BIRGIT ERTL-WAGNER, MD
A VIEW FROM ABROAD
Societal and Individual Determinants of Patients’ Radiation Safety Behavior: A Preliminary Investigation from China Yan Qiao, MS, Nan Wang, MD, Rubin Chen, MS, Yuan Liang, PhD INTRODUCTION
In recent decades, the increasing use of radiation-based diagnostic and therapeutic modalities has brought concerns about radiation safety to the forefront of patient care and public health [1-5]. The vast majority of existing radiation safety studies have focused on radiation exposure among physicians working in a hospital environment [6-11]. The existing studies demonstrate a lack of knowledge about radiation dose, exposure, and risk among physicians [12-16]. For example, survey data from Hong Kong showed that the overall accuracy of knowledge about radiation exposure was 40% for radiologists and 16% for nonradiologists [12]. There are only a handful of studies on radiation safety knowledge among patients, and there is a lack of related studies on influencing factors. In addition, according to the bio-psycho-social medical model [17], the factors affecting disease need to be extended from the individual to society, and accordingly, this model must also be extended to the factors influencing patients’ radiation safety. Furthermore, medical/hospital personnel must work together with patients Authorship statement: N.W. and Y.L. are guarantors of integrity of entire study, N.W. and Y.L. designed the study; Y.Q. and Y.L performed literature research; Y.Q. and R.C. performed the clinical studies and data acquisition; Y.Q. and R.C; N.W. and Y.L. analyzed and interpreted the data; and all authors were involved in manuscript preparation, definition of intellectual content, editing, revision and review of manuscript, and had final version approval.
and their accompanying family members to ensure the radiation safety of patients. In China, the use of radiological procedures to diagnose and treat various medical conditions has increased in recent years. Taking Shanghai, the largest city in China with a population of 23 million, as an example, 1,075 hospitals provided diagnostic x-ray services in 2007, and these hospitals had 2,743 pieces of diagnostic x-ray equipment, which is 59% more than in 1996. The frequency of x-ray diagnostics is 745.44 persons per 1,000 people, meaning that about 75% of Shanghai’s permanent population has undergone a diagnostic x-ray (up to 13.85 million people), an increase of 51.2% relative to the frequency in 1996 [18-19]. Faced with such a rapid expansion of x-ray services, patients’ radiation safety is of increasingly urgent importance in China [20-21]. To address the above issues, this study offers a preliminary survey on the societal and individual determinants of patients’ radiation safety behavior in China and seeks to provide new evidence and clues for establishing a radiological protection policy for patients. METHODS
A cross-sectional survey was conducted face-to-face from July 11, 2011, to August 26, 2011. The study population comprised adult patients aged 18 years and older who underwent a radiological examination (eg, ordinary x-ray, fluoroscopy, CT) at the Department
ª 2014 Published by Elsevier on behalf of American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.10.019
of Radiology, Gong’an People’s Hospital, Hubei Province, in central China. The per capita GDP of Hubei province was US $5,300 in 2011, ranking the province 13th among the 31 provinces in China. However, this value is lower than the national average (US $5,450). Therefore, to some degree, Hubei province represents the general socioeconomic level of China. Among the total eligible study population of 1,199 people, 1,172 (97.75%) participated in the survey, and 984 (83.96%) of the questionnaires were valid. All participants gave written informed consent. The Medical Ethics Committee of the School of Public Health, Tongji Medical College, HUST approved this study. The safety awareness and behavior of patients were investigated by asking the following questions: “Do you think that a radiation examination is harmful to your health?” and “Did you note the radiation warning signs (a red light accompanied by a text or voice reminding patients ‘Please keep a little further back’) when you approached the radiation examination room?” The individual-level variables included gender, age, education level, marital status, selfreported economic status, and number of previous radiological examinations. The social-level variables included whether or not patients were told about any safety concerns associated with radiological examinations by the doctor who ordered their radiological examination, and whether or not patients were accompanied by a 521
522 A View From Abroad
family member, as well as the accompanying family member’s safety awareness and behavior. Multiple regression and multilevel analyses were applied: model 1 was shown alone with individual-level variables, and model 2 added in social-level variables. Models 1A and 2A included all of the eligible participants, and he models 1B and 2B excluded those participants who were not accompanied by a family member. Two-sided tests were used, and P values < .05 were considered statistically significant. All analyses were performed using SPSS, version 12.0 (SPSS Inc, Chicago, Illinois). RESULTS
Table 1 summarizes the distribution of primary variables. With respect to the education level of patients, 459 participants (46.65%) were primary and lower, which was to be expected for rural central China [22]. Tables 2 and 3 summarize the effects of societal and individual factors on patients’ radiation safety awareness and behavior, respectively. Note that in Table 2, radiation safety awareness was significantly affected by whether the patient was accompanied by a family member in model 2A, and the radiation safety awareness of the accompanying family member significantly affected the radiation safety awareness of the patient in model 2B. And note that in Table 3, the addition of societal-level variables, self-reported economic status, and whether patients were told by their physician about the safety issues of radiological examinations were significantly associated with radiation safety behavior in model 2A, and the radiation safety behavior of the accompanying family member was added as a significant variable in model 2B.
Table 1. The distribution of patients’ radiation safety awareness and behavior as well as related societal and individual determination factors (N ¼ 984) Variables n % Dependent variables Patients’ safety awareness Yes 272 27.64 No 712 72.36 Patients’ safety behavior Yes 478 48.58 No 506 51.42 Individual factors Gender Male 530 53.86 Female 454 46.14 Age 29 193 19.61 30-44 225 22.87 45-59 325 33.03 60 241 24.49 Education level High school and above 208 21.14 Junior high school 317 32.22 Primary and lower 459 46.65 Marital status Unmarried 159 16.16 Others 52 5.28 Married 773 78.56 Place of residence Rural 745 75.71 Urban 239 24.29 Self-reported economic status Good 65 6.61 Average 727 73.88 Poor 192 19.51 Times of previous radiological examination 2 132 13.41 1 139 14.13 0 713 72.46 Societal factors Whether or not patients were told by the doctor about radiological safety Yes 426 43.29 No 558 56.71 Whether or not patients were accompanied by family member Yes 733 74.49 No 251 25.51 Accompanying family member’s safety awareness Yes 227 31.93 No 484 68.07 Accompanying family member’s safety behavior Yes 363 51.05 No 348 48.95
Discussion
To our knowledge, these are the first empirical data about the societal and individual determinants of patients’ radiation safety behavior in China. The results show that the
level of radiation safety awareness and behavior among patients and their accompanying family members is low, and that there is similarly low level among those told by the physician about the
A View From Abroad 523
Table 2. The effects of societal and individual factors on patients’ radiation safety awareness (N ¼ 984) Variables Model 1A Model 1B Model 2A Model 2B Individual factors Gender Male 0.71 (0.53-0.95)* 0.80 (0.57-1.12) Female 1 1 Age 29 1.72 (0.99-2.99) 1.57 (0.86-2.87) 30-44 1.06 (0.68-1.66) 1.15 (0.68-1.93) 45-59 0.82 (0.55-1.23) 1.01 (0.64-1.61) 60 1 1 Education level High school and above 1.35 (0.88-2.05) 1.10 (0.67-1.83) Junior high school 1.09 (0.77-1.56) 1.00 (0.67-1.49) Primary and lower 1 1 Marital status Others 0.71 (0.43-1.16) 0.80 (0.47-1.37) Married 1 1 Place of residence Rural 0.77 (0.55-1.10) 0.80 (0.52-1.21) Urban 1 1 Self-reported economic status Average and above 1.04 (0.72-1.51) 1.16 (0.77-1.74) Poor 1 1 Times of previous radiological examination 2 1.86 (1.25-2.76)† 1.56 (0.10-2.43) 1 1.04 (0.69-1.58) 1.03 (0.64-1.65) 0 1 1 Societal factors Whether or not patients were told by the doctor about radiological safety Yes No Whether or not patients were accompanied by family member Yes No Accompanying family member’s safety awareness Yes No Accompanying family member’s safety behavior Yes No
0.72 (0.54-0.97)* 1
0.57 (0.33-0.99)* 1
1.64 (0.94-2.86) 1.10 (0.71-1.73) 0.87 (0.58-1.31) 1
1.82 (0.72-4.60) 0.96 (0.42-2.22) 0.74 (0.35-1.52) 1
1.49 (0.97-2.28) 1.13 (0.79-1.61) 1
1.11 (0.50-2.47) 0.69 (0.36-1.30) 1
0.69 (0.42-1.13) 1
0.49 (0.22-1.12) 1
0.74 (0.52-1.05) 1
0.85 (0.43-1.67) 1
1.08 (0.75-1.56) 1
0.99 (0.51-1.91) 1
1.79 (1.20-2.66)† 1.04 (0.68-1.57) 1
1.45 (0.70-3.00) 0.89 (0.42-1.90) 1
0.99 (0.74-1.33) 1
1.25 (0.69-2.27) 1
1.70 (1.18-2.45)† 1 92.29 (52.77-161.40)z 1 0.67 (0.36-1.22) 1
Data presented are odds ratio (95% confidence interval) Model 1A and model 2A: all the participants; Model 1B and model 2B: the participants did not include those without an accompanying family member.
*P < .05 †P < .01 zP < .001
safety issues relating to radiological examination, which reveals a negligence of radiation safety and also confirms the results of existing studies [9-10,13-14,23-24]. In addition, the level of patients’ radiation safety awareness and behavior is lower than that of their accompanying family member, which may be because patients arriving at the hospital for radiological
procedures are often worried about their illness. More importantly, the effects of radiation safety awareness and behavior of the accompanying family member on patients may reveal the importance of the accompanying family member in terms of patients’ radiation safety. It is noteworthy that the patients’ radiation safe behavior is much
better than their safety awareness, and similar conclusions were reached concerning their accompanying family member. This may be because radiologists remind patients and their accompanying family members about radiation safety issues, and thus patients and family members passively adopt radiation safety behavior “following the doctor’s advice.” Specifically, among
524 A View From Abroad
Table 3. The effects of societal and individual factors on patients’ radiation safety behavior (N ¼ 984) Variables Model 1A Model 1B Model 2A Model 2B Individual factors Gender Male 1.04 (0.80-1.35) 1.17 (0.86-1.61) Female 1 1 Age 29 1.77 (1.07-2.92) 1.64 (0.94-2.87) 30-44 1.38 (0.92-2.06) 1.63 (1.00-2.64)* 45-59 1.28 (0.89-1.82) 1.49 (0.97-2.28) 60 1 1 Education level High school and above 1.30 (0.89-1.92) 1.10 (0.68-1.77) Junior high school 0.97 (0.71-1.32) 0.81 (0.50-1.30) Primary and lower 1 1 Marital status Others 0.91 (0.58-1.42) 1.07 (0.65-1.75) Married 1 1 Place of residence Rural 0.73 (0.53-1.01) 0.62 (0.42-0.93)* Urban 1 1 Self-reported economic status Average and above 1.66 (1.19-2.30)† 1.88 (1.29-2.75)† Poor 1 1 Times of previous radiological examination 2 1.06 (0.72-1.55) 1.21 (0.79-1.87) 1 1.42 (0.97-2.05) 1.35 (0.87-2.10) 0 1 1 Radiation safety awareness Yes 0.95 (0.71-1.27) 0.99 (0.71-1.38) No 1 1 Societal factors Whether or not patients were told by the doctor about radiological safety Yes No Whether or not patients were accompanied by family member Yes No Accompanying family member’s safety awareness Yes No Accompanying family member’s safety behavior Yes No
0.96 (0.71-1.29) 1
1.07 (0.65-1.76) 1
2.53 (1.42-4.50)† 1.42 (0.89-2.25) 1.33 (0.88-2.01) 1
1.80 (0.76-4.28) 2.97 (1.34-6.57)† 1.72 (0.88-3.34) 1
1.32 (0.85-2.06) 1.02 (0.71-1.45) 1
1.42 (0.67-3.04) 0.78 (0.43-1.40) 1
0.76 (0.46-1.26) 1
0.88 (0.42-1.87) 1
0.83 (0.57-1.20) 1
0.59 (0.32-1.11) 1
1.73 (1.19-2.52)† 1
2.61 (1.47-4.66)† 1
0.80 (0.52-1.24) 1.14 (0.74-1.75) 1
0.62 (0.32-1.21) 1.24 (0.62-2.49) 1
0.94 (0.68-1.31) 1
0.49 (0.20-1.20) 1
8.58 (6.34-11.60)z 1
4.55 (2.79-7.43)z 1
0.92 (0.64-1.30) 1 2.30 (0.98-5.40) 1 44.57 (26.44-75.11)z 1
Data presented are odds ratio (95% confidence interval). Model 1A and model 2A: all the participants; model 1B and model 2 B: the participants did not include those without an accompanying family member.
*P < .05 †P < .01 zP < .001
patients and their accompanying family member, “doctors tell us to pay attention to radiation safety, then, we follow the doctors’ advice;” this is not an active behavior based on awareness about radiation dangers, but a passive behavior based on following the doctor’s advice.
Although a doctor’s advice can protect patients who lack awareness of radiation safety to some degree, the process may reveal an important phenomenon, ie, there may be a great gap between radiation safety awareness and behavior. Moreover, among the factors affecting patient safety
awareness, the safety consciousness of the accompanying family member is significant; however, the safety behavior of the accompanying family member is not significant (model 2B, Table 2); meanwhile, the factors influencing patients’ safety behavior (model 2B, Table 3)
A View From Abroad 525
have similar effects, which also demonstrates a great gap between radiation safety awareness and behavior. The above issues are rarely mentioned in the existing studies. There were limitations to the study. First, although China’s public hospitals (generally named People’s Hospitals) have a higher homogeneity within a national unified management system, the sample in our preliminary investigation was confined to a hospital in central China, and determining whether the preliminary findings can be generalized will require a multicenter study. Second, we used a single variable with selfreport measures to represent radiation safety awareness and behavior, which could be prone to participant response bias. Third, like all cross-sectional studies, it is difficult to establish causal association between independent and dependent variables. Future studies are needed to clarify these important issues. ADVANCES IN KNOWLEDGE
Whether or not patients were accompanied by a family member and the accompanying family member’s radiation safety awareness had significant influences on radiation safety awareness (odds ratio [OR]: 1.70, 95% confidence interval [CI]: 1.18 to 2.46; OR: 92.29, 95% CI: 52.78 to 161.41, respectively). Whether or not they were told by their doctor about the safety issues of radiological examination and the accompanying family member’s radiation safety behavior were significantly associated with patient’s radiation safety behavior (OR: 4.55, 95% CI: 2.79 to 7.43; OR: 44.57, 95% CI: 26.44 to 75.11, respectively).
IMPLICATIONS FOR PATIENT CARE
The results provide possible new clues to understanding the role of societal-level factors in radiological protection, particularly concerning patient’s accompanying family members. There may be a great gap between radiation safety awareness and behavior, which is worthy of future in-depth study. TAKE-HOME POINTS
Despite these limitations, the current study provides preliminary insight into the societal and individual determinants of patients’ radiation safety behavior in China, especially for those developing countries. The results provide possible new clues to understanding the role of societal-level factors in radiological protection, particularly concerning patient’s accompanying family members. There may be a great gap between radiation safety awareness and behavior, which is worthy of future in-depth study. REFERENCES 1. Ikuta I, Sodickson A, Wasser EJ, Warden GI, Gerbaudo VH, Khorasani R. Exposing exposure: enhancing patient safety through automated data mining of nuclear medicine reports for quality assurance and organ dose monitoring. Radiology 2012;264:406-13. 2. Martin CJ. A survey of incidents in radiology and nuclear medicine in the West of Scotland. Br J Radiol 2005;78:913-21. 3. Hiles P, Brennen S, Scott S, Davies J. A survey of patient dose and image quality for computed tomography scanners in Wales. J Radiol Prot 2001;21:345-54. 4. Holmberg O, Malone J, Rehani M, McLean D, Czarwinski R. Current issues and actions in radiation protection of patients. Eur J Radiol 2010;76:15-9. 5. FitzGerald R. Radiological error: analysis, standard setting, targeted instruction and teamworking. Eur Radiol 2005;15: 1760-7.
6. Borgen L, Stranden E, Espeland A. Clinicians’ justification of imaging: do radiation issues play a role? Insights Imaging 2010;1: 193-200. 7. Reagan JT, Slechta AM. Factors related to radiation safety practices in California. Radiol Technol 2010;81:538-47. 8. Etard C, Celier D, Roch P, Aubert B. National survey of patient doses from whole-body FDG PET-CT examinations in France in 2011. Radiat Prot Dosimetry 2012;152:334-8. 9. Divrik Gökçe S, Gökçe E, Cos¸kun M. Radiology residents’ awareness about ionizing radiation doses in imaging studies and their cancer risk during radiological examinations. Korean J Radiol 2012;13: 202-9. 10. Wong CS, Huang B, Sin HK, Wong WL, Yiu KL, Chu Yiu Ching T. A questionnaire study assessing local physicians, radiologists and interns’ knowledge and practice pertaining to radiation exposure related to radiological imaging. Eur J Radiol 2012;81: e264-8. 11. Birnbaum S. Radiation safety in the era of helical CT: a patient-based protection program currently in place in two community hospitals in New Hampshire. J Am Coll Radiol 2008;5:714-8. 12. Lee RK, Chu WC, Graham CA, Rainer TH, Ahuja AT. Knowledge of radiation exposure in common radiological investigations: a comparison between radiologists and non-radiologists. Emerg Med J 2012;29:306-8. 13. Arslanoglu A, Bilgin S, Kubal Z, Ceyhan MN, Ilhan MN, Maral I. Doctors’ and intern doctors’ knowledge about patients’ ionizing radiation exposure doses during common radiological examinations. Diagn Interv Radiol 2007;13: 53-5. 14. Söylemez H, Sancaktutar AA, Silay MS, et al. Knowledge and attitude of European urology residents about ionizing radiation. Urology 2013;81:30-5. 15. Yucel A, Karakas E, Bulbul E, Kocar I, Duman B, Onur A. Knowledge about ionizing radiation and radiation protection among patients awaiting radiological examinations: a cross-sectional survey. Med J Kocatepe 2009;10:25-31. 16. Lee CI, Haims AH, Monico EP, Brink JA, Forman HP. Diagnostic CT scans: assessment of patient, physician, and radiologist awareness of radiation dose and possible risks. Radiology 2004;231:393-8. 17. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129-36. 18. Gao L, Yao J, Zheng J, Qian A, Shen Y. Frequency levels and distribution of medical exposure of diagnostic x-ray procedures
526 A View From Abroad
in 2007 in Shanghai. (Chinese) J Environ Occ Med 2009;26:532-6. 19. Zheng J. Radiology security needs to strengthen in China. Chinese J Med Res 2011;40:3-5. 20. Zhou L, Cao J. Investigation on radiological protection consciousness and knowledge among examinees in Xuzhou City, China. Chinese J School Doctor 2011;25:736-8.
21. Tang B, Zhang Y, Chen B, Tu Y. A survey of radiation safety and culture of radiation health staff of hospital. Chinese J Radiol Health 2010;19:412-4.
23. Luk S, Leung J, Cheng C. Knowledge of radiation dose and awareness of risks: a cross-sectional survey of junior clinicians. J Hong Kong Col Radiol 2010;13:189-94.
22. Gong Y, Zhang L, Wang Z, Liang Y. Pathway analysis of risk factors for severe suicidal ideation: a survey in rural China. Can J Public Health 2011;102: 472-5.
24. Bosanquet DC, Green G, Bosanquet AJ, Galland RB, Gower-Thomas K, Lewis MH. Doctors’ knowledge of radiation e a twocentre study and historical comparison. Clin Radiol 2011;66:748-51.
Yan Qiao, MS, and Yuan Liang, PhD are from the Department of Social Medicine, Public Health School, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China. Nan Wang, MD is from the Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China. Rubin Chen, MS is from the Department of Radiology, Gong’an People’s Hospital, Hubei Province, China. Yuan Liang, PhD, Department of Social Medicine, Public Health School, Tongji Medical College, Huazhong University of Science and Technology, China; Hangkong Road 13, Wuhan City, Hubei Province, China, Postcode: 430030; e-mail: [email protected]; [email protected].
A VIEW FROM ABROAD
Societal and Individual Determinants of Patients’ Radiation Safety Behavior: A Preliminary Investigation from China Yan Qiao, MS, Nan Wang, MD, Rubin Chen, MS, Yuan Liang, PhD INTRODUCTION
In recent decades, the increasing use of radiation-based diagnostic and therapeutic modalities has brought concerns about radiation safety to the forefront of patient care and public health [1-5]. The vast majority of existing radiation safety studies have focused on radiation exposure among physicians working in a hospital environment [6-11]. The existing studies demonstrate a lack of knowledge about radiation dose, exposure, and risk among physicians [12-16]. For example, survey data from Hong Kong showed that the overall accuracy of knowledge about radiation exposure was 40% for radiologists and 16% for nonradiologists [12]. There are only a handful of studies on radiation safety knowledge among patients, and there is a lack of related studies on influencing factors. In addition, according to the bio-psycho-social medical model [17], the factors affecting disease need to be extended from the individual to society, and accordingly, this model must also be extended to the factors influencing patients’ radiation safety. Furthermore, medical/hospital personnel must work together with patients Authorship statement: N.W. and Y.L. are guarantors of integrity of entire study, N.W. and Y.L. designed the study; Y.Q. and Y.L performed literature research; Y.Q. and R.C. performed the clinical studies and data acquisition; Y.Q. and R.C; N.W. and Y.L. analyzed and interpreted the data; and all authors were involved in manuscript preparation, definition of intellectual content, editing, revision and review of manuscript, and had final version approval.
and their accompanying family members to ensure the radiation safety of patients. In China, the use of radiological procedures to diagnose and treat various medical conditions has increased in recent years. Taking Shanghai, the largest city in China with a population of 23 million, as an example, 1,075 hospitals provided diagnostic x-ray services in 2007, and these hospitals had 2,743 pieces of diagnostic x-ray equipment, which is 59% more than in 1996. The frequency of x-ray diagnostics is 745.44 persons per 1,000 people, meaning that about 75% of Shanghai’s permanent population has undergone a diagnostic x-ray (up to 13.85 million people), an increase of 51.2% relative to the frequency in 1996 [18-19]. Faced with such a rapid expansion of x-ray services, patients’ radiation safety is of increasingly urgent importance in China [20-21]. To address the above issues, this study offers a preliminary survey on the societal and individual determinants of patients’ radiation safety behavior in China and seeks to provide new evidence and clues for establishing a radiological protection policy for patients. METHODS
A cross-sectional survey was conducted face-to-face from July 11, 2011, to August 26, 2011. The study population comprised adult patients aged 18 years and older who underwent a radiological examination (eg, ordinary x-ray, fluoroscopy, CT) at the Department
ª 2014 Published by Elsevier on behalf of American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.10.019
of Radiology, Gong’an People’s Hospital, Hubei Province, in central China. The per capita GDP of Hubei province was US $5,300 in 2011, ranking the province 13th among the 31 provinces in China. However, this value is lower than the national average (US $5,450). Therefore, to some degree, Hubei province represents the general socioeconomic level of China. Among the total eligible study population of 1,199 people, 1,172 (97.75%) participated in the survey, and 984 (83.96%) of the questionnaires were valid. All participants gave written informed consent. The Medical Ethics Committee of the School of Public Health, Tongji Medical College, HUST approved this study. The safety awareness and behavior of patients were investigated by asking the following questions: “Do you think that a radiation examination is harmful to your health?” and “Did you note the radiation warning signs (a red light accompanied by a text or voice reminding patients ‘Please keep a little further back’) when you approached the radiation examination room?” The individual-level variables included gender, age, education level, marital status, selfreported economic status, and number of previous radiological examinations. The social-level variables included whether or not patients were told about any safety concerns associated with radiological examinations by the doctor who ordered their radiological examination, and whether or not patients were accompanied by a 521
522 A View From Abroad
family member, as well as the accompanying family member’s safety awareness and behavior. Multiple regression and multilevel analyses were applied: model 1 was shown alone with individual-level variables, and model 2 added in social-level variables. Models 1A and 2A included all of the eligible participants, and he models 1B and 2B excluded those participants who were not accompanied by a family member. Two-sided tests were used, and P values < .05 were considered statistically significant. All analyses were performed using SPSS, version 12.0 (SPSS Inc, Chicago, Illinois). RESULTS
Table 1 summarizes the distribution of primary variables. With respect to the education level of patients, 459 participants (46.65%) were primary and lower, which was to be expected for rural central China [22]. Tables 2 and 3 summarize the effects of societal and individual factors on patients’ radiation safety awareness and behavior, respectively. Note that in Table 2, radiation safety awareness was significantly affected by whether the patient was accompanied by a family member in model 2A, and the radiation safety awareness of the accompanying family member significantly affected the radiation safety awareness of the patient in model 2B. And note that in Table 3, the addition of societal-level variables, self-reported economic status, and whether patients were told by their physician about the safety issues of radiological examinations were significantly associated with radiation safety behavior in model 2A, and the radiation safety behavior of the accompanying family member was added as a significant variable in model 2B.
Table 1. The distribution of patients’ radiation safety awareness and behavior as well as related societal and individual determination factors (N ¼ 984) Variables n % Dependent variables Patients’ safety awareness Yes 272 27.64 No 712 72.36 Patients’ safety behavior Yes 478 48.58 No 506 51.42 Individual factors Gender Male 530 53.86 Female 454 46.14 Age 29 193 19.61 30-44 225 22.87 45-59 325 33.03 60 241 24.49 Education level High school and above 208 21.14 Junior high school 317 32.22 Primary and lower 459 46.65 Marital status Unmarried 159 16.16 Others 52 5.28 Married 773 78.56 Place of residence Rural 745 75.71 Urban 239 24.29 Self-reported economic status Good 65 6.61 Average 727 73.88 Poor 192 19.51 Times of previous radiological examination 2 132 13.41 1 139 14.13 0 713 72.46 Societal factors Whether or not patients were told by the doctor about radiological safety Yes 426 43.29 No 558 56.71 Whether or not patients were accompanied by family member Yes 733 74.49 No 251 25.51 Accompanying family member’s safety awareness Yes 227 31.93 No 484 68.07 Accompanying family member’s safety behavior Yes 363 51.05 No 348 48.95
Discussion
To our knowledge, these are the first empirical data about the societal and individual determinants of patients’ radiation safety behavior in China. The results show that the
level of radiation safety awareness and behavior among patients and their accompanying family members is low, and that there is similarly low level among those told by the physician about the
A View From Abroad 523
Table 2. The effects of societal and individual factors on patients’ radiation safety awareness (N ¼ 984) Variables Model 1A Model 1B Model 2A Model 2B Individual factors Gender Male 0.71 (0.53-0.95)* 0.80 (0.57-1.12) Female 1 1 Age 29 1.72 (0.99-2.99) 1.57 (0.86-2.87) 30-44 1.06 (0.68-1.66) 1.15 (0.68-1.93) 45-59 0.82 (0.55-1.23) 1.01 (0.64-1.61) 60 1 1 Education level High school and above 1.35 (0.88-2.05) 1.10 (0.67-1.83) Junior high school 1.09 (0.77-1.56) 1.00 (0.67-1.49) Primary and lower 1 1 Marital status Others 0.71 (0.43-1.16) 0.80 (0.47-1.37) Married 1 1 Place of residence Rural 0.77 (0.55-1.10) 0.80 (0.52-1.21) Urban 1 1 Self-reported economic status Average and above 1.04 (0.72-1.51) 1.16 (0.77-1.74) Poor 1 1 Times of previous radiological examination 2 1.86 (1.25-2.76)† 1.56 (0.10-2.43) 1 1.04 (0.69-1.58) 1.03 (0.64-1.65) 0 1 1 Societal factors Whether or not patients were told by the doctor about radiological safety Yes No Whether or not patients were accompanied by family member Yes No Accompanying family member’s safety awareness Yes No Accompanying family member’s safety behavior Yes No
0.72 (0.54-0.97)* 1
0.57 (0.33-0.99)* 1
1.64 (0.94-2.86) 1.10 (0.71-1.73) 0.87 (0.58-1.31) 1
1.82 (0.72-4.60) 0.96 (0.42-2.22) 0.74 (0.35-1.52) 1
1.49 (0.97-2.28) 1.13 (0.79-1.61) 1
1.11 (0.50-2.47) 0.69 (0.36-1.30) 1
0.69 (0.42-1.13) 1
0.49 (0.22-1.12) 1
0.74 (0.52-1.05) 1
0.85 (0.43-1.67) 1
1.08 (0.75-1.56) 1
0.99 (0.51-1.91) 1
1.79 (1.20-2.66)† 1.04 (0.68-1.57) 1
1.45 (0.70-3.00) 0.89 (0.42-1.90) 1
0.99 (0.74-1.33) 1
1.25 (0.69-2.27) 1
1.70 (1.18-2.45)† 1 92.29 (52.77-161.40)z 1 0.67 (0.36-1.22) 1
Data presented are odds ratio (95% confidence interval) Model 1A and model 2A: all the participants; Model 1B and model 2B: the participants did not include those without an accompanying family member.
*P < .05 †P < .01 zP < .001
safety issues relating to radiological examination, which reveals a negligence of radiation safety and also confirms the results of existing studies [9-10,13-14,23-24]. In addition, the level of patients’ radiation safety awareness and behavior is lower than that of their accompanying family member, which may be because patients arriving at the hospital for radiological
procedures are often worried about their illness. More importantly, the effects of radiation safety awareness and behavior of the accompanying family member on patients may reveal the importance of the accompanying family member in terms of patients’ radiation safety. It is noteworthy that the patients’ radiation safe behavior is much
better than their safety awareness, and similar conclusions were reached concerning their accompanying family member. This may be because radiologists remind patients and their accompanying family members about radiation safety issues, and thus patients and family members passively adopt radiation safety behavior “following the doctor’s advice.” Specifically, among
524 A View From Abroad
Table 3. The effects of societal and individual factors on patients’ radiation safety behavior (N ¼ 984) Variables Model 1A Model 1B Model 2A Model 2B Individual factors Gender Male 1.04 (0.80-1.35) 1.17 (0.86-1.61) Female 1 1 Age 29 1.77 (1.07-2.92) 1.64 (0.94-2.87) 30-44 1.38 (0.92-2.06) 1.63 (1.00-2.64)* 45-59 1.28 (0.89-1.82) 1.49 (0.97-2.28) 60 1 1 Education level High school and above 1.30 (0.89-1.92) 1.10 (0.68-1.77) Junior high school 0.97 (0.71-1.32) 0.81 (0.50-1.30) Primary and lower 1 1 Marital status Others 0.91 (0.58-1.42) 1.07 (0.65-1.75) Married 1 1 Place of residence Rural 0.73 (0.53-1.01) 0.62 (0.42-0.93)* Urban 1 1 Self-reported economic status Average and above 1.66 (1.19-2.30)† 1.88 (1.29-2.75)† Poor 1 1 Times of previous radiological examination 2 1.06 (0.72-1.55) 1.21 (0.79-1.87) 1 1.42 (0.97-2.05) 1.35 (0.87-2.10) 0 1 1 Radiation safety awareness Yes 0.95 (0.71-1.27) 0.99 (0.71-1.38) No 1 1 Societal factors Whether or not patients were told by the doctor about radiological safety Yes No Whether or not patients were accompanied by family member Yes No Accompanying family member’s safety awareness Yes No Accompanying family member’s safety behavior Yes No
0.96 (0.71-1.29) 1
1.07 (0.65-1.76) 1
2.53 (1.42-4.50)† 1.42 (0.89-2.25) 1.33 (0.88-2.01) 1
1.80 (0.76-4.28) 2.97 (1.34-6.57)† 1.72 (0.88-3.34) 1
1.32 (0.85-2.06) 1.02 (0.71-1.45) 1
1.42 (0.67-3.04) 0.78 (0.43-1.40) 1
0.76 (0.46-1.26) 1
0.88 (0.42-1.87) 1
0.83 (0.57-1.20) 1
0.59 (0.32-1.11) 1
1.73 (1.19-2.52)† 1
2.61 (1.47-4.66)† 1
0.80 (0.52-1.24) 1.14 (0.74-1.75) 1
0.62 (0.32-1.21) 1.24 (0.62-2.49) 1
0.94 (0.68-1.31) 1
0.49 (0.20-1.20) 1
8.58 (6.34-11.60)z 1
4.55 (2.79-7.43)z 1
0.92 (0.64-1.30) 1 2.30 (0.98-5.40) 1 44.57 (26.44-75.11)z 1
Data presented are odds ratio (95% confidence interval). Model 1A and model 2A: all the participants; model 1B and model 2 B: the participants did not include those without an accompanying family member.
*P < .05 †P < .01 zP < .001
patients and their accompanying family member, “doctors tell us to pay attention to radiation safety, then, we follow the doctors’ advice;” this is not an active behavior based on awareness about radiation dangers, but a passive behavior based on following the doctor’s advice.
Although a doctor’s advice can protect patients who lack awareness of radiation safety to some degree, the process may reveal an important phenomenon, ie, there may be a great gap between radiation safety awareness and behavior. Moreover, among the factors affecting patient safety
awareness, the safety consciousness of the accompanying family member is significant; however, the safety behavior of the accompanying family member is not significant (model 2B, Table 2); meanwhile, the factors influencing patients’ safety behavior (model 2B, Table 3)
A View From Abroad 525
have similar effects, which also demonstrates a great gap between radiation safety awareness and behavior. The above issues are rarely mentioned in the existing studies. There were limitations to the study. First, although China’s public hospitals (generally named People’s Hospitals) have a higher homogeneity within a national unified management system, the sample in our preliminary investigation was confined to a hospital in central China, and determining whether the preliminary findings can be generalized will require a multicenter study. Second, we used a single variable with selfreport measures to represent radiation safety awareness and behavior, which could be prone to participant response bias. Third, like all cross-sectional studies, it is difficult to establish causal association between independent and dependent variables. Future studies are needed to clarify these important issues. ADVANCES IN KNOWLEDGE
Whether or not patients were accompanied by a family member and the accompanying family member’s radiation safety awareness had significant influences on radiation safety awareness (odds ratio [OR]: 1.70, 95% confidence interval [CI]: 1.18 to 2.46; OR: 92.29, 95% CI: 52.78 to 161.41, respectively). Whether or not they were told by their doctor about the safety issues of radiological examination and the accompanying family member’s radiation safety behavior were significantly associated with patient’s radiation safety behavior (OR: 4.55, 95% CI: 2.79 to 7.43; OR: 44.57, 95% CI: 26.44 to 75.11, respectively).
IMPLICATIONS FOR PATIENT CARE
The results provide possible new clues to understanding the role of societal-level factors in radiological protection, particularly concerning patient’s accompanying family members. There may be a great gap between radiation safety awareness and behavior, which is worthy of future in-depth study. TAKE-HOME POINTS
Despite these limitations, the current study provides preliminary insight into the societal and individual determinants of patients’ radiation safety behavior in China, especially for those developing countries. The results provide possible new clues to understanding the role of societal-level factors in radiological protection, particularly concerning patient’s accompanying family members. There may be a great gap between radiation safety awareness and behavior, which is worthy of future in-depth study. REFERENCES 1. Ikuta I, Sodickson A, Wasser EJ, Warden GI, Gerbaudo VH, Khorasani R. Exposing exposure: enhancing patient safety through automated data mining of nuclear medicine reports for quality assurance and organ dose monitoring. Radiology 2012;264:406-13. 2. Martin CJ. A survey of incidents in radiology and nuclear medicine in the West of Scotland. Br J Radiol 2005;78:913-21. 3. Hiles P, Brennen S, Scott S, Davies J. A survey of patient dose and image quality for computed tomography scanners in Wales. J Radiol Prot 2001;21:345-54. 4. Holmberg O, Malone J, Rehani M, McLean D, Czarwinski R. Current issues and actions in radiation protection of patients. Eur J Radiol 2010;76:15-9. 5. FitzGerald R. Radiological error: analysis, standard setting, targeted instruction and teamworking. Eur Radiol 2005;15: 1760-7.
6. Borgen L, Stranden E, Espeland A. Clinicians’ justification of imaging: do radiation issues play a role? Insights Imaging 2010;1: 193-200. 7. Reagan JT, Slechta AM. Factors related to radiation safety practices in California. Radiol Technol 2010;81:538-47. 8. Etard C, Celier D, Roch P, Aubert B. National survey of patient doses from whole-body FDG PET-CT examinations in France in 2011. Radiat Prot Dosimetry 2012;152:334-8. 9. Divrik Gökçe S, Gökçe E, Cos¸kun M. Radiology residents’ awareness about ionizing radiation doses in imaging studies and their cancer risk during radiological examinations. Korean J Radiol 2012;13: 202-9. 10. Wong CS, Huang B, Sin HK, Wong WL, Yiu KL, Chu Yiu Ching T. A questionnaire study assessing local physicians, radiologists and interns’ knowledge and practice pertaining to radiation exposure related to radiological imaging. Eur J Radiol 2012;81: e264-8. 11. Birnbaum S. Radiation safety in the era of helical CT: a patient-based protection program currently in place in two community hospitals in New Hampshire. J Am Coll Radiol 2008;5:714-8. 12. Lee RK, Chu WC, Graham CA, Rainer TH, Ahuja AT. Knowledge of radiation exposure in common radiological investigations: a comparison between radiologists and non-radiologists. Emerg Med J 2012;29:306-8. 13. Arslanoglu A, Bilgin S, Kubal Z, Ceyhan MN, Ilhan MN, Maral I. Doctors’ and intern doctors’ knowledge about patients’ ionizing radiation exposure doses during common radiological examinations. Diagn Interv Radiol 2007;13: 53-5. 14. Söylemez H, Sancaktutar AA, Silay MS, et al. Knowledge and attitude of European urology residents about ionizing radiation. Urology 2013;81:30-5. 15. Yucel A, Karakas E, Bulbul E, Kocar I, Duman B, Onur A. Knowledge about ionizing radiation and radiation protection among patients awaiting radiological examinations: a cross-sectional survey. Med J Kocatepe 2009;10:25-31. 16. Lee CI, Haims AH, Monico EP, Brink JA, Forman HP. Diagnostic CT scans: assessment of patient, physician, and radiologist awareness of radiation dose and possible risks. Radiology 2004;231:393-8. 17. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129-36. 18. Gao L, Yao J, Zheng J, Qian A, Shen Y. Frequency levels and distribution of medical exposure of diagnostic x-ray procedures
526 A View From Abroad
in 2007 in Shanghai. (Chinese) J Environ Occ Med 2009;26:532-6. 19. Zheng J. Radiology security needs to strengthen in China. Chinese J Med Res 2011;40:3-5. 20. Zhou L, Cao J. Investigation on radiological protection consciousness and knowledge among examinees in Xuzhou City, China. Chinese J School Doctor 2011;25:736-8.
21. Tang B, Zhang Y, Chen B, Tu Y. A survey of radiation safety and culture of radiation health staff of hospital. Chinese J Radiol Health 2010;19:412-4.
23. Luk S, Leung J, Cheng C. Knowledge of radiation dose and awareness of risks: a cross-sectional survey of junior clinicians. J Hong Kong Col Radiol 2010;13:189-94.
22. Gong Y, Zhang L, Wang Z, Liang Y. Pathway analysis of risk factors for severe suicidal ideation: a survey in rural China. Can J Public Health 2011;102: 472-5.
24. Bosanquet DC, Green G, Bosanquet AJ, Galland RB, Gower-Thomas K, Lewis MH. Doctors’ knowledge of radiation e a twocentre study and historical comparison. Clin Radiol 2011;66:748-51.
Yan Qiao, MS, and Yuan Liang, PhD are from the Department of Social Medicine, Public Health School, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China. Nan Wang, MD is from the Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China. Rubin Chen, MS is from the Department of Radiology, Gong’an People’s Hospital, Hubei Province, China. Yuan Liang, PhD, Department of Social Medicine, Public Health School, Tongji Medical College, Huazhong University of Science and Technology, China; Hangkong Road 13, Wuhan City, Hubei Province, China, Postcode: 430030; e-mail: [email protected]; [email protected].
