Assessing Radiation Protection Knowledge In Diagnostic Radiography In The Republic Of Cyprus. A Questionnaire Survey

Assessing radiation protection knowledge in diagnostic radiography in
the Republic of Cyprus. A questionnaire survey
C. Zervides*
, L. Sassis, P. Kefala-Karli, V. Christou, A. Derlagen, P. Papapetrou, A. Heraclides
University of Nicosia Medical School, Cyprus
a r t i c l e i n f o
Article history:
Received 26 July 2019
Received in revised form
10 November 2019
Accepted 11 November 2019
Available online xxx
Keywords:
Radiation protection
Radiation safety
Radiation dose
Diagnostic radiography
Radiation awareness
a b s t r a c t
Introduction: Radiation protection knowledge is essential for medical personnel in ensuring that the
possible risks do not outweigh the benefits of diagnostic imaging. This study aimed to assess the radi-
ation protection knowledge of radiographers in Cyprus.
Methods: A cross-sectional study was carried out among radiographers in Cyprus through the Cyprus
Society of Registered Radiologic Technologists & Radiation Therapy Technologists. The study was a
quantitative descriptive analysis, using a questionnaire with 22 multiple-choice questions. Analysis of the
data was done using the statistical software Stata, by performing mean knowledge score comparisons by
different participants’ characteristics, using t-test and analysis of variance test. Statistical significance was
assumed as a p-value < 0.05.
Results: The answers provided for each question indicate that some areas of radiation protection are less
known compared to others, as there is quite a wide range of correct-to-incorrect ratios. The analysis
based on participant characteristics in relation to overall radiation effects knowledge, identified
important determinants, namely the workplace of the participant (p ¼ 0.006), the type of work licence
the participant held at the time of the questionnaire (p ¼ 0.024), and the years of clinical experience of
the participant (p ¼ 0.021).
Conclusion: The study showed that the levels of knowledge in radiation protection are of a very good
standard. However, work is needed to clarify the specifics of dose limits and the national radiation
protection legislation with regards to informing patients about the possible effects of ionising radiation.
Implications for practice: The study results indicate the importance of educating radiographers about the
requirements of national radiation protection legislation and how this new knowledge can be linked
with practise.
© 2019 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Introduction
Radiation is defined as an emission and propagation of energy as
electromagnetic waves or as particles.1
In case there is adequate
energy to detach an orbital electron from an atom, then this type of
radiation is described as ionising radiation.2
Medical diagnostic imaging and technologies are the most
common human made ionising radiation sources and are respon-
sible for the highest amounts of radiation exposure to the general
public and environment.3,4
Because of the growth in modern
medicine and the continuous development of non-invasive
diagnostic techniques, technologies such as X-rays, Computed To-
mography (CT), Positron Emission Tomography (PET) and many
more advanced diagnostic technologies that utilize ionising radia-
tion are now used on a daily basis and are considered as the most
powerful diagnostic tools for many diseases and disorders.5,6
Indeed, each year, 3.6 billion radiological examinations, 37
million nuclear medicine, and 7.5 million radiotherapy in-
terventions take place worldwide.7
Although CT is responsible for
about 15% of the medical imaging procedures, it has a 75% contri-
bution of the total collective dose; thus, it accounts for the more
significant part of radiation dose received by patients'.8
Demon-
strably 20% of radiation exposure due to medical purposes is
avoidable9
; unnecessary exposure is estimated to be responsible for
100e250 cancer deaths that happen in the UK annually.10
Radiographer's deals with ionising radiation daily, and as a
consequence, the doses they receive are much higher than the ones
* Corresponding author. University of Nicosia Medical School, 21 Ilia Papakyr-
iakou Street, Engomi, 2414, Nicosia, Cyprus.
E-mail address: Zervides.c@unic.ac.cy (C. Zervides).
Contents lists available at ScienceDirect
Radiography
journal homepage: www.elsevier.com/locate/radi
https://doi.org/10.1016/j.radi.2019.11.003
1078-8174/© 2019 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Radiography xxx (xxxx) xxx
Please cite this article as: Zervides C et al., Assessing radiation protection knowledge in diagnostic radiography in the Republic of Cyprus. A
questionnaire survey, Radiography, https://doi.org/10.1016/j.radi.2019.11.003

of the general public. Thus, they have a higher risk in developing an
ionising radiation-induced complication.11e13
Hence their radiation
protection knowledge is of utmost importance. The general public
is not aware of the consequences of ionising radiation exposure,
therefore medical personnel who are directly involved need to take
appropriate measures for radiation protection to protect them-
selves, the general public and the environment.14
The effects of ionising radiation exposure fall into two cate-
gories, stochastic and deterministic. The chance of producing a
stochastic effect raises when the radiation dose increases. Sto-
chastic effects do not have a dose threshold and characterise a
possible outcome in any dose such as cancer; the adverse effects
could appear after 10e20 years.15,16
In deterministic effects, the
severity of the outcome increases when the radiation dose is
higher. Thus, deterministic effects have a dose threshold, and with
the threshold exceeded, several harmful outcomes are possible
depending on the radiation dose received.14
Several personal protective measures and legislations regarding
dose limits were introduced in order to protect medical personnel
and patients.14,17
Indeed, one of the most common contributing
factor for diminishing the patients’ exposure to unnecessary ion-
ising radiation due to medical imaging is the level of knowledge of
the practitioners.18,19
Radiographers have to be aware of occupational annual dose
limits as well as the most sensitive tissues of the body and the
possibilities of an adverse outcome according to different ages.
Moreover, more advanced knowledge is required on how to set up
the appropriate parameters on an ionising radiation imaging mo-
dality in order to avoid high radiation doses.
A poor radiographic technique can lead to poor image quality
and as a consequence, repeated examinations will be necessary.
Thus, the patient will have to undergo unnecessary exposures to
ionising radiation, increasing the received radiation dose.20,21
Tak-
ing into account all the adverse outcomes and how unnecessary
exposures to ionising radiation increase the received dose, radi-
ographers have to be aware and follow the ALARA (As Low As
Reasonably Achievable) principle. The ALARA principle helps to
minimise the exposure to ionising radiation and to make sure that
the benefit to the patient is not outweighed by potential harm.22e24
Radiographers undergo practise as trainees; however, this is not
a factor that will guarantee the safety of themselves and the general
public. Theoretical knowledge alongside practical knowledge will
achieve the maximum protection from ionising radiation by mini-
mising the risk of high exposures and a significantly better outcome
in their practise.21
Many studies have raised concerns about the importance of
knowledge of radiation protection among radiographers.3,6,20,21,25
The purpose of the current study, which was the first of its kind
to be performed in the Republic of Cyprus, was to assess the level of
knowledge on radiation protection in diagnostic radiography of
radiographers in the Republic of Cyprus. By understanding their
level of familiarity with the subject, actions that should be taken to
improve their education and knowledge to improve practise, such
as mandatory seminars and teaching classes throughout their ca-
reers can be designed.
Methods
Study setting and sample
A cross-sectional study was carried out anonymously and
voluntarily among radiographers in Cyprus through the Cyprus
Society of Registered Radiologic Technologists & Radiation Therapy
Technologists. This study complied with the ethical guidelines for
research, as stated by the European Commission. The descriptive
survey assessed radiographers' radiation protection knowledge and
was carried out between September and November 2018. The study
sample included 300 radiographers registered in the electronic
mailing system of the Cyprus Society of Registered Radiologic
Technologists & Radiation Therapy Technologists. However, the
total number of 104 responses was received. The participants’ re-
sponses were based on their knowledge only, without referring to
any other sources.
Radiation knowledge questionnaire
The questionnaire designed in accordance to previous stud-
ies,26e32
used Google forms survey and was purposely created to
evaluate the knowledge of radiographers in the Republic as per the
needs of the Cyprus Society of Registered Radiologic Technologists
& Radiation Therapy Technologists. The specific questions were
selected following a focus group with local experts in the field. The
questionnaire consisted of 30 questions in total, divided into two
sections. The first section included eight multiple-choice questions
regarding the demographic features of the participants, namely
gender, age, level of education, the field they are working on at this
time point (i.e. oncology, interventional radiology) and years of
clinical experience.
In the second section, the participants had to answer 22 ques-
tions regarding radiation protection. This section focused on gen-
eral radiation protection knowledge. Out of these 22 questions, 20
were multiple-choice questions, and 2 had the form of checkboxes
so that participants were able to submit more than one answer.
The questions mentioned above were combined in a cumulative
score, by scoring answers based on theory correctness and adding
them up. This resulted in a knowledge scale or score, which rep-
resents the overall knowledge of participants, as regards to radia-
tion protection. The higher the score, the higher the knowledge of
the participants.
Statistical analysis
Results were analysed statistically using the t-test for binary
exposure variables and one-way analysis of variance (ANOVA) for
exposure variables with >2 categories. The knowledge score was
normally distributed; thus, there was no need for the use of non-
parametric tests. Mean scores and mean differences were esti-
mated with participant characteristics as the independent cate-
gorical variables and the knowledge scale as a numeric dependent
variable, using ANOVA and the t-test, wherever applicable. For
analyses involving >2 categories based on an overall p-value for
group differences were estimated by default using ANOVA, fol-
lowed by post-hoc estimations using Tukey's HSD, which provided
p-values for each group comparison (as compared to the first/
reference group). Statistical significance was assumed as p-value <
0.05 (5% Significance Level). All analyses were conducted using the
statistical software Stata/IC (v.15.1).33
Results and discussion
The results show that some areas of radiation protection are less
well known compared to others, as there is quite a wide range of
correct-to-incorrect ratios.
Radiation protection knowledge
Table 1 shows general knowledge questions asked and provide
the percentages of correct, incorrect and do not know responses of
the participants.
C. Zervides et al. / Radiography xxx (xxxx) xxx
2

The average percentage of correctly answered questions in this
section was 82.99%, indicating that the levels of general knowledge
in radiation protection of radiographers in the Republic of Cyprus
are of an excellent standard. The lowest correctly answered score
was on the question regarding the percentage of the total exposure
to the general population, which is received due to medical expo-
sures. Only 9.60% of the participants answered correctly, with
61.60% of the participants answering incorrectly, and 28.80% not
knowing. The answer with the highest correct answer was the one
asking the participants to specify which age group is the most
sensitive to ionising radiation. A total of 98.1% of the participants
answered correctly.
Table 2 shows the questions asked regarding patient dose limits
and patient communication and provide the percentages of correct,
incorrect and do not know responses of the participants.
The results showed that there is a signiﬁcant lack of knowledge
or understanding of dose limits. There was an evident confusion
between patient-related dose limits and occupational exposure
dose limits as speciﬁed by national and international legislation.
80.8% and 90.4% of the participants did not know that there is no
annual total body dose limit for patients or an annual equivalent
dose limit to the skin of the patient, respectively.
Moreover, even though it is a legal requirement to discuss with
patients the risks associated with CT or any other modality that
uses ionising radiation for diagnostic purposes, only 61.5% indi-
cated that it should be done and only 18.3% of the participants
practise this. That means the majority of patients undergoing a
medical diagnostic procedure involving ionising radiation in the
Republic of Cyprus are not informed, nor are they aware of the risks
associated with the examination they will undergo.
Table 3 shows the questions asking about occupational exposure
dose limits and dosimetry and provides the percentages of correct,
incorrect and does not know responses of the participants.
The average percentage of correctly answered questions in
regards to the dose limits questions was 35.9%, indicating that
radiographers in the Republic of Cyprus have a below-average
knowledge concerning occupational exposure, with a score of
50% being considered as an average result for our study. The lowest
correctly answered score was on the question regarding the newly
changed annual equivalent dose limit to the lens of the eye.17
Only
10.60% of the participants correctly answered, with 66.30% of the
participants answering incorrectly, and 23.10% not knowing. The
answer with the highest correct answer was the one asking the
participants what the annual effective dose limit is. A total of 61.5%
Table 1
Participant response: General Knowledge.
Which of the following modalities uses ionising radiation? Correct 97.10%
Incorrect 2.90%
Do not know 1%
The ALARA principle refers to: Correct 89.40%
Incorrect 4.90%
Do not know 5.80%
What age group is more sensitive to ionising radiation? Correct 98.10%
Incorrect 2%
Do not know 0%
What is the unit of measurement of absorbed dose? Correct 96.20%
Incorrect 3.80%
Do not know 0%
What is the most sensitive tissue to ionising radiation? Correct 87.50%
Incorrect 11.50%
Do not know 1%
You accidently receive a total body dose of 100 mSv. Which of the following consequences will this have on your health? Correct 75%
Incorrect 17.30%
Do not know 7.70%
As the distance between you and the source of ionising radiation increases, how is your exposure to ionising radiation affected? Correct 93.30%
Incorrect 6.70%
Do not know 0%
The effective dose received due to an abdominal ultrasound is equivalent to how many chest X-rays? Correct 95.20%
Incorrect 1.90%
Do not know 2.90%
What type of rays does not penetrate the patient's body? Correct 88.50%
Incorrect 11.50%
Do not know 0%
The general population receives ionising radiation from both natural and man-made sources. Of these, medical exposures contribute to what
% of the total exposure?
Correct 9.60%
Incorrect 61.60%
Do not know 28.80%
Table 2
Participant response: Patient dose limits and communication.
What is the annual total body dose limit for a patient? Correct 19.20%
Incorrect 67.3%
Do not know 13.50%
What is the annual equivalent dose limit for the skin of the patient? Correct 9.60%
Incorrect 57.70%
Do not know 32.70%
In your opinion. should risks associated with CT be discussed with the patient in advance? Correct 61.50%
Incorrect 36.50%
Do not know 1.90%
At the centre you work in, is the risk of cancer due to CT discussed with patients in advance? Yes 18.30%
No 81.70%
C. Zervides et al. / Radiography xxx (xxxx) xxx 3

of the participants answered correctly, with 31.8.% of the partici-
pants answering incorrectly, and 6.7% not knowing.
Regarding the dosimetry related questions, the results indicated
excellent knowledge by the participants since the average per-
centage of correctly answered questions was 88.9%.
Determinants of knowledge
Answers were subsequently analysed for determining the as-
sociation between demographics and other work-related factors
concerning the overall radiation effects knowledge score. It appears
that the only demographics which showed a statistically significant
mean score difference (p < 0.05) were (i) the workplace of the
participant, (ii) the type of work licence the participant held at the
time of the questionnaire, and (iii) years of clinical experience. The
others, which include gender, age, highest level of education ob-
tained, country of degree, and specialisation, showed no statisti-
cally significant differences between mean score. However, it is
essential to note that two of these demographic groups should be
tentatively included to show some form of a trend: age (p ¼ 0.15),
and the highest level of education (p ¼ 0.18). While they do show
sufficiently differences, they still have lower p-values than the
other categories as can be seen from the data presented in
Tables 4e8. This might be because the sample size was small
(N ¼ 104), and therefore it may not have provided sufficient in-
formation to determine whether or not these differences are, in
fact, significant or not in determining the level of knowledge of
radiation safety.
The number of male and female participants was relatively
equal, with 45% of participants being male, and 55% being female.
The mean scores between the two genders show an insignificant
difference (male m ¼ 16.2; female m ¼ 16). The statistical insignifi-
cance is proven further by looking at the p-value (p ¼ 0.73). That
confirms that, in the study sample, there is no statistically signifi-
cant difference in mean scores between genders.
Age groups were determined based on the separations seen in
other similar research papers conducted and distributed equally in
terms of years in order to minimise any increase or decrease that
may be in the number of participants in that group due to the
broader potential age range. There is quite a vast difference in the
overall number of participants in the different age groups, with
most participants (N ¼ 59) falling within the 20-29-year-old
category.
Looking at the distribution of the mean scores between the
groups (Table 5), there is an increase in radiation protection
knowledge with increased age since the mean score increases, even
though a dip in the mean score is evident in ages between 30 and
39. This result is not statistically significant, though, as can be seen
from the p-values indicated in Table 5.
Table 3
Participant response: Occupational exposure dose limits and dosimetry.
What is the annual effective dose limit to radiation professionals? Correct 61.50%
Incorrect 31.80%
Do not know 6.70%
What is the annual equivalent dose limit to the lens of the eye of radiation professionals? Correct 10.60%
Incorrect 66.30%
Do not know 23.10%
What is the annual equivalent dose limit of radiation to the skin, feet, and hands of radiation professionals? Correct 35.60%
Incorrect 41.30%
Do not know 23.10%
Do you use a dosimeter? Yes 91.30%
No 8.70%
Should personal dosimeters be worn by professionals/workers involved with radiation? Yes 100%
No 0%
If you answered “YES” to the previous question, where should they be placed? Correct 70.20%
Incorrect 29.80%
Does not matter 0%
Do personal dosimeters offer protection from exposure to radiation? Correct 94.20%
Incorrect 5.80%
Do not know 0%
Table 4
Participant gender: radiation effects knowledge score.
Gender N Mean score p-Value
Male 47 16.2 0.73
Female 57 16
Table 5
Participant age-groups: radiation effects knowledge score.
Age group N Mean score p-Value (as compared to 1st category) p-Value (Category 2 vs 1) p-Value (Category 3 vs 1)
20e29 59 15.9 0.15 0.21 0.88
30e39 29 15.7
40e59 16 17.3
Table 6
Participant educational level: radiation effects knowledge score.
Education level N Mean score p-Value
Undergraduate 87 15.9 0.18
Postgraduate 17 16.9
Table 7
Participant country of degree: radiation effects knowledge score.
Country of
degree
N Mean
score
p-Value
(as compared
to 1st category)
p-Value
(Category
2 vs 1)
p-Value
(Category
3 vs 1)
United Kingdom 19 16.1 0.83 0.93 0.97
Cyprus 39 16.8
Greece 45 14.1
4

When looking at the difference of means between individuals
with undergraduate (m ¼ 15.9) and postgraduate (m ¼ 16.9) training,
some differences can be observed. However, the p-value (p ¼ 0.18)
is still not statistically significant to an extent which can show that
increased training and education do lead to an increase in the un-
derstanding of and knowledge on radiation, radiation protection,
and safety. Perhaps a larger sample could show a different trend.
In regards to where the participant received his/her education,
there is no statistically significant difference between the mean score
of individuals who have trained in one country compared to another.
Moving on, the working environment of the participants
showed to influence their proficiency in radiation knowledge. The
differences in score, in this case, were showed to be statistically
significant, with a p-value of 0.006. The groups which scored the
highest mean were individuals who worked in private hospitals/
clinics (m ¼ 16.8), followed by those who work in public hospital/
clinics (m ¼ 16.1). Individuals who work in private labs or diagnostic
centres (similar to outpatient clinics but do not belong to a hospital)
scored the lowest (m ¼ 14.1). Congruently, the place in which in-
dividuals practise makes a difference in their radiation protection
knowledge and therefore may serve as a guide of understanding
what methods help with ensuring consistent radiation training
throughout all types of workplaces.
The area of specialisation shows some differences between
those who practise oncology and nuclear medicine (m ¼ 17.4), and
radiographers and individuals not working (both m ¼ 15.9). Even
though there is an increase in the average score for those speci-
alised in oncology and nuclear medicine, the differences are not
shown to be statistically significant (p ¼ 0.27). Therefore, knowl-
edge of radiation protection does not depend on the area of
specialisation, based on the current sample size.
The type of work licences the participants have has shown a
statistically significant difference in means between the groups
(p ¼ 0.024). Those who have a dual licence and can work in both
radiotherapy and diagnostic radiography have a mean score of 16.6,
compared to participants that can only practise in diagnostic
radiography who had a mean average of 15.4 (see Table 9).
Finally, the number of years which participants have been
practising shows to have a statistically significant difference be-
tween the groups (p ¼ 0.021), with those practising for ten years or
more achieving a mean score of 16.8, whereas those practising up
to 1 year having the lowest mean score of 15 (see Table 10).
Conclusions
This study aimed to assess the level of knowledge of radiogra-
phers in the Republic of Cyprus regarding radiation protection. The
study showed that the levels of knowledge in radiation protection
of radiographers in the Republic of Cyprus are of a good standard
when compared with the results seen in other similar studies
which used questionnaires of similar difficulty.34e39
Unfortunately,
when it comes to an understanding of the specifics of dose limits,
there was an apparent confusion between patient-related dose
limits and occupational exposure dose limits as specified by na-
tional and international legislation in regards to diagnostic radi-
ology. Moreover, there is an urgent need for the radiographers to be
trained around the needs of the national radiation protection
legislation concerning informing their patients about the possible
effects of using ionising radiation.
In regards to the demographic characteristics, the ones that
showed a statistically significant mean score difference (p ¼ 0.05)
were (i) the workplace of the participant, (ii) the type of work
licence the participant held at the time of the questionnaire, and
(iii) the years of clinical experience of the participant, a result that
differs from other similar studies.34,40
Although this study is consistent with previous researches,41e46
which showed that there is an increased percentage of radiogra-
phers who are not aware of the accurate dose of radiation delivered
to the patients, there are several limitations. Firstly, based on the
source of information used, some questions regarding the effective
dose and cancer risk may have variable answers. Moreover, because
the survey was carried out online, there is the possibility that some
of the participants searched for the correct answers. These may
introduce bias regarding the actual knowledge status of the par-
ticipants. Lastly, a significant limitation is the sample size which
may be due to the 3-months’ time limit. Similar studies with a
larger sample size at regular intervals should be carried out.
Conflict of interest statement
None.
Acknowledgements
The authors would like to thank the Cyprus Society of Registered
Radiologic Technologists & Radiation Therapy Technologists and
Mr. Photis Kollas for disseminating the questionnaire to the society
members and all the radiographers that completed the question-
naire forms which made this study possible. This research did not
receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.radi.2019.11.003.
Table 8
Participant workplace: radiation effects knowledge score.
Workplace N Mean
score
p-Value (as
compared to
1st category)
p-Value
(Category
2 vs 1)
p-Value
(Category
3 vs 1)
p-Value
(Category
4 vs 1)
Public
Hospital/Clinic
19 16.1 0.006 0.71 0.13 0.99
Private
Hospital/Clinic
50 16.8
Private
Lab/Diagnostic
Centre
15 14.1
Not working 20 15.8
Table 9
Participant work licence: radiation effects knowledge score.
Work licence N Mean score (m) p-Value
Diagnostic Radiography 47 15.4 0.024
Radiotherapy and Diagnostic Radiography 57 16.6
Table 10
Participant clinical experience: radiation effects knowledge score.
Years of
clinical
experience
N Mean
score
p-Value
(as compared
to 1st category)
p-Value
(Category
2 vs 1)
p-Value
(Category
3 vs 1)
p-Value
(Category
4 vs 1)
0e1 years 21 15 0.021 0.11 0.99 0.030
1e5 years 39 16.7
5e10 years 19 15.1
10 years 25 16.8
C. Zervides et al. / Radiography xxx (xxxx) xxx 5

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