J Relig Health (2019) 58:628–638

https://doi.org/10.1007/s10943-018-0619-x

ORIGINAL PAPER

Religiosity and Physician Lifestyle from a Family Health

Strategy

Guilherme Ramos Sens1 • Gina Andrade Abdala1 •

Maria Dyrce Dias Meira1 • Silvana Bueno2 • Harold G. Koenig3

Published online: 21 April 2018

Ó Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract This study examines the association between religiosity and physician lifestyle
from a Family Health Strategy perspective. This is a cross-sectional study with 30
physicians, who completed the religiosity and lifestyle questionnaires. Among the par-
ticipants, 70% (n = 21) had no ‘‘focus’’ on spirituality and health. The average total
lifestyle score was 74.1 (SD = 8.1), but the ‘‘Physical Activity’’ subscale score was below
average (3.4, SD = 2.37). We found eight significant correlations between religiosity and
lifestyle subscales (p \ 0.05). Greater religious involvement is associated with better
overall and specific areas of physician lifestyle.

Keywords Spirituality
Religion
Integrality
Health promotion
Lifestyle

& Gina Andrade Abdala

[email protected]
Guilherme Ramos Sens
[email protected]
Maria Dyrce Dias Meira
[email protected]
Silvana Bueno
[email protected]
Harold G. Koenig
[email protected]
1
Adventist University of Sao Paulo, São Paulo, Brazil
2
SENAI, Joinville, Santa Catarina, Brazil
3
Center for Spirituality, Theology and Health, Duke University Medical Center, Durham, NC 27503,
USA

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Introduction

There has been an increasing number of publications indicating the influence of reli-
giousness/spirituality (R/S) on physical and mental health over the past five decades
(Lucchetti et al. 2011; Koenig et al. 2012; Gonçalves and Bellodi 2012; Koenig 2015,
Abdala et al. 2015a, b; Saleem and Saleem 2017). The subject is still undervalued in the
medical environment, probably due to a lack of academic preparation (Lucchetti et al.
2013; Borges et al. 2013). In addition, there is a belief that this is not the physician’s role in
clinical care (Lucchetti et al. 2010; McCormick 2014).
According to Koenig (2012, p. 11–13, 2015), religiosity is understood as: ‘‘a system of
beliefs, practices and symbols developed to facilitate closeness to the sacred or the tran-
scendent.’’ It can be estimated by the measuring affiliation, religious attitudes and expe-
riences, commitment, attendance to services, prayer or meditation. Spirituality, on the
other hand, is characterized as the ‘‘relation with the sacred or the transcendent (God,
superior power, ultimate reality)’’ and may or not be linked to a certain religion or prac-
tices. It includes positive experiences and personality traits, which reflect mental and social
health more than spirituality itself.
It is recommended that the term ‘‘religiosity’’ be used for research purposes, and
‘‘spirituality’’ for clinical applications. When conducting research, specific terms should be
used, while clinical interventions allow wider and more inclusive terms like spirituality.
Therefore, as religiosity is more specific, it is often used to assess relationships with health
(rather than spirituality) (Koenig et al. 2012; Koenig 2015).
In order to broaden the discussion, some researchers have examined the association
between R/S and lifestyle, defined as a ‘‘typical style or way of living that characterizes an
individual or group’’ (BVS 2017). The World Health Organization (WHO) indicates that
the lifestyle construct is a collection of habits and decisions that will influence health and
quality of life (World Health Organization, 2004, p. 37). Thus, in this study, we hypoth-
esized that there is an association between religiosity and lifestyle and that, the knowledge
resulting from this research might motivate a reflection on the need of religiosity/spiri-
tuality attention as a part of patient care.
The objective of this study was to analyze the association between religiosity and
lifestyle of physicians working in a regional Family Health Center (FHC) in Sao Paulo,
Brazil.

Method

This was a cross-sectional study with quantitative approach. The research presented in this
article is part of a larger study entitled ‘‘Perception of the Health Professionals at a Family
Health Center, regarding Spiritual Assistance to Users’’ supported by the Brazilian
Research Committee. The guidelines of the Declaration of Helsinki (World Medical
Association 2000) and the legislation of Resolution 466/12 of the National Health Council
(CNS) (Brazil 2013) were followed. This study was authorized by the Ethics Committee of
the Adventist University Center of Sao Paulo—CEP/UNASP-SP on 03/10/2014 (Protocol:
688.878) and also by the Research Ethics Committee of the Municipal Health Department
of the Municipality of Sao Paulo CEP/SMS on 03/31/2014 (Protocol: 818.071).
The study involved 30 doctors who are part of a regional family health center (FHC)
team in the South Zone of the city of Sao Paulo, Brazil. Inclusion criteria were: being

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active in the FHC; accepting to participate in all stages of the research, signing the
informed consent form (ICF) and completing the appropriate instruments used for data
collection. The socio-demographic data questionnaire was used, which also included
questions about the presence of religiosity discussions during the formative process; if
there was spiritual training in the work environment as well as The Duke Religious Index
(DUREL) and the FANTASTIC Lifestyle questionnaire.
The Duke Religious Index (DUREL) instrument contains five questions covering three
subscales, namely (1) Organizational Religious Activity (ORA): attendance at religious
meetings; (2) Non-Organizational Religious Activity (NORA): frequency of private reli-
gious activities; (3) Intrinsic Religiosity (IR): refers to the search for internalization and the
full experience of religiosity as the main objective of the individual, which contains three
questions classified as IR 1, IR 2 and IR 3. The lower the score achieved in each subscale,
the better the participant’s religiosity index. This instrument was created by Koenig in the
University of Duke, North Caroline (Koenig and Büssing 2010) and validated in Brazil by
Taunay et al. (2012).
Lifestyle was analyzed through the FANTASTIC questionnaire that seeks to identify the
behavior of individuals in the last 30 days. It encompasses 25 questions divided into nine
subscales, namely: (1) family and friends; (2) physical activity; (3) nutrition; (4) cigarettes
and drugs; (5) alcohol; (6) sleep, seatbelt, stress and safe sex; (7) type of behavior; (8)
insight and (9) career. This questionnaire was created in Canada in 1984 and validated in
Brazil by Rodriguez-Añez et al. (2008).
The sum of all points of the FANTASTIC questionnaire classifies the individuals into
five categories: ‘‘Excellent’’ (85–100 points); ‘‘Very good’’ (70–84 points); ‘‘Good’’
(55–69 points); ‘‘Regular’’ (35–54 points) and ‘‘Needs improvement’’ (0–34 points).
The data were collected from June to August 2014. As the sample consisted of 30
physicians, the normality of the data was previously tested using the Shapiro–Wilk test,
which showed that they did not present a normal distribution. Therefore, the Spearman
correlation test was performed, adopting a p \ 0.05 to be considered statistically
significant.

Results

Of the 30 physicians participating in the study, 17 (56.7%) were female, with an average of
38 years (± 10.65), 12 professionals (40%) are evangelicals, nine Catholics (30%), and six
have no religion (20%). Three of them did not respond (10%). The majority (70%) did not
discuss spirituality and health in their academic formation, nor had any training in their
work environment (for 86.7% of them) (Table 1).
Scores on the Duke Religion Index (DUREL) indicated that 36.7% attended religious
services once/week or more and 66.6% had a regular habit of praying and meditating once
a day. In the three questions of Intrinsic Religiosity (IR 1, IR 2, IR 3) 90, 83.3 and 73.3%,
respectively, indicated ‘‘definitely true’’ plus ‘‘tends to be true’’ (Table 2).
The internal reliability test of the subscale of religiousness (IR 1–IR 3) was measured by
calculating Cronbach’s alpha of 0.935, which is considered excellent.
According to FANTASTIC, the lifestyle reached a total score of 74.1 (sd = 8.1), with
61.9% ‘‘very good,’’ 23.8% ‘‘good’’ and 9.52% ‘‘excellent.’’ As for the internal reliability
test of the FANTASTIC questionnaire, a Cronbach’s alpha of 0.736 was considered very
good.

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Table 1 Characteristics of physicians from the PSF health professionals, Capao Redondo (N = 30),
according to absolute and relative frequencies. Sao Paulo, Brazil, 2016
Variable N %

Sex (n = 30)
Female 17 56.7
Male 13 43.3
Religion (n = 29)
Evangelicals 12 40.0
Catholic 9 30.0
Others (Buddhist, agnostic, spiritualist, Christian) 1 3.3
Spiritist 1 3.3
None 6 20.0
Practitioner (n = 29)
Yes 18 60.0
No 12 40.0
Number of physicians, according to the type of medicine school
where they had graduate (n = 30)
Confessional 6 20.0
Secular 24 80.0
How long did you graduate? (n = 29)
0–3 years 9 31
3.1–5 years 2 6.9
5.1–10 years 7 24.1
More than 10 years 11 37.9
Did you receive focus on Spirituality in your graduation? (n = 30)
Yes 9 30.0
No 21 70.0
Did you receive training about spirituality after your graduation? (n = 30)
Yes 4 13.3
No 26 86.7
Did you participate in the training? (n = 30)
Yes 4 13.3
No 26 86.7

When analyzing FANTASTIC by subscale, in this study, it was emphasized that the
‘‘physical activity’’ subscale (n = 30) was 3.4 (± 2.37, 0–8), being below the average in
relation to the other subscales (Table 3).
In the Spearman correlation test between the ordinal subscales of religiosity and the
quantitative subscales of the ‘‘FANTASTIC’’ lifestyle, eight significant moderate corre-
lations were found. They were: ORA and ‘‘Insight’’; ORA and IR 1 and ‘‘Career’’; IR 2 and
‘‘Family and Friends.’’ There were also inverse associations, statistically significant
between ORA, NORA, IR 3 and ‘‘Alcohol,’’ as well as between IR 2 and ‘‘Physical
Activities’’ (Table 4).

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Table 2 Frequencies for reli-

Category N %
gion variables. Sao Paulo, Brazil,
2016
ORA (n = 30) More than once/week 3 10.0
Once a week 8 26.7
A few times a month 3 10.0
A few times a year 8 26.7
Once a year or less 2 6.7
Never 6 20.0
NORA (n = 30) More than once a day 7 23.3
Daily 13 43.3
Two or more times/week 5 16.7
A few times a month 2 6.7
Rarely or never 3 10.0
IR 1 (n = 30) Definitely true of me 21 70.0
Tends to be true 6 20.0
Unsure 1 3.3
Tends not to be true 1 3.3
Definitely not true 1 3.3
IR 2 (n = 30) Definitely true of me 16 53.3
Tends to be true 9 30.0
Unsure 1 3.3
Tends not to be true 1 3.3
ORA Organizational Religious
Activity, NORA Non- Definitely not true 3 10.0
Organizational Religious IR 3 (n = 30) Definitely true of me 12 40.0
Activity, IR 1 I feel the presence Tends to be true 10 33.3
of God or the Holy Spirit in my
life, IR 2 my believes are behind Unsure 1 3.3
of my way of life, IR 3 I strive to Tends not to be true 2 6.7
live my religion in all aspects of Definitely not true 5 16.7
life

Table 3 Descriptive analysis of the ‘‘FANTASTIC’’ subscales and total score. Sao Paulo, Brazil, 2016
Variables/subscale Mean Median Standard deviation Min Max

Family and friends (N = 29) 6.8 7.0 1.36 4 8

Activities (N = 30) 3.4 3.0 2.37 0 8
Nutrition (N = 30) 7.8 8.0 2.50 2 12
Tobacco and drugs (N = 29) 14.6 15.0 1.15 12 16
Alcohol (N = 28) 11.4 12.0 1.07 8 12
Sleep/seat belt/stress/sex (N = 28) 16.0 16.0 2.44 8 20
Type of behavior (N = 30) 4.4 4.0 1.87 1 8
Insight (N = 30) 8.5 9.0 2.24 3 12
Career (N = 27) 3.0 3.0 0.96 1 4
FANTASTIC total score (N = 21) 74.1 77.0 8.07 54 85

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Table 4 Spearman Correlation between the Life Style FANTASTIC and religiosity subscales (without
reversing the score). Sao Paulo, Brazil, 2016
Lifestyle fantastic subscales Religiosity ORA NORA IR 1 IR 2 IR 3
subscales

Family and friends (N = 26) R 0.085 0.160 0.371 0.393 0.284

p value 0.681 0.435 0.062 0.047* 0.160
Activities (N = 27) R - 0.080 - 0.371 - 0.235 - 0.419 - 0.286
p value 0.693 0.056 0.239 0.030* 0.148
Nutrition (N = 27) R 0.016 0.010 0.161 0.003 0.198
p value 0.938 0.960 0.422 0.986 0.322
Tobacco/toxics (N = 26) R - 0.364 - 0.164 - 0.182 - 0.111 - 0.155
p value 0.068 0.423 0.373 0.588 0.450
Alcohol (N = 25) R - 0.424 - 0.637 - 0.288 - 0.386 - 0.537
p value 0.035* 0.001* 0.162 0.057 0.006*
Sleep, seat belt, stress, safe R 0.143 - 0.044 0.131 - 0.121 - 0.071
sex (N = 25) p value 0.497 0.836 0.531 0.565 0.737
Type of behavior (N = 27) R 0.274 0.257 0.199 0.090 - 0.018
p value 0.167 0.196 0.320 0.655 0.929
Insight (N = 27) R 0.416 0.274 0.211 0.095 0.073
p value 0.031* 0.166 0.292 0.636 0.719
Career (N = 24) R 0.532 0.247 0.459 0.237 0.238
p value 0.007* 0.245 0.024* 0.266 0.262
FANTASTIC total score R 0.294 0.147 0.263 0.254 0.077
(N = 21) p value 0.237 0.562 0.292 0.309 0.762
ORA Organizational Religious Activity, NORA Non-Organizational Religious Activity, IR 1 I feel the
presence of God or the Holy Spirit in my life, IR 2 my believes are behind of my way of life, IR 3 I strive to
live my religion in all aspects of life
*Statistically significant at p \ 0.05

Discussion

The majority of participants in our study were women (56.7%), with an average of
38 years. In Brazil, among doctors, men are still the majority, 57.5% (Scheffer 2015), but
there is a trend toward increasing the number of female physicians in medicine.
As for religion, we observed that 20% of the doctors, participants of this study, have no
religion, reaching more than twice the general population, that is 8.1% (Brazil 2010).
According to a sample of 11.7% of all Brazilian doctors, 62.9% considered themselves
Catholics, 13.6% without religion, 11.5% Spiritist, 7.3% Protestant and 4.7% of other
denominations (Barbosa et al. 2007).
The Federal Medical Council reports that 43.8% of physicians surveyed declare
themselves to be very or totally religious, compared to 30% as not at all or little religious
(Barbosa et al. 2007). In another study (Santos 2013), it was found that 65% of physicians
were very or moderately religious.
In a more detailed study in Brazil, ‘‘New Map of Religions,’’ researchers from the
Center for Social Policy of the Getúlio Vargas Foundation, found that the frequency in

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attending religious services in the country is 50% higher in women and in the elderly (Neri
2011).
Regarding the absence of the R/S approach during the training process, a study that
analyzed the curriculum of 86 of the 180 Brazilian medical schools found that only 10.4%
of these schools offer classes on this topic; 40.5% had some content about spirituality and
health; only two medical schools had practical training, and three included in the cur-
riculum. The majority (54%) of the coordinators of medical courses believe that it is
important to teach R/S and health in their schools (Lucchetti et al. 2012).
Souza (2008) mentions that 47 medical schools in the USA, including the Harvard
Medical School, have included R/S in their curriculum. However, Lucchetti (2010) says
that this number is even higher, reaching 100 American medical schools and 59% British
ones.
Fonseca et al. (2014), in a review article, analyzing references in large databases
indexed on R/S in undergraduate medical courses between 2006 and 2012, found seven
articles exclusively related to the inclusion of R/S theme in the training of physicians, six
in the USA and one from the UK. This is also true for 85.9% of 1.400 medical students in
Vienna, who would consider talking with their patients about religious/spiritual issues if
they wish to do so (Rassoulian et al. 2016).
Data from an anonymous survey enrolling 237 medical doctors from Germany reported
that ‘‘physicians with a spiritual attitude would see illness also as a chance for an individual
development and associated with a biographical meaning rather than just a useless inter-
ruption of life’’ (Büssing et al. 2013, p. 8,9).
The results of the DUREL: ORA, NORA and IR, revealed higher scores on all
dimensions when compared to the study by Santos (2013). His study involved 37 Brazilian
pediatricians who indicated ORA, attending ‘‘once per week or more’’ to be only 10.8%;
‘‘a few times a year’’ 45.9% and never 8.1%. For NORA, their practice of private religious
activities ‘‘more than once a day’’ was 43.2% and ‘‘rarely or never’’ was 13.5%.
As for Intrinsic Religiosity (IR), which evaluates whether one is sincerely committed to
a faith tradition, the studies of Fonseca et al. (2014) and Santos (2013), found that,
experiencing the presence of God or the Holy Spirit was answered ‘‘totally true’’ and at
least ‘‘somewhat true’’ 66 and 73% of the time, respectively, and ‘‘somewhat not true or
completely not true’’ 14 and 5.4% of the time, respectively; in IR 2—my beliefs are behind
my way of life, they answered ‘‘totally true’’ 69 and 81%, respectively, and ‘‘not true’’ 23
and 2.7%. In the IR 3—I strive to live my religion in all aspects of life, 63 and 73%
answered ‘‘totally true’’ and 26 and 8.1% ‘‘not true.’’
According to FANTASTIC, in the present study, a very good overall score
(74.08 ± 8.1) was found, but with deficiencies in the ‘‘physical activities’’ subscale
(3.4 ± 2.37; 0 - 8), this being below the average in relation to the other subscales.
When evaluating the lifestyle and stress levels in medical students of a private
University in Vitoria, Espı́rito Santo State—Brazil, the authors classified the general score
of the questionnaire ‘‘FANTASTIC’’ as good (Group 2—students from the 5th to 8th
semester, with 69.2 points) or very good (Group 1—1st to 4th semester, with 72.1 points,
and Group 3—9th to 12th semester, with 71.3 points) (Barbosa et al. 2015).
In a study of 1224 medical graduates from the State University of Sao Paulo (UNESP)
in Botucatu, Sao Paulo—Brazil, from 1968 to 2005, using self-administered questionnaires
with questions that sought to evaluate aspects of quality of life, physical health and mental
health, similar results were identified (adding the ‘‘good and very good’’ answers) with
67.8, 78.8 and 84.5%, respectively (Torres et al. 2011).

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In a Portuguese study, conducted with 707 college students, aged 18–20 years, health
volunteers, the total lifestyle score was 94.1 (± 10.5) points (‘‘very good,’’ in this adapted
scale that goes up to 120 points). No participants had scores below 46 points, 29 partic-
ipants (4.1%) had a ‘‘Regular’’ rating, 94 participants (13.3%) ‘‘good,’’ 434 participants
(61.4%) ‘‘very good’’ and 150 participants (21.2%) ‘‘excellent’’ (Silva et al. 2014).
As for the ‘‘activities’’ subscale that was below average in our study, similarities were
also found in the study with 482 medical students evaluated by the ‘‘FANTASTIC’’
questionnaire, whose averages were 3.2 (Group 1, students from the 1st to 4th semester);
2.8 (Group 2, 5th to 8th semester) and 3.1 (Group 3, 9th to 12th semester) (Barbosa et al.
2015).
This was also the study of 29 medical professionals from a Family Health Care Center,
whose average was 2.93 in the subscale ‘‘physical activities’’ (Silva et al. 2016).
When investigating the health of 324 medical students in Juiz de Fora, Minas Gerais—
Brazil, 43% of them did not perform any physical activity and 51% of them considered
that, their diet had deteriorated after entering college. The authors recommend intervention
measures during graduation to improve the understanding and adoption of good health
practices (Chehuen Neto et al. 2013).
The Botucatu UNESP study (Torres et al. 2011) highlights aspects that have most
positively interfered with quality of life: practicing physical activities, having leisure time
and not smoking.
In Botucatu’s study (Torres et al. 2011), less than half (44.4%) of the physicians
interviewed practiced physical activities three or more days a week.
When analyzing the correlations found in our study, it was observed that IR 2 was
associated with the subscale ‘‘Family and Friends.’’ In a study that corroborates this result,
the authors mention that this positive correlation was maintained, even after correcting
confounding variables such as marital status, age, gender, educational level and socioe-
conomic level. This is also done in a context of Intrinsic Religiosity (Moreira-Almeida and
Stroppa 2012).
According to review articles, social support from religiosity is highlighted by 14 studies
considered to be of good technical quality with a positive correlation in 79% of them. The
authors also point out that, of the 37 articles, they also considered it of good quality, it was
observed that, about 68% had positive correlation when evaluated in the context of
Intrinsic Religiosity (Koenig 2012, 2015).
As for the association between IR 2 and physical activities found in our study, we
inferred that greater religious involvement, more commitment to physical exercise, cor-
roborated by a systematic review in which groups based on faith, scripture and/or sacred
teachings and the level of religiosity represented the main factors for the adoption of an
active lifestyle (Santos et al. 2013).
When analyzing the association between ORA, NORA, IR 3 and the alcohol use in the
present study, the results of research on the influence of R/S on health behaviors are
corroborated (Koenig 2012, 2015). In a cross-sectional study with 363 individuals aged
18 years and over, organizational and Intrinsic Religiosity was found to be a protective
factor in relation to moderate and high alcohol and tobacco consumption (Queiroz et al.
2015).
Other authors also demonstrated this beneficial relationship by investigating 1124
students in an online survey, indicating that the importance given to religion had a pro-
tective effect on alcohol use among these adolescents (Neighbors et al. 2013).
In the correlation between ORA and Insight (r = 0.416, p = 0.03), the ‘‘FANTASTIC’’
instrument deals with the items: ‘‘I think positively and optimistically’’; ‘‘I feel tense and

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disappointed’’ and ‘‘I feel sad and depressed.’’ When evaluating 48,894 American nurses,
with an average age of 58 years, followed by 1996 until 2008, the same correlation of the
current study was perceived, with lower risk of being depressed among those who par-
ticipated in religious services than those who did not participate (Li et al. 2016).
Although a positive association was found in 61% of the works between depressed
patients and those who are religious or spiritual, there are also those in which this was not
the case, especially those involving negative religious coping that present punitive aspects
of religiosity. The most positive effects of R/S on depression are more intense in popu-
lations at risk and experiencing stress situations (Moreira-Almeida and Stroppa 2012).
R/S presents a positive correlation with health in 73% of 40 studies from 2000 to 2010
that evaluated the sensation of hope and 81% of 32 studies that evaluated optimism. Of the
444 papers selected on depression, 61% had correlation; 49% had an improvement in
anxiety, and only 11% presented worsening of the picture due to the punitive context, with
a negative correlation between R/S and suicide rates, that is, the higher the R/S, the lower
the suicide rates in 71% of these articles selected in his scholarly review (Koenig et al.
2012; Koenig 2015).
As for the positive association found between ORA, IR 1 and ‘‘Satisfaction with my
work or function,’’ a direct relationship was not identified in the literature. In an indirect
way, we understood that, when evaluating aspects related to the fixation of physicians in
the workplace, about one-third of physicians consider themselves overworked in their jobs
in this order (all with more than 96% of choice): salary/remuneration; working condition;
quality of life; safe environment; possibility of improvement and specialization and career
plan and professional recognition, authors pointed out that about one-third of physicians
consider themselves overworked in their work (Scheffer 2015).
Also, indirectly, regarding these issues, we highlighted that R/S brings greater meaning
and sense of purpose in life, with a positive correlation in 93% of the 45 studies evaluated.
Scholars also stated that, from 36 to 39% there was improvement in performance in daily
activities versus 18–23% leading to worsening. They also identified a 79% positive cor-
relation in 14 studies that investigated the association between R/S, social capital and
volunteering (Koenig et al. 2012; Koenig 2015).
This work has a number of limitations such as a small sample of physicians, its cross-
sectional nature and issues related to the application in clinical practice, though, more
studies are needed in order to have substantial associations.

Conclusion

Most of the physicians in this study did not have academic training regarding spirituality
and health either during training or after graduation. The level of religiosity was high;
however, it is centered in the particular activities of the religion and in the subjective
religiosity given to the intrinsic domain.
They have a very good lifestyle, except for the subscale ‘‘Physical Activities,’’ with
regard to moderate or vigorous physical exercises. We have found a positive association
between the variables ORA and ‘‘Insight’’; ORA, IR 1 and ‘‘Career’’; IR 2 and ‘‘Family
and Friends.’’ Statistically significant inverse associations between ORA, NORA, IR 3 and
‘‘Alcohol’’ as well as IR 2 and ‘‘Physical Activities’’ were also observed.

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This study led us to a deeper understanding of how religiosity is related to the physi-
cian’s lifestyle; in other words, a stronger religious involvement is associated with a better
mental health, a good relationship and a positive health behavior.
Compliance with Ethical Standards

Conflict of interest All the authors declare that they have no conflict of interest.

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