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Radiation Protection Knowledge, Attitude, and Practice (KAP) in Interventional Radiology.

It is more than 100 years since the first usage of X-ray. In the early days of its implementation, there was no vision about its potential harms, (1,2) including various dermatoses, cataract, hematological disorders, and cancer, (3) which necessitates considering radiation protection (RP) strategies such as the 'as low as reasonably achievable' (ALARA) principle. [4] For all medical imaging procedures, there are three basic principles: justification, optimization, and dose limits. (5) The optimization concept has been refined as a result of increasing knowledge about radiation effects. (6-8) RP has been one of the main concerns since the early days of radiography (9,10), and as the technology of medical imaging is continuously under revolution, the regulations needed for its safe usage is an important issue. (11) Assessing the knowledge of healthcare personnel working with radiation and holding RP courses might be beneficial in reducing patient and staff exposure to ionizing radiation. (12-15) Interventional cardiologists are among the top two professionals most likely to receive high radiation doses in routine examinations. (16) The Word Health Organization (1) recommends continuous training and regular refresher courses and state that specific training in interventional radiology is required in addition to basic training. (17) The International Commission on Radiological Protection (ICRP) states that interventional procedures are complex and tend to be operator dependent. It is particularly important that individuals performing examinations are adequately trained in both RP clinical techniques and knowledge. (18)

As a good clinical practice needs good knowledge, attitude, and practice (KAP) and as they are practically interdependent, several factors such as sex, education and practice age, and hospital type and geographical region might affect good practice.

This study aimed to assess the KAP level of RP among interventional radiology staff using a validated questionnaire. The findings of this study might help to develop educational policies for radiation workers at different levels of specialty.


A simple questionnaire survey consisting 30 multiple-choice format (which was previously validated) (19) was distributed in 2014-2015 in northern (13.0%), western (10.0%), eastern (2.0%), central (16.0%) regions, and the capital of Iran (59.0%). Ten panelists including four medical physicists, one nuclear medicine specialist, one occupational health specialist, and one epidemiologist were advised and helped to calculate content validity ratio, which the acceptance level was > 0.62. The finalized questionnaire was used in a pilot study including 15 employees in interventional radiology departments using a four-week retest design to check the reliability and validity of the questionnaire. Pearson's correlation coefficient was estimated, which showed high overall reliability of final version of questionnaire (r = 0.81, p < 0.001).

The goals, methodology, and protocols of the project were clarified to the participants who were healthcare personnel working professionally with radiation as department secretaries, radiology technologists, nurses, and physicians in educational (69.0%), non-educational (8.0%), and private health clinics (23.0%). The participants were assured of the obscurity and confidentiality of the collected data. The administered questionnaire had a demographic information section including age, sex, academic degree, job title, educational age (time since graduation) as well as a general RP section about wearing lead aprons during examinations, film badges, dose limits for occupational exposure, the ALARA principle, and participation in RP training courses over recent years. This questionnaire was designed to assess KAP of RP. The collected data were analyzed using SPSS Statistics (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.) with one-way ANOVA. A p-value < 0.050 was considered statistically significant.


Two-hundred and five questionnaires were collected from different geographical regions of Iran. The detailed scores of knowledge, attitude, practice, and overall KAP score regarding sex, educational and practice age, and type of hospital and geographical region of participants are given in Figures 1-5, respectively. The RP knowledge score of participants is presented in Table 1. The analysis of the relationship between sex and RP knowledge showed no significant difference between male and female protection knowledge (p = 0.130), as well as educational age (p = 0.860). There was no significant difference in the mean scores of RP knowledge and practice age (p = 0.400) and likewise, between RP knowledge and hospital type (p = 0.160). A comparison of means revealed a statistically significant difference between RP knowledge and geographical region (p = 0.010). Furthermore, RP knowledge score in northern Iran (mean = 58.4) was significantly higher (p = 0.010) than the capital (mean difference = 16.7).

The mean RP attitude scores are given in Table 2. Statistical analysis showed no significant difference between RP attitude and sex (p = 0.260), educational age (p = 0.570), practice age (p = 0.830), hospital type (p = 0.820), and geographical region (p = 0.110). The detailed scores of the participants RP practice are listed in Table 3. There was no significant difference between RP practice and sex (p = 0.330) and region (p = 0.070). RP practice score in those with > 15 educational age was significantly higher than those with [greater than or equal to] 15 educational age (p < 0.001). In the group with practice age (years' experience) > 15, the RP practice score was significantly higher than the group with practice age < 15 (p < 0.001). The RP practice score in non-educational clinics was higher than educational hospitals and private clinics [Table 3].

The scores of participant RP KAP are given in Table 4. Statistical analysis showed a difference in mean scores between RP KAP and educational age (p = 0.030), but no significant difference between RP KAP and sex (p = 0.470), practice age (p = 0.530), and hospital type (p = 0.200). The mean score of RP KAP in the eastern region of Iran was significantly higher than the other geographical regions.


Radiology examinations have an essential role in diagnosis. Radiation has been demonstrated to have adverse biological effects, that vary by the duration of exposure and dose, (20-22) which has shown an increased occurrence of cancer, shortening of longevity, birth defects, and cataracts. (23) The main principles for RP are time, distance, and shielding, (24) which should be carefully controlled. During an interventional cardiac catheterization procedure, an interventional cardiologist receives about 0.004-0.016 rem/case (25), nurses receive 0.8-1.6 rem/year, and technologists about 0.2 rem/year in an interventional radiology department, (26) which is mainly due to patient scatter. Modern cardiac interventional methods produce effective doses of 4-21 mSv and 9-29 mSv, respectively, and are therefore high-risk for radiation exposure, (27) which cause RP to be an occupational concern. The continuous trend towards more complex interventional examinations leads to greater exposure to staff and patients. According to the American College of Cardiology, the dose limit for occupational exposure for medical staff is 5 rem/ year for the whole body, and no one should receive a cumulative exposure of more than 1 rem x age (or 50 rems). (28) Radiology technologists are expected to have more in-depth knowledge on different aspects of radiation and should play a consultant role to the physicians in choosing a proper imaging modality with minimal radiation risk. (29) Besides, one should consider the importance of good practice as well as adequate knowledge and attitude to reduce public dose due to imaging modalities. These items depend on several factors such as educational level and current policies for training personnel as well as the available accessories needed for good practice with an acceptable dose to the patient. Considering only one center to evaluate, such a multi-parametric problem might lead to a misunderstanding of several aspects of RP.

We found no significant difference between RP KAP and gender, which is in agreement with a study by Fatahi-Asl et al. (30) Arslanoglu et al, (12) showed that more female (39%) than male doctors (19%) believed that abdominal magnetic resonance imaging exposes patients to ionizing radiation.

It has previously shown that personnel with a basic science background had better RP awareness levels. (31) Staff educational age is one of the factors that influence occupational exposures. Prabhat et al, (32) confirmed the relationship between educational age and appropriate KAP level regarding RP. The KAP level was higher in interns and the least in third-year students. (32) One study found a significant difference in knowledge between young radiographers (less than three years of experience) and older radiographers, with the former having a higher score. This might be due to the freshness of younger staff. (13) However, in our study, no significant difference was observed between RP knowledge and educational age, which might be due to continuous training courses. RP practice score in those with an educational age > 15 years was significantly higher than in those [less than or equal to] 15 years. Mojiri et al, (33) explained that the radiographers with fewer years' work experience have less knowledge about the adverse effects of radiation. So, there is an actuarial relationship between awareness about dose limit and radiographers' educational level. (33) A study performed by Svenson et al, (34) among Swedish practitioners with 5-25 years experience had higher levels of KAP than those with more or fewer years experience. Su et al, (35) confirmed that with increasing age RP knowledge gets significantly worse. Rahman et al, (36) demonstrated that the number of correct answers in those with more than 10 years experience in contrast to those with less 10 years experience was 45% vs. 56%, respectively.

We found a relationship between participants practice age and their RP performance. Older staff (practice age > 15) had better radiation safety practice than younger ones (practice age [less than or equal to] 15). With increasing age and employment period, radiation safety practice also gets significantly better. The existence of a statistically significant relationship between practice age and RP performance showed that a few radiographers with low experiences have less practical information about radiation safety. Although they were recently educated, they had insufficient knowledge of radiation effects. This means that formal continuous training is necessary for younger radiological technologists.

RP practice in non-educational clinics was significantly (p = 0.010) better than educational hospitals. This might be due to the students in educational hospitals, which might violate the general discipline of the hospital and interfere with experienced staff professional work. The relationship between the geographical region of hospitals and knowledge and RP KAP was statistically significant in our study. Knowledge and RP KAP in northern Iran was significantly better than the capital. This might be due to existing policies in the educational organization in those regions, which enforce personnel to attend these courses and limit their working shifts to have enough time to review basic items and learn new skills.


RP continues to be an important concern in the everyday practice of all medical professionals. Education and practice age, sex, and type of hospital and geographical region have their effects towards KAP of interventional radiology staff regarding RP. Based on our findings, a fundamental effort to provide more robust education and acquire greater RP KAP in interventional radiology departments is required. Many of the radiation-related harms for both interventionalists and patients can be easily prevented by having proper KAP and continuous training.

DOI 10.5001/omj.2018.26

Received: 6 June 2017

Accepted: 12 November 2017


The authors declared no conflicts of interest. No funding was received for this study.


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Fatemeh Shabani [1,3], Hadi Hasanzadeh [2,3] *, Alireza Emadi [4], Majid Mirmohammadkhani [5], Ahmad Bitarafan-Rajabi [6], Ali Abedelahi [7], Mitra Bokharaeian [1,3], Hamed Masoumi [1,3], Danial Seifi [1,3], Tahereh Khani [1,3], Mohamad Sanchooli [1,3], Shima Moshfegh [1,3] and Abbas Ziari [5]

[1] Student Research Committee, Semnan University of Medical Sciences, Semnan, Iran

[2] Cancer Research Center, Semnan University of Medical Sciences, Semnan, Iran

[3] Department of Medical Physics, Semnan University of Medical Sciences, Semnan, Iran

[4] Deputy of Research and Technology, Semnan University of Medical Sciences, Semnan, Iran

[5] Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran

[6] Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran

[7] Department of Anatomical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran

Caption: Figure 1: Mean knowledge, attitude, practice (KAP) scores, and overall KAP score regarding radiation protection between sexes.

Caption: Figure 2: Mean knowledge, attitude, practice (KAP) scores, and overall KAP score regarding radiation protection and educational age (years since graduation).

Caption: Figure 3: Mean knowledge, attitude, practice (KAP) scores, and overall KAP score regarding radiation protection and practice age.

Caption: Figure 4: Mean knowledge, attitude, practice (KAP) scores, and overall KAP score regarding radiation protection between hospital types.

Caption: Figure 5: Mean knowledge, attitude, practice (KAP) scores, and overall KAP score regarding radiation protection between geographical regions.
Table 1: Demographic characteristics of
respondents regarding radiation protection
knowledge score.

Characteristic                  Mean    SD    p-value

Sex                                            0.130
  Male                          48.9   22.4
  Female                        43.2   23.1
Educational age                                0.860
  [less than or equal to] 15    48.5   24.2
  > 15                          49.1   17.3
Practice age                                   0.400
  [less than or equal to] 15    47.4   24.8
  > 15                          44.5   18.8
Hospital type                                  0.160
  Educational                   43.6   23.2
  Non-educational               52.4   16.9
  Private clinic                49.2   23.0
Region                                         0.010
  Capital                       41.7   22.0
  Center                        45.2   24.0
  East                          61.5   22.4
  North                         58.4   22.4
  West                          48.0   20.5

SD: standard deviation

Table 2: Demographic characteristics of
respondents regarding radiation protection attitude

Characteristic                   Mean       SD     p-value

Sex                                                  0.260
  Male                           66.8     19.6
  Female                         65.3     20.5
Educational age                                      0.570
  [less than or equal to] 15     67.4     20.4
  > 15                           69.1     14.4
Practice age                                         0.830
  [less than or equal to] 15     66.4     19.9
  > 15                           65.7     18.5
Hospital type                                        0.820
  Educational                    66.6     21.2
  Non-educational                65.0     13.4
  Private clinic                 66.6     18.3
Region                                               0.110
  Capital                        63.7     21.8
  Center                         70.7     15.0
  East                           79.3      9.2
  North                          70.4     16.9
  West                           62.9     19.3

SD: standard deviation.

Table 3: Demographic characteristics of
respondents regarding radiation protection practice

Characteristic                  Mean    SD    p-value

Sex                                            0.330
  Male                          62.7   17.9
  Female                        62.5   17.2
Educational age                               < 0.001
  [less than or equal to] 15    58.4   17.8
  > 15                          71.6   13.4
Practice age                                  < 0.001
  [less than or equal to] 15    60.0   17.9
  > 15                          68.1   14.2
Hospital type                                  0.010
  Educational                   60.9   17.1
  Non-educational               75.3   12.8
  Private clinic                64.0   18.3
Region                                         0.070
  Capital                       61.4   18.0
  Center                        69.1   15.7
  East                          56.6   7.2
  North                         66.0   19.4
  West                          57.5   12.9

SD: standard deviation.

Table 4: Demographic characteristics of
respondents regarding radiation protection
knowledge attitde practice (KAP) score.

Characteristic                  Mean    SD    p-value

Sex                                            0.470
  Male                          59.5   16.0
  Female                        57.0   16.3
Educational age                                0.030
  [less than or equal to] 15    58.1   17.4
  > 15                          63.3   9.4
Practice age                                   0.530
  [less than or equal to] 15    57.9   16.7
  > 15                          59.4   13.3
Hospital type                                  0.200
  Educational                   57.0   16.8
  Non-educational               64.2   7.6
  Private clinic                59.2   15.3
Region                                         0.030
  Capital                       55.6   17.1
  Center                        61.7   13.4
  East                          65.8   9.3
  North                         64.9   14.0
  West                          56.1   13.8

SD: standard deviation.
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Article Details
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Author:Shabani, Fatemeh; Hasanzadeh, Hadi; Emadi, Alireza; Mirmohammadkhani, Majid; Bitarafan-Rajabi, Ahmad
Publication:Oman Medical Journal
Article Type:Report
Geographic Code:7OMAN
Date:Mar 1, 2018
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