Assessment of Knowledge about Nuclear Radiation, and Awareness of Radiation Protection among Medical Students in Riyadh Universities, Saudi Arabia

Introduction:

Nuclear medicine is considered one of the main medical specialties contributing to high radiation doses exposure to radiation workers.¹ Advancement in technology has led to complex interventional radiological procedures and nuclear medicine investigations. With these advancements, several concerns regarding radiation dose to workers and patients have been raised.² Harmful effects of radiation use are well studied^2–4 and therefore, it is important to comprehend the magnitude and be aware of radiation exposure. Students with clinical experience are more aware of nuclear security and safety,5 and it has been shown that the raising the level of radiation hazard awareness among doctors and clinicians can be improved by increasing knowledge of the topic in medical students.⁶ It was reported that medical students worldwide do not possess adequate knowledge with regard to ionizing radiation, diagnostic imaging, and radiation safety2. One study illustrates that while almost all students are familiar with radiation-free imaging studies and unfortunately, many are not familiar with, and commonly undervalue, the relative doses and risks of common imaging studies.⁷ With the proper level of knowledge, future doctors can play a significant role in contributing to patient safety regarding ionizing radiation.

This study aimed to assess medical students' knowledge about nuclear radiation safety and safety roles along with investigating their awareness of radiation protection and protection materials, before and during procedures. The majority of participants in this study8 preferred workshops rather than web-baseline modules, so this study also attempts to assess preferred sources or platforms for medical students in the city of Riyadh to learn about nuclear radiation.

Methodology

• Study Design

This is a cross-sectional study design which aimed to assess medical students' knowledge about nuclear radiation safety and investigate their awareness of radiation protection before and during the procedure. The research was conducted over a 5-month period, with the chosen participants being undergraduate medical students in Riyadh, Saudi Arabia.

• Population

Five hundred and eighty-four randomized participants were enrolled from the four medical schools in Riyadh, Saudi Arabia: Imam Mohammad Ibn Saud Islamic University, King Saud Bin Abdulaziz University of Health Sciences, Princess Nourah Bint Abdul Rahman University and King Saud University. The sample size was evaluated by the OpenEpi tool with a 95% confidence level as 346.

• Data Collection Methods and Study Tools

The data was collected via a self-administered questionnaire which was priorly validated9, and then distributed using Survey Monkey, an online platform for survey development and distribution. In this study, three sections in the questionnaire were used to evaluate the students’ awareness. The participant’s demographic information was collected in the first section while the second section assessed the student's perspective on radiation protection. The last section in the questionnaire covered the student’s observation of the staff and the department of nuclear medicine regarding the safety arrangements.

• Statistical Data Analysis

Statistical Package for the Social Sciences (SPSS, version 22) was used to analyze data with the help of an expert. To cater for more accurate results, the questionnaire was audited, and the questions were validated by administering a trial version to approximately 18-25 individuals. This was to ensure the clarity of the questions and establish linguistic validity.

• Ethical Consideration

This study was approved on 19/01/2021 by the Institutional Review Board (IRB) of Imam Mohammad Ibn Saud Islamic University with the following number HAPO-01-R-001. It is important to note that all participants were made aware of the study’s objective, and their informed consent was taken before the study was initiated. Likewise, the study did not require the participants to reveal their identity, and all responses were to remain confidential.

Results:

In this study, 584 completed questionnaires were returned in which 64.9% of the participants indicated that they were in their clinical years when this research was conducted. As for those in the preclinical year, they made up 30.3% of the participants. Furthermore, the study indicated that 32.1% of the students were in King Saud University, 31.9% were in Imam Muhammad Bin Saud University, and 23.6% came from King Saud Bin Abdulaziz University of Health Sciences. As established, 64.4% of the participants reported that they had previous knowledge about nuclear radiation, mostly obtained from radiology courses in their respective universities (47.4%). For 22.4%, social media was the source of the information while 20.4% and 9.9% used medical websites and research/studies respectively. Similarly, 64.6% reported having acquired some knowledge of radiation protection but only 16.1% of them indicated that they had previously participated in a program or seminar related to radiation protection (Table 1).

As revealed by the study, 16.1% of the participants had adequate knowledge and awareness toward nuclear radiation. 44.7% had moderate knowledge and for 39.2%, their level of knowledge was deemed to be inadequate (Figure 1). The data shows that 81.5% of the participants did not know how to use different personal monitoring devices while 70.7% were not aware of the types of personal monitoring devices. In addition, 53% were unacquainted with materials used for shielding inside the nuclear medicine department, and 51.5% lacked awareness on dose limits for radiation workers. However, 83.7%, 64.6% and 56.5% of the students indicated that they had noticed an area or material labeled with warning signs. Thus, they were aware of the importance of dose record keeping and had knowledge about personal monitoring devices respectively (Figure 2).

The analysis of the data revealed a significant difference in students’ awareness depending on their academic level and university. Intern year students had a higher level of awareness about nuclear radiation than clinical years, and both possessed higher levels of knowledge than preclinical students. According to the data, 74.1% of interns showed adequate awareness compared to 16.3% for clinical students, and 8.1% for preclinical students. Additionally, students from King Saud University demonstrated the highest level of awareness whereas students from Imam Mohammed Bin Saud University had the lowest awareness level. For the aforementioned universities, the former had 25.3% of students who showed adequate awareness in contrast with 10.5% for the latter. Students who indicated having prior knowledge reported more significant awareness levels (P=0.000), and depending on the source of information, a significant difference existed for students who obtained information from social media and they reported the lowest level of awareness (P=0.000). Finally, students who indicated to have been previously educated or participated in any programs/seminars about radiation protection, reported higher awareness levels more than those who had not participated or received prior education on the topic (P=0.000) (Table 2).

Regarding student satisfaction, 40.1% were noted to be satisfied with the measures, rules and application for radiation protection whereas 37.8% were registered as unsatisfied (Figure 3). In figure 4, the agreement level of the participants is shown over different statements regarding protection against nuclear radiation. The data reveals that 72.7% of the students reported that they did not notice the details of the radiation protection officer in the nuclear medicine department. Furthermore, 62.9% reported that they did not find any relevant information about dose limits, rules or safety precautions at the department. 58.9% of them also denied having been given a briefing on radiation protection measures at the nuclear medicine department. On the other hand, 71.1% of the students were satisfied with radiation protection rules and regulations that were practiced by the staff. The study also reported a difference between the students in relation to satisfaction levels depending on the level of awareness. This is true where students with adequate awareness, reported higher satisfaction level (P=0.000). As for in their internship year, they were more satisfied with measures of radiation protection than clinical and preclinical students (P=0.001). Yet, there was no difference between students of different universities (P=0.765). It must be noted that students who indicated having previous knowledge, especially from medical websites, reported higher levels of satisfaction. Likewise, students who indicated having been educated or participants in any program related to radiation protection, reported significantly higher levels of satisfaction (Table 3).

Finally, the study found that 70.8% of students preferred obtaining information about radiation protection from medical websites, 44.7% opted for E-learning and 37.3 % favored radiology courses (Table 4)

Discussion:

Crucially, radiology has a great role in modern medicine. Unfortunately, most of the diagnostic and interventional radiological procedures involve risk for practitioners in this field. This risk is the exposure to ionizing radiation or nuclear radiation in some types of the procedures3. There is growing concern about the side effects related to nuclear radiation on living organisms as radiation is known to be a dose-dependent carcinogenic agent.^4,10 Therefore, the use of diagnostic radiology requires good practice which usually needs proper knowledge of doses associated with all types of procedures. Many previously published studies highlighted that healthcare professionals have an inadequate level of knowledge considering nuclear radiation and associated risk with medical imaging examinations,6,11,12 as well as medical students.9 584 students from four universities in Al Riyadh, Saudi Arabia were included in this study, with the hope of evaluating their basic knowledge about radiation protection and share their observations on radiation protection facilities, tools. Likewise, their knowledge of radiation protection compliance and safety rules by the staff involved in dealing with the radioactive materials and patients in nuclear medicine departments was to be examined. This study also highlighted that 64.4% of the students indicated that they had information about nuclear radiation, mostly from radiology courses in the university while 64.6% and 16.1% of them indicated that they had received education on radiation protection and participated in programs or seminars related to radiation protection. This is much lower than the results reported by Sayed, who reported that all his sample had received education on radiation protection while 91.4% had indicated participation in programs or seminars related to radiation protection.³ The aforementioned study was conducted among intern students which contrasts our study as the latter includes students of different academic levels. In the study of Sultan T. Alturki in Saudi Arabia, the authors found that 70.8% of the participating students indicated that they had taken radiology courses/rotations either as part of the university curricular or as extracurricular activities.¹³ A study by Suliman Salih showed that only 8% of the students had taken a training module on radiation hazards.¹³ With that, only 16.1% of the students showed adequate awareness about nuclear radiation. The low percentage of perceived knowledge about nuclear radiations among medical students was also reported by other studies, including that of Suliman Salih who found that 98.95% of the students had low and basic knowledge of radiation protection.² The same can be said about the studies of Sarah K. Hagi14 and Jennifer O'Sullivan.¹⁰ There is a collection of other studies that showed slightly higher percentages of perceived knowledge of students, including a study by Omid Azadbakht15, and that of Surendra Maharjan.⁹ Results from this current study demonstrated most of the students did not know the types of personal monitoring devices or how to use them, which is in contrast with the results of Sayed’s study. That particular study reported that all students were aware of personal monitoring devices and how to use them.¹⁶ Personal monitoring devices ensure that the dose limits are not exceeded and, through regular review, the results of individual monitoring are used to assess the effectiveness of strategies for optimization.¹⁷ Therefore, a low percentage of students who demonstrated little awareness of these devices should be alarming and instill a need for more education on radiation protection. Many substances are used in shielding inside nuclear medicine, including lead-depending materials which are the most common ones and some new non-lead compounds.¹⁸ In this study, it was discovered that more than half of the sample did not know the materials used for shielding inside the nuclear medicine department.

The risk of exposure to nuclear radiation is a dose-dependent manner, therefore, medical staff importantly need to know the correct dose limits for radiation workers. This study found that 51.5% of students were not aware of the dose limits for radiation workers. This result is similar to those reported by other studies, including the study of Sundaran Kada, who reported that only 45% of the students knew the dose limit for radiation. 10 Despite this, other studies reported better rates of knowledge and the study of Lorenzo Faggioni is an example of that. It found that three-quarters of the students knew the correct dose-limit for radiation9 while in the study of I Sayed, the figure was stated as at 85.7%.3 As observed in this study, the academic level of students significantly affects the level of reported awareness where the student in the internship year has a higher level of awareness. This is harmonious with study of S Alturki, who found that the level of awareness significantly increases with progress in a student’s academic life 13. Similar conclusions were made by Suliman Salih,14 O'Sullivan,10 and Lorenzo Faggioni.^2-4 Interestingly, students of Imam Mohammed Bin Saud University reported the lowest level of awareness which indicated the need for more education courses that could be provided to students of this university. The effect of having previous knowledge, courses, or training on radiation protection on the students' awareness is reported by many studies9 and further strengthened by results from this study. These results are an addition to the literature review, that social media did not provide the students with complete knowledge. Furthermore, 40.1% of the students were satisfied with the measures, rules, and application of radiation protection among workers in their institutions. In light of the data obtained, there are some limitations in our institutions regarding radiation protection measures and evidence of this is that, 72.7% of students did not notice the details of the radiation protection officer in the nuclear medicine department. Additionally, 62.9% did not find any relevant information about dose limits, rules, or safety precautions at the department. 58.9% of them denied having any briefing on radiation protection measures at the nuclear medicine department. The study of I Sayed reported that 22.9% of the students revealed that they did not notice the details of the radiation protection officer in the nuclear medicine department. 100 % would find any relevant information about dose/limit/rules/safety precaution at the department while 100 % of them reported having any brief about radiation protection measures at the nuclear medicine department.⁹

Factors including a high level of knowledge, advanced academic year, having prior knowledge, and courses or training are associated with higher satisfaction levels among students. However, in this case, there is no difference amongst students of different universities. To find the most suitable method to increase student awareness regarding nuclear radiation protection, the students were asked to state the best method for acquiring the information. Interestingly, most of them preferred obtaining the information about radiation protection from medical websites (70.8%), while 44.7 % opted for E-learning and 37.3 % chose radiology courses.

Conclusion:

The study revealed that there is little awareness among medical students about nuclear radiation protection, including knowledge of personal monitoring devices and how to use them as well as dose limits for practitioners. Students of preclinical years and those of Imam Mohammed Bin Saud University exhibited the lowest level of awareness.

Conflict of interest:

No conflict of interest

Source of funding:

This research did not receive any specific grant from funding agencies in the public, commercial, or not for- profit sectors.

Conflict of interest:

We declare no conflict of interest.

Acknowledgment:

We would like to acknowledge the research committee at Al Imam Mohammed Bin Saud University

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