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TYPE
Original Research
PAGE NO.
6-14
10.37547/tajmspr/Volume07Issue01-02
OPEN ACCESS
SUBMITED
16 October 2024
ACCEPTED
09 December 2024
PUBLISHED
08 January 2025
VOLUME
Vol.07 Issue01 2025
CITATION
Walid Mahmoud Khalilia. (2025). Evaluation of radiographers knowledge
about radiation safety and cancer risks of ionizing radiation exposure. The
American Journal of Medical Sciences and Pharmaceutical Research,
7(01), 6
–
14. https://doi.org/10.37547/tajmspr/Volume07Issue01-02
COPYRIGHT
© 2025 Original content from this work may be used under the terms
of the creative commons attributes 4.0 License.
Evaluation of
radiographers knowledge
about radiation safety and
cancer risks of ionizing
radiation exposure
Walid Mahmoud Khalilia
Department of Forensic Science, Al Istiqlal University, Jericho, Palestine.
Abstract:
Ionizing Radiation (IR) crucial to both
therapeutic and diagnostic methods. However, it has
hazardous exposure effects on patients and workers in
radiation environment personnel. This study aimed to
assess the level of knowledge among radiographers
working in the private and public hospitals in Palestine
about radiation safety and cancer risks of radiation
exposure. Online questionnaires were distributed to 74
radiographers at seven private and public hospitals in
Palestine. Four demographic characteristics and 17
several options questions about radiation protection
were included in the survey. This study revealed that the
mean of correct scores was (7.20) out of 17 enquiries
from Palestinian radiographers on radiation safety. The
current investigation revealed a inadequate knowledge
of radiation protection and safety. (40.5%) of the
radiographers admitted seldom received any training
about radiation protection. While only (2.7%) of them
reported that they regularly attended such training. and
(27.0%) they never attended it. The knowledge score
according to work experience, hospital type, and gender
did not have statistical significance. In terms of
academic level showed significant differences (P< 0.05),
postgraduates’ level of knowledge score was
(10.2±2.13), higher than undergraduates (6.88±1.51).
The results show that the radiographers involved in this
study lacked sufficient understanding on radiation
protection and safety. Therefore, the most crucial topic
is the administrations of the foundations using radiation
have to exercise prudence by supplying staff or the
essential infrastructure in the form of equipment and
training.
Keywords:
Ionizing Radiation, Radiation Dose, Cancer
Risks, Radiation Safety, Radiography.
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INTRODUCTION:
Ionizing Radiation (IR) is frequently used in routine
medical procedures. It is crucial to both therapeutic
and diagnostic methods. However, IR has hazardous
exposure effects on patients as well as radiographers
and other workers in radiation environment personnel
Alyousef [1].
According to various research, exposure to medical
radiation raises the possibility of infertility, blindness,
birth defects, and stem cell inhibition [2-4]. According
to several claims, there is a connection between the
development of lifelong cancer and an increase in
radiation from artificial IR sources [5-8]. By this rises,
radiation protection has become more significant to
protect welfare and the health of healthcare workers,
patients and community [8]. Because of this rise
radiation safety, it is now more crucial than it was in
the past to safeguard the health and welfare of
patients, healthcare workers, and society.
The three main ideas of radiation safety against
ionising radiation risk are justification, optimising, and
dose limit. Because medicinal radiation exposure has
particular consequences, the diagnosis guideline value
is usually used as an indicator instead of dosage limits.
In addition to As Low As Reasonably Achievable
(ALARA) principles are believed to be the primary
concepts supporting radiation dose reduction.
Following these recommendations, a reliable
diagnostic image can be obtained at the lowest
possible dose [9]. The science of shielding people and
the environment from the harmful effects of ionising
radiation is known as radiation protection. It can also
refer to any measures implemented to limit the
radiation exposure of patients and employees during
x-ray procedures [10]. The most important objective of
radiological protection is to supply the public,
employees, and patients detailed instructions for using
IR safely [11].
Survey of the released scientific literature reveals that
the growing use of medical radiation can be partially
attributed to professionals, doctors, medical students,
trainees, and family caregivers. They have inaccurate
and frequently insufficient knowledge about radiation
safety, risks, and doses associated with regular imaging
procedures [12-16]. Surprisingly, there are few studies
among radiographers. When high dose investigations
are performed without optimizing, this kind of
knowledge about radiation risk can be quite dangerous
and keep patients at risk for a considerable biological
life. Overall, these and other studies show that medical
personnel have a limited awareness of the radiation
risks that patients face during routine imaging
investigations and are unable to accurately respond to
the questions that patients frequently ask [15-18].
Their level of radiation safety understanding influences
the reactions of employees. Insufficient knowledge of
the subject matter will make their activities unsafe and
may have unfavorable effects. It is critical that the
medical community learns the terms, common tools,
and accepted procedures used in radiation safety and
monitoring in order to protect patients, providers, and
employees [19]. According these facts, the purpose of
this study was to find out how well versed radiographers
who work in radiation-exposed environments are in
applications related to radiation protection.
METHODOLOGY
1.
Population and sample
This prospective, cross-sectional and descriptive
approach study was performed to assess the knowledge
level of radiation preventive and cancer risks of
exposure between radiographers working in the
radiology departments of seven hospitals in north
governments of West Bank in Palestine. From which
three private and four public hospitals in Nablus, Jenin,
Tubas and Tulkarm (Figure 1). The participants aware
that the findings would be used for a scientific research
only.
Figure 1. The geographical distribution of hospitals in northern governorates of West Bank in Palestine.
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2.
Study tool
Following a comprehensive evaluation of the literature
and an extensive investigation of web resources [1, 4,
20], an online item-based questionnaire was
developed. Three parts made up the validated
questionnaire. Among the socio-demographic traits
covered in the first part are sex, formal education, type
of hospitals, and work experience. The 16 multiple-
choice questions in the remaining two parts asked
about general knowledge, awareness, and experience
with medicinal radiation imaging. The degree of
knowledge and perception of radiation safety and
protection principles was assessed using ten questions
(Section 2). Specific topics include: (1) radiation safety
standards; (2) radiation exposure risks; (3) regulations;
(4) dosimeter information; (5) IR sensitivity; (6) lead
aprons and the level lead diameter in aprons and
goggles; and (7) which organ is more vulnerable to
radiation damage. The remaining six questions
assessed respondents' understanding of the dangers of
radiation exposure for cancer (Section 3).
Google Forms was used to build an online version of
the questionnaire, which makes it easier for
participants to complete and enables researchers to
automatically and instantly collect data without
introducing bias into the process. The link to complete
the questionnaire was emailed to prospective
participants between April 1, 2024, and May 30, 2024.
The participants were given explicit instructions to
finish the questionnaire within 30 minutes. An
additional email was sent to participants two weeks
following the initial one in an effort to entice more of
them to reply to the survey. The participants were
strongly advised not to reply to the questionnaire again
if they had already finished it in order to avoid
duplications.
3.
Data analysis
The SPSS, 22.0 software was applied to analyse the
obtained data; for the analysis of demographic data,
frequency and percentage was calculated and the
average and SD were studied. There was just one
correct answer for each of the five multiple-choice
questions in Sections 2 and 3. The maximum achievable
score in these two sections were 17. ANOVA was used
to study the variations in the categories' grades of
radiation safety knowledge by gender, formal
education, expertise, and medical institution type, in
addition to the chi-square test was performed.
RESULTS
1. Analysis of radiographers’ knowledge about
radiation protection and safety
A total of 74 potential radiographers participated and
completed the questionnaire for a reply rate of (67.3%).
Most of the participants were males (56.8%) and had
undergraduate formal education (67.6%). Only (43.2%)
of participants were employed in a private hospital and
(56.8%) in a public hospital. Regarding to their work
experience, The majority of the respondents (40.5%)
had previous expertise which was less than 3 years.
(32.4%) more than 10 years, while (27.0%) between 3 to
10 years of experience (Figure 2A).
A B
Figure 2. Distribution of the respondent community according to the demographic data and Percent of
participants attending training programs about IR protection
3%
30%
40%
27%
Regularly
Irregularly
Seldom
Never
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When participants were asked about attending
training programs in IR protection, only (2.7%) of the
respondents answered that they regularly attended
training courses and (27.0%) they never attended
training. While (40.5%) of them admitted that they
seldom had any training about IR protection (Fig. 2B).
With a result of one for every right response and zero
for wrong or unclear responses, the overall average of
the correct answers was 7.20 out of 17. The lowest and
highest scores were 2 and 12, respectively. As shown in
Figure (3), the average of right responses for the second
section on knowledge level of IR protection and safety
(6.58 out of 11) were better than the average of the
third section on radiographers knowledge of cancer
risks of radiation exposure (0.62 out of 6).
Fig. 3. Mean of participants correct score for the knowledge level of ionizing radiation protection and safety
(11 questions), cancer risks of radiation exposure (6 questions), and the total mean of correct score (17
questions)
2. Analysis of radiographers’ knowledge about cancer
risks of radiation exposure
Most of the questions (59.83 %) related to the
knowledge of radiation safety were answered
correctly, (31.45%) were incorrect and (8.72%) were
with no idea (Table 1). (94.59 %) of the radiographers
knew the meaning of ALARA principle of radiation
safety and (89.19%) of them knew that MRI has no
radiation risks. Only (18.92%) of participants knew that
the average natural background radiation is in the range
2
–3 mSv annually. The radiographers’ knowledge about
dosimeters and lead goggle questions was low, only
(35.14%) answered correct for both questions. More
than (55%) of participants answered correctly the two
questions about lead apron and (75.68%) of participants
knew that IR could be hazardous to the eyes, thyroid
gland, and ovary organs (Table 1).
Table 1. Analysis of respondents’ knowledge about radiation protection, safety and cancer risks of radiation
exposure (N = 74)
Section 2:
Radiographers’ knowledge about radiation protection and safety
No.
Question
Correct
answer
Incorrect
answer
No Idea
answer
Freq.
%
Freq.
%
Freq.
%
1
Meaning of ALARA principle of radiation protection
70
94.59
0
0
4
5.41
2
Which of these poses no risk of radiation?
66
89.19
4
5.41
4
5.41
3
Average natural background radiation
14
18.92
50
67.57
10
13.51
4
Most sensitive age group to radiation
50
67.57
20
27.03
4
5.41
5
Most sensitive organ to radiation
56
75.68
14
18.92
4
5.41
6
The main source of radiation exposure for employees
in the intervention room
24
32.43
46
62.16
4
5.41
7
Thickness of lead in the lead apron
58
78.38
8
10.81
8
10.81
8
What is the safe separation between the employee
54
72.97
8
10.81
12
16.22
6.58
0.62
7.2
0
1
2
3
4
5
6
7
8
Mean of participants correct scour
11 questions
6 questions
17 questions
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and the X-ray machine?
9
Regarding dosimeters, which of the following claims
is accurate?
26
35.14
46
62.16
2
2.70
10
Regarding lead goggle, which of the following
claims is accurate?
26
35.14
32
43.24
16
21.62
11
Regarding lead apron, which of the following claims
is accurate?
43
58.11
28
37.84
3
4.05
Average
44.27
59.83
23.27
31.45
6.45
8.72
Section 3: Respondents’ knowledge about imaging techniques and the lethal cancer risks they pose
1
Chest CT
18
24.32
16
21.62
40
54.05
2
Abdomen CT
4
5.41
32
43.24
38
51.35
3
Coronary CT angiography
6
8.11
24
32.43
44
59.46
4
Brain CT
6
8.11
25
33.78
43
58.11
5
Whole-div Positron Emission Tomography (PET)
3
4.05
27
36.49
44
59.46
6
Chest CT
10
13.51
20
27.03
44
59.46
Average
7.83
10.59
24
32.43
42.17
56.98
Analysis of radiographers’ knowledge about cancer
risks of radiation exposure
By analyzing the data of this third section about
radiographers’ awareness of the risks of IR on the
development of fatal cancer, it was found that most of
the participants in this study answered the six
questions incorrectly or no idea, with an average of
(32.43%) and (56.98%), respectively. Only (10.59%) of
them answered correctly the same questions of this
section (Table 1).
3. Analysis of radiogra
phers’ knowledge according to
the demographical parameters
The study participants' responses were examined in
light of individual characteristics including the
radiographers' gender, experience, hospital type, and
level of education. The findings are shown in Table (2).
The maximum possible score of sections two and
three, and the total correct score (out of 17) were for
postgraduate radiographers with mean scores of
(8.21±2.09), (1.96±1.96), and (10.2±2.13) respectively
(Table 2). As for the gender of the participants, the
average correct responses for males and females were
adjacent, with a slight advantage for females regarding
knowledge of radiation safety (section2) with a mean
score of (7.31± 0.95) for females and (6.02± 1.55) for
males. Regarding to the type of hospital in which the
participants worked, the mean score of correct answers
of radiographers in public hospitals were slightly better
than those in private hospitals for the two sections and
for total (Table 2).
It is evident from Table (2) that the results supported
the hypothesis that there are no notable variation (P >
0.05) between the means of participants' correct
responses concerning gender, experience and type of
hospital in terms of their awareness of IR safety (section
2) and their knowledge level of cancer risks of radiation
exposure (section 3).
Table (2) clearly shows a notable distinction (P < 0.05) in
the averages of radiographers' responses based on the
educational level variable. This disparity is observed
both in terms of radiographers’ knowledge of sections
two and three. Specifically, postgraduates exhibit the
highest mean level of knowledge score toward radiation
safety for all questions (10.2±2.13) compared to
undergraduates’ radiographers (6.88±1.51) (Table 2).
Table 2. Mean score of participants’ c
orrect answers for each of studied section and total with statistical
significance.
Variables
Category
Frequency
(%)
Mean correct scour ± SD
P- Value
Section 1
out of 11
Section 2
out of 6
Total
out of 17
Gender
Male
32 (43.2)
6.02± 1.55
0.71± 0.98
6.74± 1.80
0.122
Female
42 (56.8)
7.31± 0.95
0.50± 1.20
7.81± 1.05
Education
Undergraduate
50 (67.6)
6.24±1.49
0.64±1.72
6.88±1.51
0.041
Postgraduate
24 (32.4)
8.21±2.09
1.96±1.96
10.2±2.13
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Type of
hospital
Private hospital
32 (43.2)
6.19± 2.10
0.44± 1.95
6.63± 2.05
0.075
Public hospital
42 (56.8)
6.88± 1.90
0.76± 2.15
7.64± 2.03
Experience/year
Less than 3
30 (40.5)
6.53±1.23
0.57±1.55
7.1±1.05
0.082
4 to 10
20 (27.0)
6.6±1.98
0.85±2.13
7.45±2.09
More than 10
24 (32.4)
6.63±1.62
0.50±1.93
7.13±1.39
DISCUSSION
Since radiographers are essential to the structure of
radiation safety. The radiographer may be held
accountable for excessively raising the IR dosage given
to the patient during a particular imaging trial if he/she
lacks sufficient knowledge of radiation risks. As far as
we are aware, this study was the 1st survey
accomplished in the West Bank in Palestine to examine
stage of knowledge about radiation protection and
cancer risks of exposure among Palestinian
radiographers.
The main findings of this survey show that most
radiographers had insufficient knowledge about IR
protection; mainly their level of knowledge about
cancer risks of IR exposure. The total mean of correct
score of radiation safety knowledge was (7.20) out of
(17) questions. Several scientific articles have
emphasized the requirement for radiographers to
enhance their knowledge in radiation safety cases [8,
21-22].
This study was conducted in occupied Palestine, which
has limited resources regarding radiation protection.
The outcome revealed insufficient knowledge in
radiation safety, in spite of the existence of specialized
undergraduate
and
postgraduate
educational
programs in radiology in Palestinian universities.
However, there is a clear weakness in the quality of
radiology education compared to developed countries.
Palestine's government and the authorized bodies
have not improved the current situation of IR safety;
Palestine is still not a member of the International
Atomic Energy Agency (IAEA). It is tragic that Palestine
still lacks laws protecting patients and radiation
workers from radiation exposure. In addition to the
lack of legislation that obliges medical institutions to
train medical workers regarding radiation safety,
especially training in modern knowledge and
technology in this field. Al-Jamal et al. (2021) stated in
their study that there is no radiation safety officer
responsible for radiation protection in all hospitals and
health centers in Palestine [23]. There are no
regulations in Palestine to appoint a person
responsible for supervising radiation protection
practices in medical imaging departments, and
therefore there are no regulations regarding
monitoring violations that occur in medical imaging
centers and there is no fear of potential penalties
among radiographers who do not take into account
radiation safety standards during X-ray examination.
Responses of radiographers in this present study,
revealed a lack knowledge among them about radiation
doses associated with imaging techniques and the lethal
cancer threats they pose. To our surprise, near (90%) of
participants answered all questions about that
incorrectly or no idea with a total mean of scores was
(32.43%) and (56.98%), respectively. Paolicchi et al.,
(2016), have also conducted similarly research, which
has led to a lack of awareness among urology residents
from twenty different European countries, and almost
50% of respondents were unaware that widely used
imaging methods carry a lethal cancer risk [24].
Upon careful analysis of this present study, it is
surprising that a significant proportion of radiographers
had either seldom or never attended specific radiation
protection training courses during their working time in
the hospitals. This is inconsistent with the European
Union's 97/43/Euratom of June 30, 1997 transposition,
which confirms that all member states provide
continuing
education
and
training
following
qualification. In the unique situation of the clinical use
of new methods, training related to these techniques is
scheduled
and
related
radiation
protection
requirements are taken into consideration [25]. Regular
training programs should be developed on a health care
institutions and national level at scheduled times [26].
Many research studies have also determined that
radiographers need to become more knowledgeable
about radiation risks [22, 24, 27], with a focus on
increasing awareness during the study time [28-30].
This important research focus on the knowledge of IR
safety in public and private hospitals in Palestine.
Previously, Hamarsheh and Amro (2017), who found
that radio-technologists lacked sufficient knowledge,
with a mean percentage of correct responses to
knowledge and awareness questions being 26.4%,
conducted
another
study
in
Palestine
[31].
Awadghanem et al. (2020) also concluded not enough
knowledge of radiation protection of IR exposure and its
hazards between medical undergraduates from
Palestine. The participants' average level of knowledge
was 11% [21].
From the results of this research, there is a knowledge
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shortage through radiographers concerning the use of
individual safety tools such as lead gloves or protective
eyeglasses. These results are consistent with previous
study conducted by Sharma et al., (2016) [32]. To fulfil
the identified gap, the concerned department must
initiate Information Education Communication (IEC)
campaigns through training courses, workshops, and
the distribution of IR sensitization materials.
The knowledge about IR protection did not vary
notably among radiographers groups regarding to the
type of hospitals and between groups that differ in
gender and experience. In a similar study, Paolicchi, et
al., (2016) reported that IR danger is independent of
sex [24]. Although there was not a significant
distinction between knowledge in the current research
and the period of time employed in the sector. No
correlation was found between the length of time
spent in the field and the knowledge pertaining to
radiation safety in the similar studies [33-35].
However, there was a slight but notable difference in
knowledge between the groups based on their
academic qualification. Postgraduate radiologists
scored slightly higher level of knowledge than
undergraduates. These findings are in line with a prior
study by Maharjan et al., (2020), who found that
students' knowledge
levels were
inadequate
compared with that who graduated with higher
education degrees [30].
Study limitations
This research focused solely on radiographers from
seven hospitals in the Northern governorates of West
Bank, with sample size (n = 74) is insufficient to
represent the entirety of Palestine. Unlike the study
conducted by Paolicchi et al. (2016) (24), with 780
Italian radiographers completed the questionnaire,
and other study by Erkan et al., (2019) [35], which
included a broader spectrum of participants. A more
extensive sample drawn from other institutions would
have improved the outcomes.
CONCLUSIONS
This study's findings indicate that Palestinian
radiographers lack adequate knowledge of radiation
safety. This emphasizes the necessity for specific
education in radiation protection in order to improve
the standard of nursing for all radiological methods. It
is essential that workers in IR environments take
annual recertification courses in order to stay up to
date on the latest developments and to be reminded
of occasionally ignored safety measures. To ensure
patient safety, specific measures need to be put in
place to raise attention of ray’s dangers and to support
learning of radiation protection. By incorporating
sufficient radiation protection modules into the study
curriculum, the author anticipates that graduates in
medical imaging will have a better understanding of
radiation protection. It is crucial to have regular
conferences, workshops, and seminars on radiation
protection and to extend invitations to all radiographers
in the community. It is vital to receive formal training in
radiation safety and protection, particularly in relation
to the training in radiation doses associated with
imaging methods and the serious cancer threats they
pose. The author anticipate that the adoption of
regulations governing the proper use of radiation would
mark a significant turning point in starting this difficult
process.
ACKNOWLEDGMENTS
We gratefully acknowledge the Palestinian hospitals
personals for cooperation during this study. Sincere
thanks are also extended to Dr. Abdallatif Abuowda
from Al Istiqlal University's, Department of Public
Administration for his assistance with the statistical data
analysis.
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