health - promoting lifestyle is a multidimensional pattern of self - initiated perceptions and actions , aimed to maintain and improve the individual s wellness1 , 2 . according to walker et al . , healthy lifestyle consists of six basic components : spiritual growth , nutrition , physical activity , interpersonal relations , health responsibility , and stress management1 , 2 . the relation between adoption of healthy lifestyle and disease prevention and health maintenance is well recognized3 , 4 . this might be derived from a direct influence , such as physical working conditions ( e.g. , exposure to heat or noise , work injuries ) , or through indirect influence , as a result of work characteristics ( e.g. , high workload and lack of flexibility in working hours ) , work environment policies ( e.g. , smoking prohibition ) , and through the effect of income on health outcomes . although one might expect that healthcare workers education and experience will promote their adherence to health - promoting behaviors , current evidence is inconclusive . studies among specific groups of health workers ( e.g. , medical doctors , nurses , etc . ) conclude that those were more inclined to adopt a healthy lifestyle including physical activity , lower alcohol consumption , periodic screening tests and healthier nutrition7 , 8 , 9 , 10 , 11 . on the contrary , other studies have shown that health workers do not adopt healthy lifestyle behaviors for various reasons , such as a false feeling of  protection  due to their medical knowledge , the tendency to prioritize their patients health over their own ( a dominant factor within the nursing profession ) , lack of time , fatigue , lack of motivation and insufficient exposure to healthy lifestyle promoting academic contents during their academic qualification12 , 13 , 14 , 15 . moreover , in a healthy - lifestyle - promotion project among health care workers , those reporting relatively unfavorable lifestyles were not more motivated to participate16 . to the best of our knowledge , there is no study that analyzed patterns of healthy lifestyle among a diverse group of healthcare workers including physicians , nurses , pharmacists , dietitians and administrators in comparison to workers in other professions . healthcare workers are expected to be more knowledgeable than others about health care behaviors and their long - term consequences . some are exposed on a daily basis to chronically ill patients whose illness is closely related to health - risk behaviors ( e.g. , diabetes ) . in addition , they are expected to act as role models17 , 18 ; physicians health behaviors were found to affect patients attitudes and motivation to make lifestyle changes19 . therefore , understanding the lifestyle patterns of healthcare workers , as well as the motivation for these patterns , may have possible implications on public health . this study s first objective was to examine whether healthcare workers adopt healthier lifestyles than workers in other professions . in addition , assuming such differences exist , the second objective was to explore whether being defined as a  caregiver  within the healthcare system ( thus directly involved in patients medical treatment ) is related to adoption of healthier lifestyle patterns . a cross - sectional observational study was conducted among a convenience sample of health care workers ( n=285 ) and workers in occupations ( n=137 ) . healthcare workers were recruited from leumit health services and meuhedet , two health plans ( hmos ) in israel and constituted of medical doctors ( n=43 ) , nurses ( n=105 ) , pharmacists ( n=75 ) , administrators ( n=27 ) , nutritionists ( n=10 ) and other health workers ( n=25 ) . a secondary classification of health workers defined caregivers as medical doctors , pharmacists , nurses and nutritionists ( n=233 ) , and non - caregivers as other healthcare workers ( n=48 ) . workers in other professions were recruited mainly from modiin - maccabim - reut municipality ( n=95 ) , and others were recruited using a snowball sampling technique ( n=42 ) . the health promoting lifestyle profile in its second version ( hplp - ii ) is a validated questionnaire that has been widely used for the measurement of health behaviors of workers in various occupations20 , 21 , 22 , 23 , 24 , 25 . it is a 52-item measure that refers to the six components of healthy lifestyle1 , namely , spiritual growth , nutrition , physical activity , interpersonal relations , health responsibility and stress management . respondents were asked to report how frequently they adopt the behavior presented in each item on a 4-point scale ranging from 1 ( never ) to 4 ( routinely ) . the second part of the questionnaire collected demographic characteristics ( gender , age , family status , religion , religiosity ) , education , income , work duration and self - rated health . the hplp - ii questionnaire was translated to hebrew following accepted standards , and aspects regarding the questionnaire s clarity were assessed through a pilot study prior to distributing the final version . the questionnaires were distributed via e - mails and workers were informed that their responses would be kept anonymous . in order to increase response rate , reminders were sent periodically by the contact person in each of the cooperating institutions . the overall response rate was 19.1% ( 26.1% at leumit health services , 9.5% at meuhedet , 29.6% at modiin - maccabim - reut municipality and 23.7% in the snowball sampling method ) . the study was approved by all cooperating institutions and by the human subjects research committee of the gilford glazer faculty of business and management , ben - gurion university of the negev ( # ts09072013 ) . a non - normally distributed continuous variable ( age ) is presented as median ( minimum - maximum ) . comparison between groups medians and proportions was done using mann - whitney u test and chi - square test , respectively . we used multivariable linear regression analysis to examine predictors of adoption of each of the six components of the healthy lifestyle profile ( dependent variables ) . in order to examine whether healthcare occupation increases the odds to engage in healthy lifestyle , we specified multivariable logistic regression models . for this purpose , respondents were defined as those who never or sometimes engage in healthy lifestyle , score2.5 , and those who often or routinely engage in healthy lifestyle , score>2.5 . for the analysis of the odds to adopt physical activity ( and since the variable distribution enabled it ) , respondents were defined as those who never engage in physical activity , score<1.5 , and those who sometimes , often , or routinely engage in physical activity , score1.5 . the area under the receiver operating characteristic ( roc ) curve was presented for the models predictive power . all models included occupation type ( healthcare vs. others ; caregivers vs. other healthcare workers ) , age , gender and education ( higher education ( i.e. , bachelors , master s , or doctoral degree ) vs. secondary education ) , as independent variables . additional independent variables including religion , marital status and health status , were included following evidence of bivariate significant association . a cross - sectional observational study was conducted among a convenience sample of health care workers ( n=285 ) and workers in occupations ( n=137 ) . healthcare workers were recruited from leumit health services and meuhedet , two health plans ( hmos ) in israel and constituted of medical doctors ( n=43 ) , nurses ( n=105 ) , pharmacists ( n=75 ) , administrators ( n=27 ) , nutritionists ( n=10 ) and other health workers ( n=25 ) . a secondary classification of health workers defined caregivers as medical doctors , pharmacists , nurses and nutritionists ( n=233 ) , and non - caregivers as other healthcare workers ( n=48 ) . workers in other professions were recruited mainly from modiin - maccabim - reut municipality ( n=95 ) , and others were recruited using a snowball sampling technique ( n=42 ) . the health promoting lifestyle profile in its second version ( hplp - ii ) is a validated questionnaire that has been widely used for the measurement of health behaviors of workers in various occupations20 , 21 , 22 , 23 , 24 , 25 . it is a 52-item measure that refers to the six components of healthy lifestyle1 , namely , spiritual growth , nutrition , physical activity , interpersonal relations , health responsibility and stress management . respondents were asked to report how frequently they adopt the behavior presented in each item on a 4-point scale ranging from 1 ( never ) to 4 ( routinely ) . the second part of the questionnaire collected demographic characteristics ( gender , age , family status , religion , religiosity ) , education , income , work duration and self - rated health . the hplp - ii questionnaire was translated to hebrew following accepted standards , and aspects regarding the questionnaire s clarity were assessed through a pilot study prior to distributing the final version . the questionnaires were distributed via e - mails and workers were informed that their responses would be kept anonymous . in order to increase response rate , the overall response rate was 19.1% ( 26.1% at leumit health services , 9.5% at meuhedet , 29.6% at modiin - maccabim - reut municipality and 23.7% in the snowball sampling method ) . the study was approved by all cooperating institutions and by the human subjects research committee of the gilford glazer faculty of business and management , ben - gurion university of the negev ( # ts09072013 ) . a non - normally distributed continuous variable ( age ) is presented as median ( minimum - maximum ) . comparison between groups medians and proportions was done using mann - whitney u test and chi - square test , respectively . we used multivariable linear regression analysis to examine predictors of adoption of each of the six components of the healthy lifestyle profile ( dependent variables ) . in order to examine whether healthcare occupation increases the odds to engage in healthy lifestyle , we specified multivariable logistic regression models . for this purpose , respondents were defined as those who never or sometimes engage in healthy lifestyle , score2.5 , and those who often or routinely engage in healthy lifestyle , score>2.5 . for the analysis of the odds to adopt physical activity ( and since the variable distribution enabled it ) , respondents were defined as those who never engage in physical activity , score<1.5 , and those who sometimes , often , or routinely engage in physical activity , score1.5 . the area under the receiver operating characteristic ( roc ) curve was presented for the models predictive power . all models included occupation type ( healthcare vs. others ; caregivers vs. other healthcare workers ) , age , gender and education ( higher education ( i.e. , bachelors , master s , or doctoral degree ) vs. secondary education ) , as independent variables . additional independent variables including religion , marital status and health status , were included following evidence of bivariate significant association . four hundred twenty - two participants were included in our analysis ( median age of 43 ( 2373 ) and 23.8% males ) . table 1 summarizes the differences in personal characteristics between healthcare workers ( n=285 ) and workers in other occupations ( n=137 ) . no significant differences were found between groups with regard to age , family status , income per person and self - rated health . however , compared to others , lower proportions of healthcare workers were male and jewish ( 20.4% versus 30.6% , p=0.024 ; 90.4% versus 99.3% , p=0.001 ; respectively ) . in addition , a higher proportion of healthcare workers were employed 2025 years and more than 25 years ( 13.7% versus 6.0% , 26.4% versus 11.9% , p<0.001 ) . finally , a higher proportion of health care workers had higher education compared to workers of other professions ( 85.8% versus 72.8% , p=0.001).table 1 . comparison of characteristics between healthcare workers and workers of other occupationscharacteristichealthcare workersnon - healthcare workersp - valuen285137age ( median ( min - max))43 ( 2368)43 ( 2773)0.785gender ( % male)20.430.60.024religion ( % jews)90.499.30.001religiosity among jews ( % ) secular34.756.9<0.001traditional14.424.1religious30.514.6orthodox9.12.2family status ( % married)87.985.20.433employment years ( % ) 059.918.7<0.00151020.117.2101520.422.415209.523.9202513.76.0above 2526.411.9education ( % higher education)85.872.80.001mean monthly income per person ( % ) low / very low compared to average38.245.50.314average24.023.5high / very high compared to average37.831.1self - rated health ( % ) not very good / not good at all4.22.90.513good40.433.6very good49.156.9 mann - whitney u test the analyses reveal that healthcare workers adopt better nutrition ( =0.228 , p<0.001 ) , more physical activity ( =0.133 , p=0.049 ) and higher health responsibility ( =0.131 , p=0.016 ) . however , such differences were not found between healthcare workers and others with regard to spiritual growth ( =0.097 , p=0.121 ) , interpersonal relations ( =0.039 , p=0.444 ) and stress management ( =0.053 , p=0.299 ) . first , healthcare occupation increased the odds of workers to adopt better nutrition ( or ; 95% confidence interval ( ci ) : 1.68 ; 1.042.73 ) and physical activity ( or ; 95% ci : 1.96 ; 1.113.48 ) ; however , we could not confirm the results with regard to health responsibility . namely , healthcare occupation did not increase the odds of healthcare workers to adopt higher health responsibility ( or ; 95% ci : 1.30 ; 0.762.21 ) . similar to the findings of the linear models , healthcare occupation did not increase the odds of healthcare workers to engage in spiritual growth ( or ; 95% ci : 1.34 ; 0.722.50 ) , better interpersonal relationships ( or ; 95% ci : 1.30 ; 0.692.46 ) , and better stress management ( or ; 95% ci : 1.08 ; 0.582.01).table 2 . multivariable linear analyses of determinants of adoption of healthy lifestyle - healthcare workers compared to othershealthy lifestyle componentsp - valuenutrition ( n=365 , r=0.11)0.228<0.001physical activity ( n=366 , r=0.12)0.1330.049health responsibility ( n=391 , r=0.13)0.1310.016spiritual growth ( n=341 , r=0.07)0.0970.121interpersonal relationships ( n=365 , r=0.05)0.0390.444stress management ( n=366 , r=0.05)0.0530.299 independent variables included in the model : age , gender , education multivariable logistic models of determinants of adoption of healthy lifestyle- healthcare workers compared to othershealthy lifestyle componentsor95% cip - valuearea under the roc curvenutrition ( n=365)1.681.042.730.0360.686physical activity ( n=366)1.961.113.480.0210.697health responsibility ( n=391)1.300.762.210.3370.690spiritual growth ( n=341)1.340.722.500.3500.708interpersonal relationships ( n=365)1.300.692.460.4140.716stress management ( n=366)1.080.582.010.8020.646 respondents who reported they adopted a healthy lifestyle often or routinely vs. those reported never or sometimes . respondents who reported they exercise sometimes , often or routinely vs. those reported they never exercise additional significant predictors : religion respondents who reported they adopted a healthy lifestyle often or routinely vs. those reported never or sometimes . respondents who reported they exercise sometimes , often or routinely vs. those reported they never exercise   additional significant predictors : religion .   additional significant predictors : health status , religiosity . two hundred and eighty - five healthcare workers were included in our analysis , of whom 233 were caregivers and 48 were administrative workers ( median age 43 ( 2368 ) , and 20.4% males ) . no significant differences were found between groups with regard to age , family status and self - rated health . however , compared to others , higher proportions of caregivers were males ( 22.9% versus 8.3% , p=0.023 ) and lower proportions of caregivers were jewish ( 88.2% versus 100% , p=0.012 ) . in addition , higher proportions of caregivers were employed 2025 years and more than 25 years ( 14.7% versus 10.4% , 30.6% versus 8.3% , respectively ; p=0.003 ) and had a higher education ( 91.7% versus 56.3% , p<0.001 ) . finally , higher proportions of caregivers had higher than average monthly income ( 43.3% versus 10.6% , p<0.001 ) . the multivariable linear analyses presented in table 4 examine whether the healthier lifestyle adopted by healthcare workers with regard to nutrition , physical activity and health responsibility is related to being caregivers . among healthcare workers , compared to non - caregivers , being a caregiver was not associated with better nutrition ( =0.077 , p=0.416 ) , more physical activity ( =0.026 , p=0.809 ) , or greater health responsibility ( =0.145 , p=0.092 ) . compared to the administrative personnel , health caregivers did not have higher odds to adopt physical activity ( or ; 95% ci : 1.45 ; 0.524.02 ) or higher health responsibility ( or ; 95% ci : 0.67 ; 0.311.43 ) . however , this analysis revealed that compared to the administrative personnel , health caregivers had higher odds to adopt better nutrition ( or ; 95% ci : 2.70 ; 1.196.13).table 4 . multivariable linear analyses of determinants of adoption of healthy lifestyle - caregivers compared to administrative personnel within the healthcare systemhealthy lifestyle componentsp - valuenutrition ( n=240 , r=0.05)0.0770.416physical activity ( n=240 , r=0.11)0.0260.809health responsibility ( n=257 , r=0.15)0.1450.092 independent variables included in the model : age , gender , education multivariable logistic models of determinants of adoption of healthy lifestyle- caregivers compared to administrative personnel within the healthcare systemhealthy lifestyle componentsor95% cip - valuearea under the roc curvenutrition ( n=240)2.701.196.130.0180.737physical activity ( n=240)1.45.524.020.4740.730health responsibility ( n=257)0.67.311.430.3020.733 respondents who reported they adopted a healthy lifestyle often or routinely vs. those reported never or sometimes . respondents who reported they exercise sometimes , often or routinely vs. those reported they never exercise additional significant predictors : religion . respondents who reported they adopted a healthy lifestyle often or routinely vs. those reported never or sometimes . respondents who reported they exercise sometimes , often or routinely vs. those reported they never exercise   additional significant predictors : religion . according to our findings , healthcare workers adopt healthier nutrition , more physical activity and greater health responsibility compared to workers in other occupations . however , this trend was not observed with regard to spiritual growth , interpersonal relations , and stress management . finally , compared to healthcare workers who are not caregivers , being a caregiver was not associated with better nutrition and greater health responsibility . our finding that healthcare workers adopt better nutrition is congruent with those of two other studies among physicians7 , 9 . as noted by the authors in one of these studies , the reason for this is that physicians typically believe they were perceived as being more professional if they lived balanced lives . however , a review of health behaviors ( including nutrition ) of israeli doctors found that physicians disregard maintaining a healthy diet , perhaps due to feeling protected by their own knowledge12 . our study investigated health - promoting behaviors among healthcare workers mainly in community clinics , whereas the review addressed both community and hospital workers . work in hospitals is characterized by long and often stressful working hours that may not enable workers to adjust mealtime to hunger , thus they may eat larger amounts eventually . in addition , hospital workers have greater accessibility to buffets , which typically serve fatty , salty and non - balanced meals , as well as food machines with snacks , sweets or sweetened beverages ; thus compared to community clinic workers , they may be more inclined to consume unhealthy food . intervention targeted at improving healthcare workers attitudes toward better lifestyle resulted in a decrease in waist circumference due to actual adherence to a better diet26 . thus , qualitative research may be required in order to reveal healthcare workers perceptions and preferences and discover reasons for their behavior . we demonstrate that healthcare workers practice physical activity more often than workers in other occupations . these findings are similar to the findings of other studies among physicians , cardiac nurses and medical students8 , 10 , 11 , 27 , 28 , 29 . compared to healthcare workers in the community setting , workers in hospitals face heavier workloads and rotating longer shifts , and thus may feel more tired and do not have the time to practice physical activities . in addition , our results are different from studies that were focused on physical activity patterns only among nurses13 , 15 , 30 . physical activity patterns among nurses were , according to the investigators , very poor , and led the investigators to strongly recommend an intervention15 . however , our study population consisted of a mixed group of healthcare workers , i.e. , 285 workers of which only 37% were nurses . future research should analyze each sector separately and explore the reasons if and why specific groups are more likely to adopt physical activity than others . another study that investigated lifestyle patterns among physicians provided similar conclusions7 . yet , other studies that examined rates of performing preventive screenings ( such as cholesterol levels , blood pressure , mammograms , colonoscopy , etc . ) among healthcare workers compared to the general population , either displayed no differences , or even showed that healthcare workers performed less preventive screening17 , 31 . the reason for this apparent contradiction may be derived from the fact , that the hplp - ii part that refers to health responsibility does not address the actual performance of preventive checkups , but rather general statements in this regard , for example , reporting unusual signs or symptoms , seeking health education and consulting professionals . first , it is assumed that healthcare workers believe that they are expected to act as role models and that adopting a healthier lifestyle is important in order to be perceived as a professional by their patients . a study aiming to examine the relationship between adoption of healthy lifestyle and self - perception of professionalism among nurses , has found that nurses who adopted healthier lifestyle patterns had a significantly better self - perception of their own professionalism and self - rated health30 . another study among physicians has shown that 75% of the respondents believe that they are expected to act as role models by following a healthy lifestyle32 . nonetheless , our hypothesis that healthcare workers adopt healthier lifestyle behaviors due to being caregivers who are expected to act as role models was not confirmed . no significant differences in the adoption of health promoting behaviors were found between caregivers and other healthcare workers . however , due to the small sample of non - caregiver workers ( n=48 ) and the low predictive power of the models , this issue should be further examined both qualitatively and quantitatively among a representative samples in order to reach a definite conclusion . secondly , we suggest that healthcare workers adopt healthier nutrition , physical activity and health responsibility patterns , because they possess much greater knowledge regarding health promoting behaviors and their long - term effects on health outcomes , and are exposed on a daily basis to chronically ill patients , whose illness is closely related to health - risk habits . these unique characteristics of healthcare workers may facilitate the changing horizon in occupational health , namely the progress from work - related hazards prevention towards healthy lifestyle - related disease prevention33 . however , little is known about the relationship between routine exposure to chronically ill patients and the healthy lifestyle of healthcare workers that are involved in their therapy . considering the fact that no differences in healthy lifestyle behaviors were found between caregivers and other healthcare workers in our study , this assumption was not confirmed . as opposed to the above mentioned components of the healthy lifestyle profile , no differences were found between healthcare workers and others with regard to spiritual growth and interpersonal relations . the underlying reason might be that these components may not be perceived to have direct influence on health outcomes ( in contrast to physical activity and diet ) . the aspects of spiritual growth and interpersonal relations are somewhat neglected in literature , and to the best of our knowledge , there is no study that explores the relationship between these unique components and healthcare occupation . moreover , the low predictive power of the multivariable models of these components implies that there are other independent variables influencing these components that were not observed in our study , thus requiring further exploration . finally , no differences were found between healthcare workers and others with regard to stress management abilities . the high levels of occupational stress and burnout among healthcare workers have been widely explored34 , 35 , 36 , 37 , 38 . although there are no studies comparing stress management between health care workers and others , some non - comparative studies among nurses have shown they demonstrate poor stress management skills15 , 30 . many reasons contribute to the nurses inability to cope with work stressors , including lack of time , lack of tools to choose a specific method for coping with stress , the difficulty in prioritizing between many tasks simultaneously and the lack of social and occupational support networks15 . future studies are also needed in this regard , since the predictive power of our multivariable model for this component was relatively low . first , neither of the groups of workers examined is a representative one , due to study settings , low sample size and low response rates . in both groups of respondents , healthcare workers were recruited in the community setting and thus do not represent hospital workers . workers of other occupations were recruited mainly from modiin - maccabim - reut municipality , and since the population of this city is characterized by higher than average socio - economic status39 , it can not be regarded as representative of the general population . due to the well - established connection between socio - economic level and healthy lifestyle and health outcomes40 , there might have been an overestimation of health promoting behaviors among this group . yet , the fact that healthcare workers reported they adopt better nutrition , more physical activity and greater health responsibility , despite being compared to workers with relatively high socio - economic status , strengthens our findings . the distribution of questionnaires via e - mails , which resulted in relatively low response rates , led to the misrepresentation as well . despite the obvious advantages of web - based surveys , there is evidence that gathering information through this method might lead to low response rates , which remain low even after sending periodic reminders41 . future studies should consider other measures of questionnaire and reminders distribution and design them in a way that would enhance response rate . the second limitation of this study is the low predictive power of the multivariable models of spiritual growth , interpersonal relations and stress management . this indicates the existence of other influential variables related to these unique components , which we are unaware of , and should be investigated in future research . possible variables that may be considered in this exploration include self - efficacy , mental wellbeing ( depression , in particular ) , self - esteem and time proximity to health shocks . notwithstanding these limitations , this preliminary study is , to our knowledge , the first to address the healthy lifestyle profile of a diverse group of healthcare workers in israel . moreover , besides examining the traditional aspects of healthy lifestyle ( such as nutrition and physical activity ) , this study is unique by addressing spiritual growth , interpersonal relations and stress management , which are known as integral components of a healthy lifestyle , yet are usually ignored . future research among representative samples of both healthcare workers and others is warranted to substantiate these results , with special attention to exploring the reasons of the observed differences and the obstacles that prevent adoption of a healthier lifestyle . these analyses may ultimately enable design of workplace health promotion programs aimed to improve adoption of health promoting behaviors . health care workers may be key actors in promoting healthy lifestyles of the public ; it was found that improving adoption of healthy lifestyle of healthcare workers had a positive impact on the adoption of healthy lifestyle by their patients , thus their patients health outcomes improve through a  halo effect42 . hence , another potential promising benefit to such tailor - made worksite interventions may be improving public health . in this era of continuous lack of resources in the healthcare system and the growing expenditures on chronic illnesses , the possibility of improving adherence to health promoting behaviors and public health outcomes through improving the health lifestyle profile of their health caregivers is a promising strategy that should be further explored .
to compare the adoption of healthy lifestyle behaviors , including : spiritual growth , nutrition , physical activity , interpersonal relations , health responsibility , and stress management , of healthcare workers with workers of other professions . 
 cross - sectional observational study among a convenience sample of 285 healthcare workers and 137 of other professions . 
 the health - promoting lifestyle profile - ii ( hplp - ii ) , a 52-item measure regarding the six components of healthy lifestyle . 
 demographic characteristics , education , income , work duration and self - rated health were also collected . 
 multivariable linear models were specified for each of the components of healthy lifestyle . 
 both groups were comparable in their age , family status , income and self - rated health . 
 results of multivariable linear models revealed that healthcare workers adopt better nutrition ( =0.228 , p<0.001 ) , more physical activity ( =0.133 , p=0.049 ) , and greater health responsibility ( =0.131 , p=0.016 ) , compared to other professions . 
 such differences were not found with regard to spiritual growth ( =0.097 , p=0.121 ) , interpersonal relations ( =0.039 , p=0.444 ) , or stress management ( =0.053 , p=0.299 ) . 
 healthcare workers adopt better healthy lifestyle only in components that may be perceived to have direct influence on health outcomes , namely nutrition , physical activity , and health responsibility . further research that will explore the reasons for the observed differences may enable designing health - improving interventions .