1(8284): 1290–4 Unemployement Includes psychological aspects
Period b
4. Vahtera et al. 1997 Oct 18; 350(9085): 1124–8 Organisational downsizing Equivalent to sick leave
5. Unwin et al. 1999 Jan 16; 353(9148): 169–78 Serving in Gulf War Includes psychological aspects
6. Jenkinson et al. 1999 Jun 19; 353(9170): 2100–5 Obstructive sleep apnoea Includes psychological and social aspects
7. Hitt et al. 1999 Aug 21; 354(9179): 652 Centenarian age Includes psychological and social aspects

Fig. 1. Percentage of studies including healthy subjects in control or treatment groups according to their used health criteria.
 Y. Alonso / Patient Education and Counseling 53 (2004) 239–244
b) includes psychological assessment together with medical
assessment. These authors offer as well an interesting con-
ception of health: they consider any octogenarian suffering
neurological, mental or other functional impairing disorder
as healthy.
3.2. Studies using ‘health’ as dependent variable
(‘health’ studies)
Just as in the ‘healthy’ studies, none of the seven reports
incorporating health as a dependent variable gives an ex-
plicit or direct definition of it. However, the results are dras-
tically different from the previous search. Despite the lack
of definition, all of these seven reports incorporate social
or psychological factors in their conception of health. Four
of them (studies 1, 3, 4 and 5 of Table 2) are approaches
to health questions from a social perspective. Studies 1, 3
and 5 include psychological dimensions in their measures of
health. Study 4 measures health negatively as absenteeism
because of ill health, which surely includes sick leave due
to psychological symptoms.
Two other studies include psychological and behavioural
(study 2 of Table 2) or psychological and social dimen-
sions (study 6 of Table 2). The remaining report (study 7
of Table 2) considers functional capacities among its health
measures, which are an indirect indicator of psychosocial
well-being (e.g. functional independence).
Concerning the main question of the present study, no dif-
ference in the concept of health was found between periods
a and b.
4. Discussion and conclusions
4.1. Changes in the concept of health
Contrary to expectations, findings show no change in the
conceptualization of health in medical research articles writ-
ten 20 years ago and now. This result differs from the study
by Hwu et al. [15], who found a significant increase in the
number of papers on nursing research that included psycho-
logical and social dimensions in their operational definition
of health, when comparing publication years 1977–1987 and
1988–1998. A holistic conception of health seems to be
more prevalent among nursing professionals, who have to
deal with the ill person as a whole and take responsibility
for the patient’s general well-being. Physicians, in contrast,
have traditionally dealt with the ill part of the patient [1,17],
which means focussing on the medically relevant symptoms
and on following medical treatment.
The results show clearly that the number of papers re-
garding psychological or social measures did not increase.
‘Health’ papers included psychological dimensions in every
case, and social dimensions were included in one case of
three in period a and in two cases of four in b. No greater
number of medical researchers now use a holistic concept
243
of health than 20 years ago. One could conclude that the
spreading of the biopsychosocial model in other contexts
has not been substantially reflected in the practical areas of
medicine.
The only change found between the two periods studied
is the increasing number of papers defining their criteria of
health at all. This may reflect an increasing awareness or
concern about the question of what health is. Nevertheless,
no one author offers an operative and/or positive definition.
Healthy subjects are mostly selected by exclusion of one or
more somatic signs and symptoms, which fully agree with
the biomedical consideration of health as the absence of
illness. As pointed out in the results, only one report makes
use of a positive definition, but unfortunately this definition
is not replicable from a methodological point of view. A
more restrictive use of the term ‘health’ would be desirable
by using nuances such as ‘apparently healthy’ or diagnostic
paraphrases like ‘not suffering disease x’.
In western culture, at least since the advent of Cartesian
dualism, medicine has used a mechanistic approach to hu-
man nature and has centred its interest around illness and its
signs. In my opinion, the results of this study are an accu-
rate reflection of this position. Based on this assumption, it
can be concluded that the main reason for the failure of psy-
chological and social measures in the reports examined lies
in the still deep-rooted dominance of the biomedical model
which, despite the criticism of its reductionism, remains use-
ful and still enables advances in medicine. This dominance
has surely been reinforced in recent years because of the
push of genetic research and therapies. Perhaps, holistic and
biological-reductionistic models should not compete but try
to coexist, as two different but not necessarily incompati-
ble possibilities for approaching health questions. The result
would be, however, a reduction of biomedical terrain. First,
clinical and health psychology have demonstrated their ca-
pacity to explain and treat many somatic symptoms. Second,
some holistic medical models—such as Traditional Chinese
Medicine or Hanneman’s homeopathy—are gaining ground
because of patients who do not find satisfactory solutions in
biomedical care. Third, biomedical care implies enormous
and rapidly-rising costs that are beginning to exceed the bud-
get of the health care systems.
4.2. Practice implications
The biopsychosocial model has been successfully applied
to obtain a better understanding of the disease processes
and their causes [18], and also for public health purposes
[19,20], or to improve physician–patient relations [21,22],
but medical practitioners are still reluctant to incorporate
it into treatment plans [16]. Holistic approaches remain till
now restricted to chronic illness management [23], which
is the field of medical care where regaining health, in a
biomedical sense, is not the main goal.
For the medical practitioner, the difficulties attached to
the change from a biomedical to a biopsychosocial model
 244 Y. Alonso / Patient Education and Counseling 53 (2004) 239–244
of health can be well understood. First, this change neces-
sarily implies taking into account a much wider spectrum
of the factors influencing health and the healing process,
which in turn demands greater knowledge and time invest-
ment. Second, the new paradigm implies a new style of the
patient–doctor relationship, a style which enables, among
other things, the doctor’s attention to the patient’s psychoso-
cial circumstances, in order to better manage his or her situ-
ation, and not only his or her illness. Undoubtedly, this kind
of interaction requires a greater effort from practitioners, but
also from the health care systems, which should provide the
necessary context and resources for it, such as communica-
tion skills training, adequate settings, or enough personnel.
Despite these hindrances, which will probably continue
to relegate the biopsychosocial model to a secondary place
in medical practice, the broadening of the doctor’s perspec-
tive to encompass psychological and social aspects would be
really beneficial for the patient, since as Engel [24] lucidly
pointed out, even though both patient and doctor may cul-
turally adhere to the biomedical model, the patient’s needs
and ultimate criteria are always psychosocial.
References
[1] Engel GL. The need for a new medical model: a challenge for
biomedicine. Science 1977;196:129–36.
[2] McWinney IR. Are we on the brink of a major transformation in
clinical method? CMAJ 1986;135:873–8.
[3] Virchow R. Die Cellularpathologie in ihrer Begrundung auf phys-
iologische und pathologische Gebewelehre. Berlin: A. Hirschwald;
1858.
[4] WHO. The first ten years of the World Health Organisation. Geneva:
World Health Organisation; 1958.
[5] Engel GL. A unified concept of health and disease. Perspect Biol
Med 1960;3:445–59.
[6] Engel GL. The clinical application of the biopsychosocial model.
Am J Psychiatr 1980;137:535–44.
[7] Leigh H, Reiser MF. The patient. Biological, psychological and social
dimension of medical practice. New York: Plenum Press; 1980.
View publication stats
[8] Matarazzo JD, Weiss SM, Herd JA, Miller NE, Weiss SM, editors.
Behavioral health. A handbook of health enhancement and disease
prevention. New York: Wiley; 1984.
[9] Sarafino EP. Health psychology. Biopsychosocial interactions. New
York: Wiley; 1994.
[10] WHO. Health education. A programme review. Geneva: World Health
Organisation; 1974.
[11] Stokes J, Noren J, Shindell S. Definitions of terms and concepts ap-
plicables to clinical preventive medicine. J Comm Health 1982;8:33–
41.
[12] Seeman J. Toward a model of positive health. Am Psychol
1989;44:1099–109.
[13] Ribes E. Psicologı́a y salud: un análisis conceptual (health psychol-
ogy: a conceptual analysis) Barcelona: Martı́nez Roca; 1990.
[14] Reynolds CL. The measurement of health in nursing research. Adv
Nurs Sci 1988;10:23–31.
[15] Hwu Y, Coates VE, Boore JRP. The evolving concept of health in
nursing research: 1988–1998. Patient Educ Couns 2001;42:105–14.
[16] Arnetz BB. Causes of change in the health of populations: a biopsy-
chosocial viewpoint. Soc Sci Med 1996;43:605–60 (health concepts
and nursing).
[17] Gil Roales-Nieto J. Conceptos de salud y enfermedad. In: Blanco
Coronado JL, editor. Impacto medioambiental en la salud. Granada:
Némesis; 2000. p. 1–21.
[18] Matarazzo JD, Leckliter IN. Behavioral health: the role of good and
bad habits in health and illness. In: Maes S, Spielberger CD, Defares
PB, Sarason IG, editors. Topics in health psychology. Chichester:
Wiley; 1988. p. 3–18.
[19] Elola J, Daponte A, Navarro V. Health indicators and the organization
of health care in western Europe. Am J Publ Health 1995;85:1397–
401.
[20] Huyse FJ, Lyons JS, Stiefel FC, Slaets JPP, de Jonge P, et al.
“Intermed”: a method to assess health service needs. Gen Hosp
Psychiatr 1999;21:39–48.
[21] Yamada S, Green G, Bauman K, Maskarinec G. A biopsychosocial
approach to finding common ground in the clinical encounter. Acad
Med 2000;75:643–8.
[22] Mead N, Bower P. Patient-centredness: a conceptual framework and
review of the empirical literature. Soc Sci Med 2000;51:1087–110.
[23] Main CJ, Richards HL, Fortune DG. Why to put old wine in new
bottles: the need for a biopsychosocial approach to the assessement,
treatment, and understanding of unexplained and explained symptoms
in medicine. J Psychosomat Res 2000;48:511–4.
[24] Engel GL. The biopsychosocial model and the education of health
professionals. Ann N Y Acad Sci 1978;310:169–81.