Physicians’ eligious/spi i ual cha ac e is ics and
hei beha io ega ding eligiosi y and spi i uali y
in clinical p ac ice
A me a-analysis o indi idual pa icipan da a
Alex K. Kø up, MD
a,b,∗
, Jens Sønde gaa d, MD, PhD
a
, Gianca lo Lucche i, MD, PhD
c
,
Pa ameshwa an Ramak ishnan, MD, MDi
d,e
, Klaus Baumann, D . heol
, Eunmi Lee, PhD
,
Eckha d F ick, MD, D .med
g,h
, A nd Büssing, MD, PhD
i
, Nada A. Alyousefi, MBBS, PhD
j
,
Azima ul Ka imah, MD
k
, Es he Schou en, MD, D .med
l
, Inga We mu h, MD, D .med
m
,
René He i, MD, D .med
n,o
, Rocío de Diego-Co de o, PhD
p
, Ma ia Cecilia Menega i-Chequini, PhD
q
,
Niels Ch is ian H id , Cand. heol Theol.D
a,
Edi o : Da yle Wane.
E hics app o al and consen o pa icipa e: Wi hin he esea ch field o “Religiosi y and Heal h”i is only na u al o eade s o ques ion po en ial influences o eligious
alues o he esea che s conduc ing he esea ch. All au ho s o his s udy a e commi ed o anspa ency and o ob aining he highes scien ific s anda ds. Nowhe e
in his a icle is one belie sys em, pe sonal alue o i ue se abo e ano he , and we ha e no in en ion, no igh , o a gue in a o o any. Some o he au ho s a e
a heis s. O he s a e de o ed o own eligious o spi i ual belie sys ems, and se e al a e a filia ed wi h o ganized eligious o ganiza ions.
Alex Kø up: Schola ship om Uni e si y o Sou he n Denma k, and esea ch g an om Psychia ic Resea ch Founda ion o Sou he n Denma k (Psykia iens
o sknings ond, Region o Sou he n Denma k).
Gianca lo Lucche i: G an ee o Resea ch P oduc i i y Schola ship –Le el 1D (Medicine) - B azilian Na ional Council o Scien ific and Technological De elopmen (CNPq), B azil
Alex Kappel Kø up w o e he a icle as fi s au ho . S udy concep ion and design. S a is ical analysis. Da a manage o he NERSH Da a Pool.
Jens Sønde gaa d, hos ing he NERSH Da a Pool, esea ch o e sigh ; S udy design and c i ical manusc ip e ision;
Gianca lo Lucche i concei ed, designed and pe o med he 2 B azilian su eys. Da a collec ion. C i ical manusc ip e ision;
Pa ameshwa an Ramak ishnan concei ed, designed and pe o med Indian su ey. Da a collec ion. C i ical manusc ip e ision;
Klaus Baumann concei ed, designed and pe o med he Ge man su ey in F eibu g: Da a collec ion. Co- ounde o he NERSH-Ne wo k; C i ical manusc ip e ision;
Eunmi Lee concei ed, designed and pe o med he su ey Ge man sample in F eibu g. Da a collec ion. C i ical manusc ip e ision;
Eckha d F ick, co- ounde o he NERSH-Ne wo k, concei ed, designed and pe o med a local Ge man su ey. Da a collec ion. C i ical manusc ip e ision;
A nd Büssing, co- ounde o he NERSH-Ne wo k. C i ical manusc ip e ision. Pe o med eliabili y analyses in he fi s e alua ion ound;
Nada A. AlYouseficoncei ed, designed, and pe o med he Saudi A abian su ey. Da a collec ion. C i ical manusc ip e ision;
Azima ul Ka imah concei ed, designed and pe o med Indonesian su ey. Da a collec ion. C i ical manusc ip e ision;
Es he Schou en, Da a collec ion o he Ge man pe ina al sample. C i ical manusc ip e ision;
Inga We mu h, S udy concep ion and design o he Ge man pe ina al sample; Da a collec ion; C i ical manusc ip e ision;
Rene He i, S udy concep ion and design o he Swiss sample; Da a collec ion; C i ical manusc ip e ision;
Niels Ch is ian H id , p ojec concep ion. Co- ounde and coo dina o o he NERSH-Ne wo k. Da a collec ion o Danish sample. C i ical manusc ip e ision;
The au ho s ha e no conflic s o in e es s o disclose.
Supplemen al Digi al Con en is a ailable o his a icle.
The da ase s gene a ed du ing and/o analyzed du ing he cu en s udy a e no publicly a ailable, bu a e a ailable om he co esponding au ho on easonable eques .
a
Resea ch Uni o Gene al P ac ice, Ins i u e o Public Heal h, Uni e si y o Sou he n Denma k, Odense C, Denma k,
b
Depa men o Men al Heal maxh Se ice, Vejle,
Region o Sou he n Denma k,
c
Depa men o Medicine, Fede al Uni e si y o Juiz de Fo a, A enida Eugênio de Nascimen o s/n-Ae opo o, Juiz de Fo a, MG, B azil,
d
G adua e Theological Union-Uni e si y o Cali o nia, Be keley, 2400 Ridge Rd, Be keley, CA,
e
AdiBha Founda ion, New Delhi, India,
Ca i as Science and Ch is ian
Social Wo k, Facul y o Theology, Albe -Ludwig-Uni e si y, F eibu g, Ge many,
g
Resea ch Cen e Spi i ual Ca e, Depa men o Psychosoma ic Medicine and
Psycho he apy, The Uni e si y Hospi al Klinikum ech s de Isa , Lange s , 3, Munich, Ge many,
h
Munich School o Philosophy, Kaulbachs , 31, Munich, Ge many,
i
Ins i u e o In eg a i e Medicine, Facul y o Medicine, Wi en/He decke Uni e si y, Ge ha d-Kienle-Weg 4, He decke, Ge many,
j
Depa men o Family and Communi y
Medicine, College o Medicine, King Saud Uni e si y (KSU), Riyadh, Saudi A abia,
k
Depa men o Psychia y, Facul y o Medicine, Uni e si as Ai langga, D . Soe omo
Gene al Academic Hospi al, Su abaya, Eas Ja a, Indonesia,
l
Depa men o Neona ology, Uni e si y Hospi al Munich, Ma chioninis asse 15, Munich, Ge many,
m
Depa men o Child and Adolescen Psychia y, Psychosoma ics and Psycho he apy, Uni e si y Hospi al Munich, Ge many,
n
Resea ch Ins i u e o Spi i uali y and
Heal h, Weissens eins asse 30, Langen hal, Swi ze land,
o
Medical Facul y, Uni e si y o Be n and Basel, Swi ze land,
p
Depa men o Nu sing. Uni e si y o Se ille,
q
Depa men and Ins i u e o Psychia y (P oSER). Uni e si y o São Paulo,
Academy o Ge ia ic Cance Resea ch (AgeCa e), Odense Uni e si y Hospi al, Odense C, Denma k.
∗
Co espondence: Alex K. Kø up, Resea ch Uni o Gene al P ac ice, J.B. Winsløws Vej 9, 5000 Odense C, Denma k (e-mail: ako u[email p o ec ed]).
Copy igh ©2021 he Au ho (s). Published by Wol e s Kluwe Heal h, Inc.
This is an open access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion-Non Comme cial License 4.0 (CCBY-NC), whe e i is pe missible o
download, sha e, emix, ans o m, and buildup he wo k p o ided i is p ope ly ci ed. The wo k canno be used comme cially wi hou pe mission om he jou nal.
How o ci e his a icle: Kø up AK, Sønde gaa d J, Lucche i G, Ramak ishnan P, Baumann K, Lee E, F ick E, Büssing A, AlyousefiNA, Ka imah A, Schou en E,
We mu h I, He i R, de Diego-Co de o R, Menega i-Chequini MC, H id NC. Physicians’ eligious/spi i ual cha ac e is ics and hei beha io ega ding eligiosi y and
spi i uali y in clinical p ac ice: a me a-analysis o indi idual pa icipan da a. Medicine 2021;100:52(e27750).
Recei ed: 23 July 2021 / Recei ed in final o m: 26 Oc obe 2021 / Accep ed: 27 Oc obe 2021
h p://dx.doi.o g/10.1097/MD.0000000000027750
Sys ema ic Re iew and Me a-Analysis Medicine®
OPEN
1
Abs ac
Backg ound: Religiosi y and/o spi i uali y (R/S) o physicians ha e been epo ed o in o m beha io ega ding eligiosi y and
spi i uali y in clinical p ac ice (R/S-B). Ou aim was o s udy his associa ion.
Me hods: Building upon a la ge in e na ional da a pool o physician alues we pe o med ne wo k and sys ema ic li e a u e
sea ches using Google Schola , Web o Science, Embase, Medline, and PsycIn o. Measu es o R/S and R/S-B we e selec ed o
compa abili y wi h exis ing esea ch. We pe o med a wo-s age IPDMA using R/S coe ficien s om sample-wise mul iple eg ession
analyses as summa y measu es. We con olled o age, gende , and medical special y. An addi ional sub-analysis compa ed
psychia is s o non-psychia is s.
Resul s: We ound 11 eligible su eys om 8 coun ies (n=3159). We ound a posi i e associa ion be ween R/S and R/S-B wi h an
o e all R/S coe ficien o 0.65 (0.48–0.83). All samples e ealed a posi i e associa ion be ween R/S and R/S-B. Only 2 ou o he 11
samples di e ed om he o e all confidence in e al. Psychia is s had a highe deg ee o R/S-B, bu associa ions wi h R/S did no
di e compa ed o non-psychia is s.
Conclusions: We confi med a significan associa ion be ween R/S and R/S-B in his s udy. Despi e la ge cul u al di e ences
be ween samples, coe ficien s emained almos cons an when con olling o con ounde s, indica ing a cul u al independen e ec o
R/S on R/S-B, which o ou knowledge has no been documen ed be o e.
Such in e ac ion can cons i u e bo h acili a o s and ba ie s o high quali y heal h ca e and should be conside ed in all aspec s o
pa ien and ela ionship-cen e ed medicine.
Abb e ia ions: IPDMA =indi idual pa icipan da a me a-analysis, NERSH =ne wo k o esea ch in spi i uali y and heal h, R/S =
eligiosi y and/o spi i uali y, R/S-B =sel - epo ed beha io ega ding R/S in clinical p ac ice, RSMPP = eligion and spi i uali y in
medicine: physicians’pe spec i es (ques ionnai e).
Keywo ds: me a-analysis, physicians, eligion, eligiosi y, spi i uali y
1. In oduc ion
Physicians’a i udes and sel - epo ed beha io ega ding
eligiosi y and spi i uali y in clinical p ac ice (R/S-B) ha e been
epo ed o be in o med by physicians’own eligious and/o
spi i ual cha ac e is ics (R/S).
[1]
Physicians who desc ibe hem-
sel es as eligious o spi i ual ha e been linked wi h a highe
likelihood o discussing and a ending o pa ien s’R/S issues,
[1–8]
o p ay wi h pa ien s,
[1]
and less o en e e ing pa ien s o men al
heal h acili ies han hei non- eligious pee s.
[9]
Also, coope a-
ion wi h cle gy and/o pas o al p o essionals a e epo ed mo e
o en by eligious physicians.
[10]
S a emen s like hese ha e been one-se ing h oughou his
esea ch field du ing he las 2 decades. S ill, findings s em
p ima ily om an Ame ican su ey om 2005
[11]
and se e al
addi ional obse a ional s udies. Mos commonly he associa ion
be ween R/S and R/S-B has been analyzed using single a iable
measu es o R/S-B (i.e., sel - epo ed endency o inqui e abou
pa ien s’R/S), and while measu emen s o R/S ha e some imes
been based on a single a iable
[8,12,13]
o he s ha e used a
composi e scale.
[1,4,5,14,15]
Findings ha e been mixed. While
some epo a posi i e associa ion,
[1,4,5,7,8,14]
o he s ha e no
been able o confi m his ela ionship,
[3,12,13]
and some ha e
epo ed mixed esul s.
[15]
Mos s udies known o us epo
findings based on analyses ha do no con ol o known
con ounde s like age, gende and medical special y.
[3,5,7,8,12,14]
In
summa y, he designs and obus ness o p e ious analyses seem
la gely a ied and deficien as a basis o d awing alid and
compa able conclusions.
Only a ew s udies ha e a emp ed in e na ional compa ison o
findings,
[6,16]
and he associa ion be ween R/S and R/S-B has
ne e been explo ed in a sys ema ic me a-analysis. The
in e na ional compa isons ha exis ha e poin ed owa d la ge
c oss-cul u al di e ences in bo h physicians’ eligiosi y and hei
a i udes and beha io owa ds R/S. Also, besides age and gende ,
medical special y has been ound o influence beha io ,
[3]
and
mainly psychia is s ha e been poin ed ou as being less eligious,
bu possibly mo e spi i ual, han hei colleagues om o he
medical special ies.
[9,17]
Due o he many he e ogeneous s udies
and findings o e he las 2 decades, he e is a need o an
in e na ional o e iew using s anda dized measu emen s in a
weigh ed compa ison.
In his s udy ou aim was o in es iga e he associa ion be ween
physicians’ eligious cha ac e is ics (R/S) and hei sel - epo ed
beha io ega ding R/S in clinical p ac ice (R/S-B) using aw da a
om a la ge in e na ional da a pool o physician alues. Using
compa able ou come measu es o associa ions, we we e able o
compa e he deg ee o associa ion be ween he samples.
2. Me hods and ma e ials
2.1. Da a sou ce
We used he NERSH Da a Pool 3.0 as da a sou ce.
[18,19]
Membe s o he in e na ional Ne wo k o Resea ch in
Spi i uali y and Heal h (NERSH) ha e sha ed ideas and da a
since 2003. The o iginal ques ionnai e used was he Religion and
Spi i uali y in Medicine: Physicians’Pe spec i es (RSMPP) by
Cu lin, which was used in a na ion-wide su ey o Ame ican
physicians in 2005.
[11]
La e , membe s o NERSH c ea ed a new
ques ionnai e based on he RSMPP called he “NERSH
Ques ionnai e.”By 2015 he ne wo k had pe o med a o al
o 12 su eys in nine di e en coun ies. These su eys became
he ounding da ase s o he fi s e sion o he NERSH Da a Pool
(N=5353).
[20,21]
The da a pool has been upda ed wice since 2015 using
3di e en s a egies: Ne wo k, ci a ion, and li e a u e sea ches.
Ne wo k sea ches we e pe o med con inuously in an un o mal
way using p ima ily e-mail co espondences be ween NERSH
collabo a o s wi h a ocus on a ailable aw da ase s based on
Kø up e al. Medicine (2021) 100:52 Medicine
2
ei he he RSMPP o he NERSH Ques ionnai e ega dless i
published o unpublished. Ci a ion and li e a u e sea ches we e
pe o med in 2016 and 2020 looking o a icles based on ei he
he RSMPP o he NERSH Ques ionnai e (See Table S1,
Supplemen al Digi al Con en , h p://links.lww.com/MD2/
A684 in Supplemen al Con en o sea ch de ails including
sea ch s ings).
In 2016 we added 3 mo e samples om known NERSH
collabo a o s: A sample o B azilian esiden physicians by
Lucche i (N=171), a Sou h Ko ean sample o psychia ic s a
membe s by Lee e al (N=281)
[22,23]
and a sample o Swiss
physicians used in he hesis by Münge (N=79).
[24]
In addi ion,
we pe o med a ci a ions sea ch in Web o Science, and sys ema ic
li e a u e sea ches (Medline, Embase, PsycIn o, Web o Science
and Google Schola ).
[25]
Sea ches we e pe o med by he fi s and
las au ho , looking o RSMPP o NERSH su eys ha we e no
al eady known wi hin ou ne wo k.
[20]
The ci a ion sea ch
yielded 316 and 1572 i ems, espec i ely, and iden ified 2 samples
no p e iously known o us: Tomasso e al (N=146)
[26]
and Al-
Yousefi(N=225).
[13]
Bo h esea ch g oups we e in i ed o join
he collabo a ion, and bo h ag eed. The sys ema ic li e a u e
sea ch using he sea ch s ings did no find any samples no
al eady ound using he ne wo k o ci a ion sea ches. In o al, 5
new samples we e added o he da a pool in 2016 and was
eleased as NERSH Da a Pool 2.0 comp ising a o al o 17
samples.
In 2020 we enewed he sea ches, applying he same s a egy
and sea ch s ings.
[18]
In o al 6 new su eys we e eligible o
impo in o he NERSH Da a Pool. Two om he ne wo k sea ch
and 4 om he ci a ion sea ch in Web o Science. The sys ema ic
li e a u e sea ch using he sea ch s ings did no find any samples
no al eady ound using he ne wo k o ci a ion sea ches. F om
wi hin he NERSH collabo a ion Lee e al we e able o sha e wi h
us a sample o Ge man hospi al chaplains (N=138),
[27]
and He i
e al had used he ques ionnai e o que y amily p ac i ione s
om he egion o Bale and Aa au in Swi ze land (N=105).
[28]
The ci a ion sea ch ound 4 eligible su eys. Co de o e al had
collec ed 2 samples o Spanish and Po uguese nu sing
s uden s,
[29,30]
(N=75 and N=158 espec i ely), and om
B azil by Menega i-Chequini e al we iden ified 2 samples o
psychia is s: he fi s based on a su ey among membe s o he
B azilian Psychia y Associa ion (ABP) (N=508), and also a
sample om a psychia ic depa men in São Paulo (N=84). All
esea che s we e con ac ed and in i ed o sha e hei da a, and all
ag eed o join he NERSH collabo a ion.
Signed da a sha ing ag eemen s we e collec ed om all
con ibu o s o he da a pool. Raw da a we e sen o he fi s
au ho in cha ge o da a managemen and da a cu a ion in he
NERSH Da a Pool. Whe e in e p e a ion o da a was unclea , he
o iginal au ho s/ esea che s we e con ac ed, and issues we e
esol ed in collabo a ion. Each s udy included in he NERSH
Da a Pool was app o ed by he local esea ch e hics commi ee i
applicable.
We expec ed he published a icles ound in he sys ema ic
sea ches o epo e y dis inc ou come measu es. Also, because
ou goal was o find and ec ui only aw da ase s, ega dless o
indi idual local s udy goals, i did no make sense o quali y g ade
he ound a icles.
Some local esea che s used only a pa o he o iginal
ques ionnai e, and o he s added u he ques ions o hei su ey.
Samples we e acqui ed by adi ional sel -adminis e ed ques-
ionnai es excep o he 2012 B azilian physician s udy whe e
ace- o- ace in e iews we e used.
The hi d e sion o he NERSH Da a Pool used in his me a-
analysis comp ised a o al o 7323 heal h p o essionals o which
4872 we e physicians. The da a pool has been desc ibed in de ail
in ano he publica ion,
[18]
and i s codebook is a ailable o
download h ough he Open Science F amewo k.
[19]
2.2. Me a-analysis design
Based on he o iginal da a desc ibed abo e we pe o med
IPDMA. This design ca ies se e al ad an ages o e adi ional
me a-analysis on agg ega ed da a, allowing us o en o ce s ic
inclusion/exclusion c i e ia, a uni o m handling o missing alues
and also, we we e able o include p e iously unpublished da a.
[31]
We pe o med 2 me a-analyses: a) Ou p ima y analysis using
all eligible su eys wi hou g ouping, and b) a sepa a e analysis o
he same samples bu g ouped in o 2 g oups: Psychia is s and
Non-psychia is s. Bo h me a-analyses we e pe o med as wo-
s age analyses using a andom-e ec s in e se- a iance model
wi h De Simonian-Lai d es ima e o au. The dependen a iables
used we e su ey-wise mul iple eg ession coe ficien s o
physician R/S wi h physician R/S-B. We included age, gende ,
and medical special y as po en ial con ounde s in bo h analyses.
Fo he Congo sample (N=112) we did no ha e in o ma ion
abou medical special y and could only con ol o age and
gende .
All s a is ics we e made wi h S a a 16.
[32]
2.3. Physician R/S
A measu e o physician R/S was cons uc ed based on he 3
a iables selec ed by Cu lin e al in 2006.
[1]
This cons uc was
chosen o i s compa abili y o ea lie esea ch, and as a b ie and
p agma ic measu e ha includes bo h a “doing”and “being”
aspec o in insic eligiosi y:
[33]
”I y ha d o ca y my eligious
belie s o e in o all my o he dealings in li e”(RS1) and “My
whole app oach o li e is based on my eligion”(RS2),
espec i ely, as well as a measu e o he iden ifica ion as a
spi i ual pe son: “To wha ex en do you conside you sel a
spi i ual pe son”(RS3). RS1 and RS2 a e he same i ems used as
2 ou o 3 i ems in he in insic eligiosi y sub-scale o he DUREL
index.
[34]
RS3 was se as manda o y as i was he only measu e o
spi i uali y. I RS1 o RS2 was missing a alue was impu ed as he
a e age o he o he 2 a iables. Sum sco es we e calcula ed as
RS1+RS2+RS3=R/S sco e. In e nal consis ency was e alua ed
using C onbach’s alpha. Cha ac e is ics including de ails o
impu a ion a e p esen ed in Table 2.
2.4. Physician R/S-B
Fo compa abili y wi h he o iginal esea ch by Cu lin and o
define a meaning ul cons uc o sel - epo ed beha io ega ding
R/S in clinical p ac ice (R/S-B) we chose o cons uc a measu e
based on he 5 beha io a iables epo ed by Cu lin in 2006.
[1]
This cons uc co e s di e en aspec s o physician beha io
including collec ion o in o ma ion abou pa ien R/S: “Ido
inqui e abou R/S (yes/no)”(B1), willingness o sha e pe sonal R/
S ideas and expe iences wi h pa ien s ac i ely: “I sha e my own R/
S ideas and expe iences”(B2), physician use o pa ien s’R/S as a
esou ce in ea men : “I encou age pa ien s’R/S belie s and
Kø up e al. Medicine (2021) 100:52 www.md-jou nal.com
3
p ac ices”(B3), a oidan beha io o he physician when
con on ed wi h R/S in he clinical se ing: “I y o change he
subjec when R/S comes up”(B4), and whe he he physician
engages in ac i e p aye wi h pa ien s: “I p ay wi h pa ien s”
(B5).
We equi ed a leas 4 ou o he 5 ques ion answe ed o he
obse a ion o be included in he me a-analysis. I B1 was missing
we impu ed a new alue as ei he 0, 0.5 o 1 depending on he
mean sco e o he a ailable alues B2-B5. I B2, B3, B4, o B5 was
missing we se he alue o he mean alue o he emaining i ems.
The sco e o he BS4-i em was e e sed, and he o al R/S-B
sco e was calcula ed B1+B2+B3+B4 ( e e sed)+B5=R/S-B.
In e nal consis ency was e alua ed using C onbach’s alpha.
Cha ac e is ics including de ails o impu a ion a e p esen ed in
Table 2.
2.5. Exclusion c i e ia
Gende iden ifica ion and an age equi emen o a leas 18yea s
we e en o ced when building he da a pool. Fo his s udy, we
excluded u he all non-physician pa icipan s (N=2451). Fo
he R/S-measu e RS3 was se as manda o y, while we allowed
ei he RS1 o RS2 o be omi ed. This excluded 893 physicians. In
addi ion, we equi ed a leas 4 ou o he 5 R/S-B-measu es,
emo ing ano he 820 physicians. The ull inclusion/exclusion
diag am is p esen ed in Figu e 1.
3. Resul s
The la es sys ema ic ci a ion and li e a u e sea ches in 2020
ound 763 and 4,929 hi s, espec i ely. Toge he wi h he
ne wo k sea ches he o iginal Da a Pool comp ised 7323 heal h
p o essionals a he ime o analysis.
A e exclusion c i e ia we e en o ced a o al o 3159
physicians om 11 samples emained o he me a-analysis.
Eigh coun ies we e ep esen ed. Fi e s udies we e Eu opean, 2
we e B azilian, 2 we e Asian, one was A ican, and one was
Ame ican. The exclusion c i e ia seemed o a o samples om
he ea lie e sions o he da a pool. This was unin en ional.
Adjus ing he c i e ia du ing o a e analysis would comp omise
good esea ch p ac ice and was hus no an op ion.
Obse a ions we e sampled be ween 2002 (Ame ican sample
by Cu lin) and 2018 (B azilian sample by Lucche i). Age di e ed
significan ly be ween he samples, wi h he Ame ican and Danish
physicians being eldes wi h a mean age o 48.8 and 48.5,
espec i ely. The physicians om he samples by Ramak ishnan
(Indonesia), 2014, and Lucche i (B azil), 2018, we e he
younges wi h mean ages o 29.1 and 28.4. The gende
Figu e 1. Inclusion and exclusion c i e ia.
Kø up e al. Medicine (2021) 100:52 Medicine
4
composi ion o he samples di e ed as well. In o al 42% o he
included physicians we e emale. See Table 1 o he cha ac e -
is ics o he included physicians. (Table 1).
The cons uc ed measu es we e e alua ed o in e nal
consis ency wi h C onbach’s alpha. The R/S scale had an alpha
alue o 0.82, and he R/S-B scale 0.61 (Table 2), which we e
ound accep able o his s udy. The mean R/S-sco e in he
combined da ase was 7.02 (SD=2.49), and he mean R/S-B was
7.54 (SD=3.13). (See Table S2, Supplemen al Digi al Con en ,
h p://links.lww.com/MD2/A685 in Supplemen al Con en , o
sample-wise unweigh ed mean-sco es).
3.1. Associa ion be ween R/S and R/S-B
The o e all coe ficien o R/S (95% confidence in e al) was
0.65 (0.48–0.83). All samples e ealed a posi i e associa ion and
only 2 ou o he 11 samples we e ou side he o e all confidence
in e al. The Indonesian sample by Ramak ishnan (n=102) and
he B azilian sample om Lucche i, 2012 (n=194) we e no able
o confi m a significan influence o R/S on R/S-B as hei
confidence in e als o e lapped ze o and P alues we e abo e
.05. A significan and posi i e associa ion was ound o he
emaining nine samples, P<.001 (Fig. 2). The be ween-s udy
a iance was high (O e all I
2
=92.5%), explaining mos o he
o al a iance. (See Table S3, Supplemen al Digi al Con en ,
h p://links.lww.com/MD2/A686 in Supplemen al Con en o
sample-wise and unweigh ed esul s o he mul iple eg ession
analyses, including coe ficien s, confidence in e als, and signifi-
cance le els o co a ia es).
3.2. Psychia is s e sus non-psychia is s
In a sepa a e analysis o he psychia is s included in he s udy we
did no find any di e ence in o e all R/S sco es (95% confidence
Table 1
Cha ac e is ics o he physicians in he s udy (N=3,159).
Age Gende (%) Medical special y (%)
Au ho /s udy
∗
Coun y
Sample
yea Mean SD Female Male
Medical
special y
Gene al
p ac i io-
ne
Gyn/
Obs Su gical
Pa a-
clinial Pedia ic
Psych-
ia y O he
Cu lin, 2005 USA 2002 48.8 8.4 280 (27) 774 (73) 291 (28) 294 (28) 77 (7) 109 (10) 17 (2) 141 (13) 94 (9) 31 (3)
Schou en-We mu h, 2016
†
Ge many 2014 37.9 8.9 334 (66) 172 (34) ––506 (100) –– – ––
Kusey i, 2016
†
Ge many 2016 34.8 8.3 27 (53) 24 (47) 17 (34) –2 (4) 12 (24) –4 (8) 3 (6) 12 (24)
H id -F ick, 2016 Ge many 2014 38.3 10.2 16 (37) 27 (63) 28 (65) –9 (21) –– – –6 (14)
Büssing, 2014
‡
Aus ia 2014 41.6 10.5 12 (43) 16 (57) 16 (59) ––4 (15) –––7 (26)
an Randwijk, 2018 Denma k 2012 48.5 12.2 284 (42) 388 (58) 111 (24) 159 (35) 21 (5) 99 (22) 11 (2) 14 (3) 36 (8) 8 (2)
Ramak ishnan, 2014 India 2012 31.9 10.5 127 (56) 100 (44) 14 (8) 43 (24) 11 (6) 5 (3) 38 (21) 10 (6) 38 (21) 20 (11)
Ramak ishnan, 2014 Indonesia 2010 29.1 3.6 60 (54) 52 (46) 8 (9) 21 (22) 7 (7) 24 (26) 14 (15) 2 (2) 1 (1) 17 (18)
Mukwayakala, 2018
†
Congo 2012 35.1 8.0 28 (25) 83 (75) n/a
Lucche i, 2016 B azil 2012 37.7 11.1 49 (25) 145 (75) 146 (75) –10 (5) 26 (13) –12 (6) ––
Lucche i 2018
‡
B azil 2018 28.4 3.3 99 (61) 62 (39) 40 (25) –19 (12) 10 (6) –17 (11) 10 (6) 65 (40)
To al 1,316 (42) 1,843 (58) 671 517 662 289 80 200 182 166
∗
Fi s publica ion o local sample i any. I un-published he name o he head esea che and sample yea was used.
†
Thesis.
‡
No published locally, sampling yea used o iden ifica ion.
Figu e 2. Fo es plo o associa ions be ween physician eligiosi y/spi i uali y (R/S) and hei sel - epo ed beha io ega ding R/S in clinical p ac ice (R/S-B).
Weigh s a e om andom e ec s model.
Kø up e al. Medicine (2021) 100:52 www.md-jou nal.com
5

in e al), 7.0 (6.92–7.10) o non-psychia is s (N=2977)
compa ed o 7.2 (6.83–7.52) o psychia is s (N=182), bu
we ound ha o e all sel - epo ed beha io ega ding R/S in
clinical p ac ice (R/S-B) was significan ly di e en be ween he 2
g oups. R/S-B o non-psychia is s we e 7.5 (7.38–7.61)
compa ed o 8.3 (7.93–8.71) o he psychia is s (see
Table S4, Supplemen al Digi al Con en , h p://links.lww.com/
MD2/A687, Supplemen al Con en , o de ailed s a is ics o he 2
g oups).
To analyze he associa ion be ween R/S and R/S-B o he 2
g oups we pe o med a sepa a e me a-analysis using he same
se ings as he main me a-analysis in he s udy ( andom-e ec s
model). Fo non-psychia is s we ound an o e all coe ficien o
0.55 (0.41–0.69), I
2
=87.0%, and o he psychia is s an o e all
coe ficien o R/S o 0.49 (0.23–0.75), I
2
=60.6%. The g oup
coe ficien s we e no s a is ically di e en . (See Figu e S1,
Supplemen al Digi al Con en in Supplemen al Con en o he
o es plo , h p://links.lww.com/MD2/A683, including sample
sizes and R/S coe ficien significance le els.
4. Discussion
We ound a significan associa ion be ween R/S and R/S-B in he
included samples. Coe ficien s we e alike o all su eys excep 2
samples om B azil and Congo which we will discuss below.
Psychia is s epo ed a highe deg ee o R/S-B han hei non-
psychia is colleagues. S ill he e ec s o R/S on R/S-B we e equal
o bo h g oups. In nei he me a-analysis pe o med did we find
eason o suspec R/S o influence R/S-B di e en ly ac oss he
included samples and cul u es.
In he discussion below, we wan o add ess 2 easonable
ques ions abou he s udy design, and second o commen on ou
findings in ela ion o exis ing esea ch.
4.1. C oss-cul u al pe spec i e
Fi s , we need o answe whe he i is easible o compa e
physicians ac oss cul u es using a common R/S measu e, and also
whe he i concep ually makes sense o do c oss-cul u al
compa isons o physicians’R/S and R/S-B a all when bo h ha e
clea cul u al unde pinnings.
Albei se e al ins umen s exis ,
[34–37]
he e is no consensus on
how o measu e R/S in esea ch. Some ha e a gued agains
finding a common R/S-measu e, and ins ead a o ed a ocus on
be e alidi y o local measu emen s wi hin he local cul u al
con ex . Due o he mul i-dimensional na u e o eligiosi y and
spi i uali y de eloping a uni-dimensional scale wi h bo h high
in e nal and ex e nal alidi y has no been ui ul, and some ha e
a gued ins ead o ocus on single- a iable measu es o epo ing
sub-scales like in insic eligiosi y.
[34]
While we ag ee wi h hese
hough s and s a egies o some deg ee, we mus poin ou ha
scales adap ed o local s udies inhibi la e me a-analyses, and
hus limi s in e na ional and c oss-cul u al esea ch. The e o e,
we mus choose be ween uni o m compa able measu es wi h
lowe alidi y ha enables me a-analyses, o a lo o sepa a e
de eloped measu es wi h high in e nal alidi y, bu wi h e y
limi ed ex e nal alidi y and di ficul o include in me a-analyses.
We canno ha e bo h.
We he e o e sugges ha bo h s a egies be applied in ou
esea ch field, and ha esea che s lea n o oggle be ween hem
Table 2
Cha ac e is ics o measu emen s used.
Measu e
I em
sco ing
∗
Impu ed, N Sum sco e N
∗∗
Mean (SD) Min-max C onbachs a
Religiosi y/Spi i uali y (R/S)
RS1 ”I y ha d o ca y my eligious belie s
o e in o all my o he dealings in li e”
1–491
†
Calcula ed as sum
o indi idual
sco es. To al
sco e anging
om 3 o 12
3159 7.02 (2.49) 3–12 0.82
‡
RS2 “My whole app oach o li e is based
on my eligion”
1–427
†
RS3 “To wha ex en do you conside
you sel a spi i ual pe son”
1–4 No impu ed
Sel - epo ed beha io ega ding R/S in clinical p ac ice (R/S-B)
B1 “I do inqui e abou R/S (yes/no)”0–179
x
Calcula ed as sum
o indi idual
sco es. To al
sco e anging
om 0 o 17
3,159 7.54 (3.13) 0-17 0.61
‡
B2 “I sha e my own R/S ideas and
expe iences”
0–43
†
B3 “I encou age pa ien s’R/S belie s and
p ac ices”
0–4 689
†
B4 “I y o change he subjec when R/S
comes up”
0–4( e e sed) 10
†
B5 “I p ay wi h pa ien s”0–43
†
∗
Highe sco es indica ing highe deg ee o he cons uc measu ed.
∗∗
Comple e cases only.
†
Impu ed as mean o emaining i ems.
‡
Impu a ion did no al e acoe ficien .
x
Mean o emaining i em sco es was con e ed o ei he 0, 0.5, o 1.
Kø up e al. Medicine (2021) 100:52 Medicine
6
when in e p e ing he li e a u e awa e o hei s eng hs and
limi a ions.
In his s udy we chose o pe o m he me a-analysis using
IPDMA and u ilized his s udy design’s ad an ages o e
adi ional me a-analyses, one o hem being he possibili y o
en o ce equal ou come measu es o all s udies. En o cing less
s ic c i e ia on he alida ion o he measu emen s in exchange
o be e compa abili y, we had he possibili y o en o ce equal
accoun o con ounding influence s like age, gende , and medical
special y ac oss all samples, which mos o he s udies in his field
ha e no been able o do.
S ill, we we e no able o con ol o influence om local
cul u e o he han ha exe ed by he medical special y o which
he physicians belong. Di e ence in cul u al backg ound is no
solely an in e na ional challenge, bu a phenomenon ha may
jus as well be p esen in a sample o physicians om a single
uni e si y hospi al in a coun y wi h a di e se e hnic and eligious
landscape like he USA o mos Eu opean coun ies.
As coun ies keep acing simila diseases and p oblems in
heal h ca e i ollows ha hey should p io i ize in e na ional
pe spec i es in o he de elopmen o na ional heal hca e
s a egies. No leas wi h he Co id-19 pandemic we saw jus
how quickly a local i us ou b eak became he highes heal hca e
p io i y in e e y co ne o he wo ld. Illnesses ha con ain
spi i ual o exis en ial dimensions a e ubiqui ous, unde lining he
need o heal hca e p o essionals ha unde s and and can wo k
wi h hese dimensions o illnesses.
[38]
We also see how he wo ld is becoming inc easingly connec ed.
Medical knowledge, educa ion and e en heal h ca e wo ke s a e
c ossing bo de s e e y day, sha ing hough s and expe iences on
how o pe o m op imal heal h ca e. This con inual exchange o
in o ma ion (and cul u e) impac s fi s indi idual heal hca e
p o essionals, and second, he global medical communi y as a
whole in o some hing less dispa a e, and wi h g ea e and
compa able o e laps in ou iews on heal h ca e. We hus belie e
i impo an o con inually in es iga e he simila i ies and
di e ences be ween physicians wo ldwide, accep ing ha cul u e
con ibu es o he a ia ion in he sample.
4.2. Associa ion be ween R/S and R/S-B
This s udy u ilized aw da a om all samples ound in he
sys ema ic sea ches, which allowed us o measu e sample-wise
associa ions using mul iple eg ession while con olling o
known con ounde s. Coe ficien s we e weigh ed in he analysis
and p esen ed in he Fo es plo (Fig. 2). En o cing equal
calcula ion o ou come measu es o each included sample enabled
us o limi a ia ions in all compa isons. S ill, he included
samples we e collec ed om di e en pa s o he wo ld, and
hence i is only expec ed ha he g oups ha e dis inc
cha ac e is ics. Mos likely one o he p ima y influence s he e
we e local, egional, o na ional cul u e. S ill, no o he s udy has
pe o med c oss-cul u al compa isons while con olling o as
many o he possible con ounde s as we did in his s udy, and we
belie e ha we ha e aised he le el o e idence behind he
pos ula e ha eligious physicians mo e o en han hei non-
eligious colleagues engage in discussions wi h hei pa ien s
abou R/S-issues, including a en ion o he R/S needs o hei
pa ien s.
We we e no su p ised o find a posi i e associa ion be ween R/
S and R/S-B looking solely on he Ame ican sample because we
designed ou ou come measu es based on he a iables selec ed
by he o iginal Ame ican s udy.
[1]
This is, howe e , he fi s ime
his associa ion is documen ed using combined measu es o bo h
R/S and R/S-B in an Ame ican sample. Re- es ing his hypo hesis
using ano he s a is ical design li s he le el o e idence and
eassu es us in he now widely held belie ha many physicians
may be influenced by pe sonal belie and alue sys ems in clinical
p ac ice.
Due o ou exclusion c i e ia, 2 new B azilian samples by
Menega i-Chequini e al we e excluded om he analysis as hey
did no include he necessa y R/S-B a iables. Local analysis o
hei pilo sample did no find a significan co ela ion be ween
physicians’ equency o inqui y abou pa ien s’ eligious/
spi i ual issues and he physicians’ eligiosi y o spi i ual y in
an uncon olled compa ison o 2 single- a iables measu es.
[12]
La e he same esea ch g oup pe o med a mo e de ailed la en
p ofile analysis using a mo e complex measu e o R/S on 592
psychia is s con olling o co a ia es, showing ha less
eligious psychia is s less equen ly asked abou R/S-issues o
hei pa ien s.
[4]
Thei findings highligh he impo ance o obus
s a is ical analysis ha con ols o con ounde s. Menega i-
Chequini e al also sugges ha du a ion o psychia ic p ac ice
and le el o academic educa ion nega i ely co ela ed wi h being
in he g oup o highly eligious psychia is s. Un o una ely, ou
aw ma e ial a ailable in he p esen s udy did no allow us o
include hese pa ame e s as co a ia es.
Influences by co a ia es we e also epo ed in a Muslim sample
o 225 physicians by Al-Yousefie al The analysis con olled o
co a ia es, and did no find physician R/S a significan ac o o
inqui ing pa ien s abou R/S, bu a he ha highe age, male
gende and in insic eligiosi y we e posi i ely associa ed wi h
odds o physicians sha ing hei own R/S expe iences.
[13]
Also, a
Ge man s udy by Vol me e al epo s ha especially o emale
physicians, eligiosi y and spi i uali y we e posi i ely associa ed
wi h add essing R/S issues wi h pa ien s.
[8]
Two Danish s udies by Randwijk e al used a alida ed 4-i em
scale o “Religiosi y o Heal h P o essionals” ha epo ed a
posi i e associa ion bu did no con ol o a po en ial influence
o age, gende , o medical special y.
[5,7]
We included hese da a in
ou analysis and confi med he ea lie published findings e en
when co a ia es we e aken in o accoun .
4.3. Psychia is s e sus non-psychia is s
We pe o med a sub-analysis s a i ying he physicians in o a
g oup o psychia is s and a con ol g oup o physicians o o he
medical special ies. We could no de ec a di e ence in R/S
be ween he g oups using ou combined R/S-measu e (See
Table S4, Supplemen al Digi al Con en , h p://links.lww.com/
MD2/A687). Ea lie s udies iden ified a so-called “ eligiosi y
gap”be ween physicians and hei pa ien s, a gap ha was la ge
in psychia is s han in o he special ies;
[39]
ou s udy did no
subs an ia e his di e ence, on he con a y. Due o ou esea ch
design we we e no able o delinea e po en ial di e ences be ween
he mo e dis inc eligious and spi i ual dimensions in his
measu e, why we a e no able o disca d he hypo hesis ha
psychia is s a e less eligious bu mo e spi i ual.
Looking a he sel - epo ed beha io o he psychia is we
ound a significan di e ence compa ed o o he medical
special ies using ou combined R/S-B measu e in which
psychia is s sco ed highe . This di e ence may be explained
by how psychia is s wo k in a field whe e pa ien s o en ace
exis en ial c ises in ol ing p i a e sac ed en i ies ha a e ei he
Kø up e al. Medicine (2021) 100:52 www.md-jou nal.com
7
iola ed, h ea ened, o e en los . We use he e m “sac ed
en i ies”he e in he sense desc ibed by Pa gamen as p i a e co e
expe iences co e ing anscendence, boundlessness and ul ima-
cy.
[40]
This p emise in psychia y may cul i a e psychia is s’
abili y o mee , diagnose and ea hese pa ien s wi hin a
amewo k o unde s anding ha acili a es he exp ession o R/
S- alues cen al o he pa ien s’su e ing.
In he compa a i e analysis we did no find any significan
di e ence be ween he associa ion be ween R/S and R/S-B
be ween he 2 g oups. Based on hese da a we ha e no eason o
suspec ha any influence o pe sonal alues, whe he eligious o
spi i ual, exe a mo e significan o less influence on he
psychia is s han equal alues would a ec physicians om
o he medical special ies.
4.4. Cul u al independen influence o R/S on R/S-B?
In each mul iple eg ession analysis, we measu ed how much a
single poin inc ease in R/S-sco e changed he R/S-B sco e on
a e age o ha s udy. Following he hypo hesis ha eligion and
spi i uali y a e e y dis inc concep s we could no disca d he
possibili y ha an inc ease in R/S-sco e would impac R/S-B a
e y di e en a es o sepa a e samples and cul u es. Howe e ,
we ound ha he co ela ion coe ficien s o nine ou o he
ele en samples did no di e . We saw no significan posi i e
co ela ion o he sample om B azil, which may be explained
by he ac ha answe s we e collec ed using ace- o- ace
in e iews possibly limi ed ex eme answe s due o ea o
s igma iza ion. The sample om Congo di e ed significan ly
om all o he samples wi h an almos 2-poin inc ease in R/S-B
alue o each inc ease in R/S (1.87, 95% CI 1.57–2.17).
Howe e , his finding may be biased because we lacked
in o ma ion abou he medical special y o he physicians om
Congo and we e hus no able o include his a iable in he local
eg ession analysis. Fu he mo e, he samples om Congo and
Indonesia we e he only samples no o include any physicians
wi hou a eligious a filia ion. We hus canno ejec he
possibili y ha coe ficien s o hese 2 samples a e ou lie s due
o hei di e en designs, and o he Congo sample also
sampling.
We belie e we a e he fi s esea ch g oup o p esen plausible
s a is ical e idence ha he influence o R/S on R/S-B appea s o
be uni o m ac oss cul u es.
4.5. Limi a ions
Any compa ison o local su ey esul s mus be done wi h cau ion
due o he significan be ween-samples he e ogenei y. The
he e ogenei y was lowe in he analysis g ouped by medical
special y. Fu he s a ifica ion in u u e s udies may make
compa isons mo e easible.
E en hough he ques ionnai es we e adap ed o local cul u al
con ex , esponden s’unde s anding o eligiosi y and spi i uali y
may s ill a y be ween s udies o a deg ee no accoun ed o by
he ques ionnai es. This may ha e added o he he e ogenei y.
We ha e no been able o con ol o coho e ec s because
none o he samples ha e pe o med a ollow-up su ey.
The da ase om Lucche i, 2016, o B azilian physicians
[6]
was based on in e iews a he han sel -adminis e ed ques ion-
nai es, which may ha e led esponden s o gi e less-ex eme
answe s in ea o s igma iza ion. Con a y, ace- o- ace in e -
iews may limi acquiescence bias whe e esponde s i e ou in
w i en ques ionnai es and gi e he same answe o mul iple
subsequen ques ions.
The ou come measu es used in his s udy we e chosen om
a ailable da ase s, and o ensu e compa abili y wi h ea lie
esea ch, mainly he one-se ing wo k by Cu lin. The measu es
showed p omising ini ial eliabili y and we ound hem sui able
o ou pu pose. Should hey be used hence o h in new su eys
we highly ecommend e alua ing hem p io hand using bes
p ac ice guidelines like COSMIN
[41]
and s a is ical es ing using
ac o analysis.
We may ha e missed ele an po en ial con ounde s no
a ailable o us on ou da a ma e ial. Du a ion o wo king
expe ience and le el o academic deg ee a e wo h conside ing o
u u e s udies.
4.6. Pe spec i es
Ou s udy poin s o subs an ial in e ac ion o pe sonal alues and
clinical p ac ice ac oss cul u al se ings, whe he highly secula o
mo e eligiously inclined cul u es. Such in e ac ion can cons i u e
bo h ba ie s and acili a o s o high quali y heal h ca e. As
examples o ba ie s physician subjec i e alues can
1. b each wi h alues and p e e ences o pa ien s wi h di e en
alues,
2. can become a ojan ho se o hidden missiona y ambi ions
and
3. can b each wi h ideals o neu ali y in heal hca e.
As examples o acili a o s subjec i e alues can
1. enhance sensi i i y, unde s anding and empa hy wi h he
pa ien s wi h R/S o o he alue-based challenges o esou ces,
2. can s eng hen he pe sonal mo i a ion o he physician, and
3. can help an o ganiza ion eflec he alues ha ound i s
p ac ice.
5. Conclusion
This s udy confi med a posi i e associa ion be ween physicians’
own eligious and/o spi i ual cha ac e is ics and hei sel -
epo ed beha io ega ding eligiosi y and spi i uali y in clinical
p ac ice. Al hough R/S-B was mo e p e alen among psychia-
is s we did no find di e ences in R/S and R/S-B associa ion
compa ed o non-psychia is s.
We suspec ha cul u al di e ences con ibu ed o he la ge
he e ogenei y o he samples. S ill, associa ion coe ficien s
emained almos cons an when con olling o con ounde s,
indica ing a cul u al independen e ec o R/S on R/S-B, which o
ou knowledge, has no been documen ed be o e.
Reflexi i y on he in e play be ween subjec i e alues and
clinical p ac ice is o high ele ance o high quali y heal h ca e
and should be conside ed in all aspec s o pa ien and ela ionship
cen e ed medicine. T anspa ency seems o us he mos iable
app oach o a oiding ba ie s and enhance acili a o s o
subjec i e alues o physicians, an app oach o which he
p esen s udy seeks o con ibu e.
While local cul u e may explain why some physicians seem
mo e p epa ed o handle R/S-issues in clinical p ac ice han
o he s, we belie e hese skills can be augh and p ac iced ac oss
cul u es.
We ecommend u u e esea ch o include he de elopmen and
e alua ion o R/S p og ams o physicians, and ha a u u e
Kø up e al. Medicine (2021) 100:52 Medicine
8
me a-analysis o he associa ion be ween R/S and R/S-B be
pe o med as he NERSH Da a Pool g ows.
Acknowledgmen s
The au ho s wish o hank Fa A. Cu lin o his wo k wi hin his
field o esea ch and no leas o he de elopmen o he RSMPP,
upon which he NERSH da a pool es s. Also, Cu lin con ibu ed
wi h he Ame ican da ase included in he da a pool. Se e al
NERSH collabo a o s ha e con ibu ed o he NERSH da a pool
wi h local samples, o which we a e e y g a e ul: Ch is ian
Balsle an Randwijk, Can Kusey i, T yphon Mukwayakala,
Wya Bu che .
We also hank s a is ician Sonja Wehbe g who e iewed he
me a-analyses pe o med by he au ho s.
Au ho con ibu ions
Concep ualiza ion: Alex Kappel Kø up, Niels Ch is ian H id .
Da a cu a ion: Alex Kappel Kø up, Rocío de Diego-Co de o,
Ma ia Cecilia Menega i-Chequini.
Fo mal analysis: Alex Kappel Kø up.
Funding acquisi ion: Alex Kappel Kø up, Gianca lo Lucche i.
In es iga ion: Gianca lo Lucche i, Pa ameshwa an Ramak-
ishnan, Klaus Baumann, Eunmi Lee, Eckha d F ick, A nd
Büssing, Nada A Alyousefi, Azima ul Ka imah, Es he
Schou en, Inga We mu h, René He i, Niels Ch is ian H id .
Me hodology: Alex Kappel Kø up.
P ojec adminis a ion: Alex Kappel Kø up, Niels Ch is ian
H id .
Resou ces: Jens Sønde gaa d.
Supe ision: Jens Sønde gaa d, Niels Ch is ian H id .
Visualiza ion: Alex Kappel Kø up.
W i ing –o iginal d a : Alex Kappel Kø up.
W i ing – e iew & edi ing: Jens Sønde gaa d, Gianca lo
Lucche i, Pa ameshwa an Ramak ishnan, Klaus Baumann,
Eunmi Lee, Eckha d F ick, A nd Büssing, Nada A Alyousefi,
Azima ul Ka imah, Es he Schou en, Inga We mu h, René
He i, Rocío de Diego-Co de o, Ma ia Cecilia Menega i-
Chequini, Niels Ch is ian H id .
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