|Year : 2016 | Volume
| Issue : 4 | Page : 132-138
Knowledge, attitude, and practices regarding radiological modalities among health-care providers, Karachi, Pakistan
Mubashir Zafar, Aroob Farhan, Tooba Shaikh, Rida Rafiq, Salwa Usman, Hafsa Abrar, Madiha Saleem, Hafsa Naz, Nazia Haider, Sidra Khan, Arsalna Javed
Department of Community Medicine, Jinnah Sind Medical University, Karachi, Pakistan
|Date of Web Publication||27-Dec-2016|
Department of Community Medicine, Jinnah Sind Medical University, Karachi
Source of Support: None, Conflict of Interest: None
Background: Health-care providers are unaware of the hazards associated with the use of radiation. Requesting radiological examinations send to underestimate hazards and have poor knowledge about the possible risks to the health of the patients. There are no any studies regarding awareness of radiation among health-care providers in Pakistan. The objective of the study is to assess the knowledge, attitude, and practice (KAP) regarding radiological modalities among young doctors in hospital. Methodology: It is a cross-sectional study and was conducted from February to July 2016. Convenient sampling was used. One hundred and sixty participants were selected. House officers and postgraduate's students were included, and structured validated questionnaire was used. Logistic regression was used to determine the association between sociodemographic characteristics and their KAPs level. Results: Majority of study participants had appropriate knowledge (72%), positive attitude (70%) but unsafe practices (65.5%). After adjustment of covariates, house officers and those order <30 investigation had more than two time inappropriate knowledge (odds ratio [OR]: 2.374, confidence interval [CI]: 0.836-6.379), (OR: 2.319 CI: 0.817-6.581), respectively, and more than one time negative attitude (OR: 1.372 CI: 0.491-3.835), (OR: 1.304 CI: 0.481-3.532), respectively. Female participants had more than one time unsafe practices (OR: 1.867, CI: 0.789-4.421). Conclusion: Health-care providers had appropriate knowledge, positive attitude, but unsafe practices because of lack of facilities in public sector hospitals. Proper providence of required facilities in health facilities will improve their practices.
Keywords: Attitude, hazard, knowledge, Pakistan, practice, radiation
|How to cite this article:|
Zafar M, Farhan A, Shaikh T, Rafiq R, Usman S, Abrar H, Saleem M, Naz H, Haider N, Khan S, Javed A. Knowledge, attitude, and practices regarding radiological modalities among health-care providers, Karachi, Pakistan. Int J Health Syst Disaster Manage 2016;4:132-8
|How to cite this URL:|
Zafar M, Farhan A, Shaikh T, Rafiq R, Usman S, Abrar H, Saleem M, Naz H, Haider N, Khan S, Javed A. Knowledge, attitude, and practices regarding radiological modalities among health-care providers, Karachi, Pakistan. Int J Health Syst Disaster Manage [serial online] 2016 [cited 2021 Mar 2];4:132-8. Available from: https://www.ijhsdm.org/text.asp?2016/4/4/132/196794
| Introduction|| |
The term "radiation" means energy that comes from a source and travel through some medium or space. Light, heat, and sound are types of radiations.  Furthermore, it covers a wide spectrum of different forms of energy; most of which have been suspected to cause ill health to human beings.  Well, radiations are used in a variety of field such as therapeutic and diagnostic modalities. Radiological modalities used more frequently nowadays are X-ray, computed tomography (CT) scan, magnetic resonance imaging (MRI), positron emission tomography scan, ultrasound, and much more.
Nowadays, radiological tests frequently used by health-care provider which have different health risks such as cancer, cataract, risk to antenatal mother, these radiation caused alteration human gene, and damage DNA. , Different studies found that radiation during antenatal period caused malformation of child at birth and leukemia in early childhood two times higher compare to adult. 
It is one of the responsibilities of a health-care professional to provide firsthand knowledge to the patients undergoing all radiological procedures and processes. The physician can answer to queries of a common man regarding radiation hazards, which can be reliable provided their knowledge is adequate and up-to-date. The knowledge related to radiation is taught during undergraduate training in medical colleges. However, physicians grossly underestimated the proper risk regarding proper use of medical imaging tools and their associated radiation risks. ,
Many studies indicate that primary care providers are unaware of the hazards associated with the use of radiation. Physicians who are responsible for requesting radiological examinations tend to underestimate the actual doses involved, have poor knowledge about the possible risks to the health of populations, and do not discuss the potential risks of CT scans with their patients. 
A research done in Australia among doctors working in the emergency department assessed emergency doctors' knowledge of radiation exposure for medical imaging, and it was found to be poor, and whether they would inform their patients of the risks of radiation exposure varied with the clinical scenario. Overall, these doctors underestimated radiation exposure of frequently used diagnostic imaging and the associated risks. Underestimation of doses and risks may lead to doctors requesting more diagnostic imaging than they would if they had accurate knowledge. 
In a research done in Pakistan, the majority of medical students have limited knowledge about various aspects of radiation sources, the risk involved, and protection. Literature review has revealed that there is a lack of studies on aspects of radiation among medical students in Pakistan. 
The curriculum for a medical student involves teaching various subjects that aims specifically at the application of knowledge and problem-solving skills during in a preassigned academic period. In Pakistan, medical students underwent their clinical rotation in the department of radiology either in the fourth or in the final year of undergraduate training program. Within the curriculum, the Pakistan Medical and Dental Council has combined six subjects that include radiology and has allocated a total of 40 h in 5 years. ,
Objective of this study is to check knowledge, attitude, and practices (KAPs) of radiological modalities among health-care providers in Karachi, Pakistan.
Knowledge was determent by 15 questions, the cutoff value was 50%, means if they mark around , correct answer, it will be considered as appropriate knowledge and who answer less than that were having inappropriate knowledge. For attitude, there were 10 questions, the doctors who marked 50% correct answers were thought to have positive attitude and those who did not were considered as having negative attitude. Then for practice, it 8 questions, those answering 50% methodology must compile unsafe practices.
| Methodology|| |
This is a cross-sectional study. The study was conducted from February to July 2016.
The research was conducted at Gynecology, Orthopedics, Surgery and Medicine Departments of Tertiary Care Hospital in Karachi, Pakistan.
The study was done in an almost 6-month period.
Convenient sampling was used.
The sample size was calculated by given formula:
nz^2p (100−p)/D^2 (n−1) z^2p (100−p)
- n = Population
- z = Level of significance "1.96"
- p = Proportion of previous study (0.19)
- D^2 = Margin of error.
Age, ethnicity, family history, addiction, years in practice, designation, wards they are in currently, medical and surgical history, investigations they order per month, their annual income, and smoking history.
Health-care providers practicing for 1-8 years were included in the research.
Doctors under the age of 24 and above 35 years were not included in the research.
Permissions of health-care providers by taken consent that basically was ensuring them that their information will be kept private and respect their privacy and their will to fill questionnaire, as if they do not want to answer any question, they will not be forced to do so. After going through the consent form, they signed it.
Participant was interviewed after getting written consent, after taking permission from hospital administration and written consent from participant. Questionnaires were collected immediately after completion and were kept anonymous.
Data collection tool
The study instrument was a validated questionnaire which comprised four sections. Part 1 was related to the sociodemographic characteristics, part 2, 3, and 4 related to KAPs of health-care providers regarding radiological modalities, respectively. KAP of radiological modalities were assessed by 33 items questionnaire which included questions regarding different aspects of diagnostic modalities, there uses, implementations, impacts, effects, and their priorities. The questionnaire was prepared in English version.
Questionnaire had a cutoff point of about 50%; the doctors who had marked 50% correct answers were considered to have good knowledge while who scored below 50% were considered to have inappropriate knowledge [Figure 1] [Figure 2] [Figure 3]. Similar attitude and practice were assessed by attitude and practice section. Three variables which were dichotomous, i.e., knowledge (appropriate/inappropriate), attitude (positive/negative), and practices (safe/unsafe) were used as outcome variables.
|Figure 1: Postgraduates trainee doctors have 77% appropriate knowledge while house officers have 60% appropriate knowledge|
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|Figure 2: Seventy-two percent of postgraduates have positive attitude while house officers have 68%|
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|Figure 3: Thirty-five percent of postgraduates do safe practice while house officers do 31%|
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Data management and statistical analysis
During data collection process, the data were checked for completeness, and any incomplete or misfiled question was sent back for correction. Data were double entered in Epi Data software version 1.3, through this missing values were cleaned and error rate was determined accordingly.
Before analysis, all variables were reviewed for accuracy of data entry, missing values, and outliers, using SPSS. Descriptive statistics were used to describe sociodemographic characteristics. The frequency distribution of both dependent and independent variables was worked out. Logistic regression analysis for determine the association of sociodemographic characteristics and KAP level.
Study was approved by Ethical Committee of department. The research questions were asked after taking informed consent. Participants were informed about the evaluation being conducted. Participation should be voluntary, and participants are free to withdraw at any time without any explanation. All information provided by each particular should be kept confidential as the identity of participant remains unknown to research team.
| Results|| |
[Table 1] shows the participants of this research were 93.80% from the age group 20-27 years, from which 60% were females. In this study, 72.50% were house officers, 85.63% were nonsmokers, 75.60% of the doctors have experience less than a year, 72.50% were specializing in surgery and 46.20% were Urdu speaking. The doctors participated in this research, 97.50% have no medical history, and 94.40% have no surgical history. Nearly 81.20% of the doctors order <30 investigations per month and 59.40% of these doctors have income <300,000
[Table 2] shows that (odds ratio [OR]: 0.44, confidence interval [CI]: 0.202-0.993) house officers are 56% less likely to have inappropriate knowledge. Female, nonsmoker, and medicine specialty have more inappropriate knowledge. All other values are statistically insignificant.
|Table 2: Relationship between sociodemographic and knowledge of study participant (univariate), n=160 |
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[Table 3] shows that all values are statistically insignificant.
|Table 3: Relationship between sociodemographic and attitude of study participant (univariate), n=160 |
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[Table 4] shows that younger age and female have more unsafe practice, but all values are statistically insignificant.
|Table 4: Relationship between sociodemographic and practice of study participant (univariate), n=160 |
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[Table 5] shows that all values are statistically insignificant.
|Table 5: Relationship between sociodemographic/knowledge, attitude and practice of study participant (multivariate), n=160 |
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| Discussion|| |
Study revealed that majority of health-care providers have appropriate knowledge, positive attitude, but unsafe practice regarding radiological modalities and also identified several deficiencies in the practices of radiological modalities in certain departments, such as practices in recommendation of radiological modalities and their therapeutic as well as diagnostic uses.
These results show that doctors aged 28-35 years (OR: 1, CI: 0.169-6.948) have more appropriate knowledge (80%) than doctors aged 20-27 years (OR: 1.01, CI: 0.169-6.948) is 64%. Knowledge among male doctors (OR: 1, CI: 0.675-2.582) is more appropriate (68.80%) than female doctors (OR: 1.32, CI: 0.675-2.582) is 62.50%. These results are in contrast with the level of radiological knowledge found in other studies from the university hospital emergency department,  suggesting that knowledge of radiation exposure from radiological investigations and the associated risk among interns, residents, and radiographs was inappropriate.
This result could imply that the young doctors are not aware of radiation risk and are inattentive in informing their patients about the radiation exposure related to different imaging modalities. These results are in concordance to the finding of European Society of Radiology 2010 where knowledge among students who were postgraduates was much better compared with undergraduate doctors with the mean score achieved in the 5 th year student was 81%.  This may be due to many important shortcomings in medical students' knowledge regarding important aspects of radiation protection that should be considered when developing the undergraduate medical curriculum to meet challenges of the future.
In this study, 24.4% and 23.1% associated ultrasound and MRI, respectively, with ionizing radiation.  The finding of ultrasound association with ionizing radiation is slightly higher than the findings in the literature on physicians. Prior studies on physicians report a 4%-14% incorrect association for ultrasound. This indicates a lack of knowledge likely resulting in requesting less number of ultrasound (almost 59.5% consultants request ultrasound ordering <1 test per day). Had they been known about the lack of ionizing radiation in ultrasound they could request more number of ultrasound wherever needed thus reducing the load of radiation exposure on patient. This finding is consistent with previous studies which reported 7%-28% incorrect association. Significantly, more men than women (64.3% and 35.7%, respectively) consultants accurately recognized that MRI is not associated with ionizing radiation which is consistent with previous findings among consultants. 
In a study by  for pediatric surgeons, 47% respondents said that there was no increased cancer risk because of radiation from one CT scan.  In comparison, our study revealed higher rate of awareness of radiological modalities in doctors.
In our study, there is a difference of knowledge among postgraduates (OR: 1, CI: 0.202-0.993) who have more knowledge (77.30%) than house officers (OR: 1.339, CI: 0.202-0.993) is 60.30%. This is perhaps due to more experiences and practices of postgraduates than the house officers. This is in concordance to other studies where education levels were significantly associated with the knowledge of  doctor. One reason for the appropriate knowledge find in this study is that the 5 years integrated curriculum that included instruction in clinical radiology; their understanding and knowledge of the basic concepts central to radiation protection has proven very knowledgeable for the undergraduates.
This study revealed that young doctors have positive attitude toward ordering radiological investigations, and they clearly explain to their patients about all the prerequisite and preventions that should be taken before the investigations. The study clearly revealed negative practice of young doctors for ordering least hazardous investigation for their patients, and they do not care about the risks of radiation exposure. This is in contrast to the study in the Society for Academic Emergency Medicine where it is revealed that the emergency physicians have a positive practice of radiological investigations emergency physians society (EPS) agreed that overuse of CT to ordered another CT is a problem with a significant opportunity to reduce utilization and radiation in the erectile dysfunction.  EPS reported that information on CT study count affects their decisions to order CT scans and the type of imaging study to order only some of the time. However, EPS had strongly agreed that when they know that a patient has been exposed to multiple CT scans for a particular indication, this makes them less likely to ordered another CT.
In one of the cross-sectional studies in a tertiary hospital in Malaysia, respondents were unable to provide an accurate estimate of the dose for four commonly requested radiological investigations in terms of chest radiograph equivalents.  They were also largely uninformed about the increased cancer risks associated with diagnostic radiation exposure. There are various responses in doctors' practices of discussing potential risks involved with ionizing radiation may have many causes. It may be due to difference in clinical picture, i.e., the risk to a small child or a pregnant female may be greater than the risk to a 76-year-old woman. It also depends on the consultant's confidence and knowledge of risks associated with radiation exposure. They were more likely to discuss the risks if they were more knowledgeable about the subject. It is also possible that different specialties may have more exposure to specific types of imaging modalities, i.e., ultrasound in obstetrics, MRI in orthopedics and thus have more knowledge about some tests than others and thereby affecting the likelihood of informing patients of the risks involved with different imaging modalities. Sometimes, the consultants may discuss the risks only when it is justified.
| Conclusion|| |
Appropriate knowledge and positive attitude of health-care providers but unsafe practices toward radiological modalities. There is a need for collaboration between radiologists and doctors to necessary investigation. Curriculum should design about radiological investigations so that doctors could be able to order the least hazardous investigations with the least possible hazardous dose.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]