i

Ionizing Radiation Leakage and Radiation Protection Measures in

Radio-Diagnostic Centers in Governmental Hospitals of Gaza

Governorates, Palestine

,

By:

Samer S. Abu Zer

Supervisors:

A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of

Master of Science in Environmental Health

Dec./2014

The Islamic University–Gaza

Deanship of Graduate Studies

Faculty of Science

Master of Environmental Science

Environmental Health

Prof. Mohammed R. Al Agha Dr. Samir S. Yassin Professor of Environmental Sciences Associate Prof. of Physics

The Islamic University of Gaza The Islamic University of Gaza

ii

ABSTRACT

The fact of using radiation in medicine has led to major improvements in the

diagnostic and treatment of human diseases. However, it carries some risks of

health problems. This subject has received a great concern in the recent years.

The work is based on measurement of equivalent radiation dose rate in different

locations in radio-diagnostic rooms at governmental Gaza governorates

hospitals. These include: 19 basic X-ray, 8 fluoroscopy, 3 CT scan and

mammography machines. The measurements were carried out by using the

radiation survey meter (OD-01), since there is no obvious work have been

previously done experimentally.

A questionnaire is designed for matching the study needs and 182 radio-

diagnostic workers participated in the work in order to obtain an information

about their radiation protection measures and practices.

The results indicate that the fluoroscopy and CT scan rooms were not efficiently

lead lined and the radiation protection is not well organized. The measured

values of radiation dose rate at different locations in basic X-ray and

mammography rooms are found within a permissible limits for workers and

public. However, the recommended distance between the X-ray machine and

control panel have not been achieved in some rooms.

In addition, the results of questionnaire indicate unsatisfactory practices toward

radiation protection issues, where approximately half of participants have

negative practices. The participants have reported that 35.2% of personal

radiation protection devices are available in radio-diagnostic centers. Also the

results revealed very poor of personal radiation exposure monitoring process.

Overall, the results represented in this work reflect that majority of participants

believe there is no radiation safety officer to provide the service. Therefore,

there is a desperate need for rules, regulations and radiation protection act in the

field of radiation in medical field.

Finally, recommendations in the light of the outcome of study results were

given to improve the radiation protection and safety measures.

Key Words: Ionizing radiation, Radiation protection, X-ray, Radio-diagnostic,

Equivalent radiation dose rate, Workload.

iii

ملخص الدراسة

تشخيص والعالج من األمراض التي تصيب اإلنسان. أدى استخدام اإلشعاع في الطب إلى تحسينات كبيرة في ال

من المخاطر و المشاكل الصحية. وقد حظي هذا الموضوع باهتمام كبير في اومع ذلك، فإنه يحمل كثير

السنوات األخيرة. ويستند هذا العمل على قياس معدل الجرعة اإلشعاعية في مواقع مختلفة في غرف األشعة

8، أشعة سينيةجهاز 19حكومية في محافظات غزة. حيث شملت هذه الدراسة: التشخيصية في المستشفيات ال

أجهزة أشعة مقطعية. و جهاز تصوير الثدي. وقد أجريت القياسات باستخدام جهاز 3وسكوبي، فلورأجهزة

دراسة عملية سابقةال يوجد أي ( لقياس معدل الجرعة االشعاعية المكافئة، حيث أنهOD-01المسح االشعاعي )

لقياس هذه الجرعات في المستشفيات الحكومية في محافظات غزة.

شخص يعملون في مراكز األشعة التشخيصية 182 ، حيث شاركاحتياجات الدراسة لمالئمةتم تصميم استبيان

.من اإلشعاع اجراءات وممارسات الوقايةمعلومات عن بهذه المستشفيات وذلك للحصول على

ألشعة المقطعية لم تبطن بالرصاص بكفاءة وغير و غرف ا وسكوبيالفلوررف غالنتائج إلى أن أشارت

مصممة جيدا للوقاية من االشعاع. لقد وجد أن قياس معدالت الجرعة االشعاعية في مواقع مختلفة من غرف

مسافة ال ومع ذلك فانوالجمهور. املينللثدي ضمن الحدود المسموح بها للع االشعاعيوالتصوير األشعة السينية

السنية ولوحة التحكم في بعض الغرف لم تتحقق. الموصى بها بين جهاز أشعة

ما أن من اإلشعاع، حيث الوقاية إلى ممارسات غير مرضية تجاه قضايا أشارتنتائج االستبيان فإنباإلضافة

ية الشخصية من الوقاأجهزة من٪ 35.2 المشاركين أنيقرب من نصف المشاركين لديهم ممارسات سلبية. وأفاد

ة. وكشفت النتائج أيضا ضعف في عملية مراقبة التعرض ياالشعاع متوفرة في مراكز األشعة التشخيص

.لإلشعاعالشخصي

جهة تحرص على أن غالبية المشاركين يعتقدون أنه ال يوجد تفيدممثلة في هذا العمل العموما، فإن النتائج

تتعلق ن يانولوائح وقوقواعد لوضع . ولذلك، هناك حاجة ماسةينلماجراءات الوقاية من االشعاع وسالمة العا

في المجال الطبي. بالوقاية من االشعاع

في المجال اإلشعاعاجراءات وممارسات الوقاية من لتحسين على ضوء هذه النتائج أعطيت توصيات وأخيرا،

.يطبال

، األشعة السينية، األشعة التشخيصية ، الجرعة اإلشعاع المؤين ، الوقاية من اإلشعاع ح :

اإلشعاعية المكافئة ، حمولة العمل.

iv

Dedication

I would like first and most to thank almighty

God for the blessings and power that made

my project a reality.

I would like to extend my deepest gratitude

to:

My Parents for their unending love and

support,

My lovely wife who supports me,

My beloved daughters Jana and Lana,

My brothers and sisters,

My friends and colleagues who participated

in bringing this project to the happy end.

Samer S. Abu Zer

v

Acknowledgments IN THE NAME OF ALLAH, THE MOST GRACIOUS, THE MOST MERCIFUL

I would like to express my sincere thanks and gratitude to my supervisor Prof. Dr.

Mohammed Al Agha, for his continuous guidance, support and encouragement

throughout my research, that leads to the emergence of this work in current form.

Also, my sincere thanks to my supervisor Dr. Samir Yassin, due to his initiating and

planning of this work, without whom I could not have made this progress. He was

with me step by step and he was very keen to show me everything right.

My thanks should be extended to physicist Mr. Rami Al Agha for his help in

radiation doses measurements conducting.

My thanks should be extended to Dr. Said Al Husseini (General Director Of

Radiology Unit "MOH").

I'm greatly indebted to Mr. Ibrahim Abbas, Mr. Mohammed Al Sersawy, Mr. Maher

Marzooq, Mr. Rami Dwaima, Mr. Yasser Al Ya'qoby and Mr. Ahmed Wishah for

their support, encouragement and helpful suggestions.

Special thanks and admiration to Eng. Nader Skaik, Eng. Ahmed Lolo, Eng. Hazem

Al Qasass and Eng. Abed Al Hameed Siam for their cooperation and help during my

study.

I would like to highly thank Mr. Jihad Okasha for his help in statistical analysis.

At the end, I am very grateful to those who participated and help me to complete this

study.

vi

List of Contents

ii Abstract……………………………………………………….……………..……

iii …………………………………………………..……………..…….ملخص الدراسة

iv Dedication……………………...…………………………..……………………..

v Acknowledgment……………………..…………………..………………………

vi List of contents…...…………............……....……………………………………

ix List of tables………………………….……………..…………………..………..

x List of figures………………..…………………………………………..………..

xii List of annexes……………………………………………………………………

xiii List of abbreviations……………………………………………………………...

xiv List of glossary………………………………………………………………..…

Chapter 1: Introduction

1 1.1 Overview………………………..……………………………………………

3 1.2 Problem statement……………...…………………………………………….

3 1.3 Significance……………………...…………………………………………...

4 1.4 Justification……………………...……………………………………………

5 1.5 Objectives……………………...……………………………………………..

5 1.5.1 General objectives………….……………………………...…………...

5 1.5.2 Specific objectives………..……………………………...……………..

5 1.6 Context of the study………………………………………………………….

6 1.6.1 Radio-diagnostic services in governmental hospitals of Gaza……...….

11 1.6.2 Demographic context……………..………………………………....….

11 1.6.3 Gaza Strip population………………...………………………………

12 1.6.4 Socioeconomic and political context ………...……………….………..

12 1.6.5 Environmental status………..………………...……….………….……

13 1.7 Cancer in Palestine……….……………...………………...…………………

Chapter 2: Literature Review

15 2.1 Introduction……………………………….……………………….…………

15 2.2 Conceptual framework…………………………….………….……………...

18 2.3 Ionizing radiation...……………………….………………..…………………

18 2.4 Natural ionizing radiation sources……………………………………………

19 2.5 Artificial ionizing radiation sources…………………………..……………...

20 2.6 Types of individual exposure to ionizing radiation………..……………........

20 2.7 Ionizing radiation dose and units……………..………………………………

21 2.8 Medical uses of ionizing radiation……………………………………………

21 2.8.1 Radio-therapy…………………………………………………………..

22 2.8.2 Radio-diagnostic………………………………………………………..

22 2.8.2.1 Nuclear medicine………………………………………………..

22 2.8.2.2 Diagnostic X-ray………………………………………………

24 2.9 Radiation protection………………………………………………………….

24 2.9.1 Radiation protection principle………………………………………….

24 2.9.1.1 Justification……………………………………………………...

25 2.9.1.2 Optimization…………………………………………………….

25 2.9.1.3 Individual dose limits…………………………………………...

25 2.9.2 Radiation protection techniques…………………………………….....

vii

26 2.9.3 Radiation monitoring…………………………………………………..

26 2.9.3.1 Personal radiation monitoring in radio-diagnostic centers…..…

27 2.9.3.2 Ensuring effective radiation protection of medical staff……….

27 2.9.4 Personal radiation protection devices………………………………….

28 2.9.5 Radiation protection training…………………………………………..

28 2.10 The use of radiation for medical exposure …………………………………

30 2.11 Biological effects of ionizing radiation……………………………………..

31 2.12 Previous studies related to this research…………………………………….

Chapter 3: Methodology

35 3.1 Introduction…………………………………………………………………

35 3.2 Study design………………………………………………………………..

35 3.3 Study population………………………………………………………......

35 3.4 Sample size…………………………………………………………………

36 3.5 Locations of the study………...…………………………………………….

36 3.6 Ethical considerations ………………………………………………………..

36 3.7 Study instruments ……………………………………………………………

36 3.7.1 Radiation survey meter……….…………………………..…………….

37 3.7.2 Radio-diagnostic machines and rooms specifications…..……………...

38 3.7.3 Questionnaire interview…….………………………..…………………

39 3.8 Study techniques …..…………….…………………………………………...

39 3.8.1 Locations of measurements…………………………………………..

40 3.8.2 The workload…………….………..……………………………………

41 3.8.3 The equivalent radiation dose rate ..….….……………...….…………..

43 3.9 Limitation of the study……………………………………………………….

44 3.10 Statistical tools and data analysis…………………………………………

Chapter 4: Results and Discussion

45 4.1 Introduction……………………………………….………………………….

46 Part one

46 4.2 The equivalent radiation dose rate at the selected nine hospitals………..…...

46 4.2.1 The measurements at Al Shifa Medical Complex…...............................

48 4.2.2 The measurements at Nasser Medical Complex………………..…..…..

49 4.2.3 The measurements at European Gaza hospital……………….…..…….

50 4.2.4 The measurements at Abu Yousef Al Najjar Martyr hospital….…..…..

51 4.2.5 The measurements at Kamal Adwan Martyr hospital…………..….…..

52 4.2.6 The measurements at Al Aqsa Martyrs hospital………………..…..…..

53 4.2.7 The measurements at Abdel Aziz Rantessi Martyr hospital…..…..……

54 4.2.8 The measurements at Al Naser Pediatric hospital……………...……....

54 4.2.9 The measurements at Beit Hanoun hospital……………………………

55 4.3 The equivalent radiation dose rate at the different locations………………...

55 4.3.1 The equivalent radiation dose rate at control panels……….…………..

56 4.3.2 The equivalent radiation dose rate at corridors……………….………..

57 4.3.3 The equivalent radiation dose rate at patient waiting rooms…..……….

58 4.3.4 The equivalent radiation dose rate at dark rooms……………………..

59

4.3.5 Directional equivalent radiation dose rate and at one meter from the X-

ray tube in basic X-ray and mammography rooms…………………...

61 4.3.6 Directional equivalent radiation dose rate and at one meter from the

viii

X-ray tube in fluoroscopy and CT scan rooms………………………..

62 4.4 Specifications of radio-diagnostic machines and rooms at selected hospitals.

65 Part two

65 4.5 The questionnaire contents analysis…..……………………………………..

65 4.5.1 Socio-demographic and work related information…………………..…

70 4.5.2 Participants response about the availability of radiation protection……

72 4.5.3 Participants response to awareness items about radiation protection .....

76 4.5.4 Participants response to practices items about radiation protection…....

80 4.5.5 Participants response to personal radiation exposure monitoring.…..…

86 4.6 The relationship between the independent variables and the participants……

Chapter 5: Conclusion and Recommendations

101 5.1 Conclusion……………………………………………………………………

103 5.2 Recommendations……………………………………………………………

104 5.3 Suggestions for future studies………………………………………………...

105 References………………………………………………………………………..

116 Annexes…………………………………………………………………………..

ix

List of Tables

Table No. Subject Page

Table (1.1) Population distribution in Gaza governorates 12

Table (2.1) Time evolution of the number of radiological procedures,

collective dose and annual dose per capita, worldwide 29

Table (4.1) The dependent variables according to participants age 87

Table (4.2) The dependent variables according to participants sex 90

Table (4.3) The dependent variables according to participants occupation 91

Table (4.4) The dependent variables according to participants academic

qualification 93

Table (4.5) The dependent variables according to participants practical

experience 95

Table (4.6) The dependent variables according to participants hospitals 97

Table (4.7) The dependent variables according to participants daily work

hours in radio-diagnostic rooms 100

x

List of Figures

Figure No. Subject Page

Figure (1.1) Gaza Strip map and the selected nine governmental

hospitals locations 10

Figure (2.1) Schematic representation of the study framework. 17

Figure (3.1) Radiation survey meter (OD-01) 37

Figure (3.2) The radiation parameters were taken in basic X-ray

machine 41

Figure (3.3) The reference phantom was used as a scattering medium 42

Figure (3.4) Source Image Distance (SID) is equal 100 cm 43

Figure (4:1) The equivalent radiation dose rate in basic X-ray rooms at

Al Shifa Medical Complex 46

Figure (4.2) The equivalent radiation dose rate in fluoroscopy and CT

scan rooms at Al Shifa Medical 47

Figure (4.3) The equivalent radiation dose rate in basic X-ray and

mammography rooms at Nasser Medical Complex 48

Figure (4.4) The equivalent radiation dose rate in fluoroscopy and CT

scan rooms at Nasser Medical Complex 49

Figure (4.5) The equivalent radiation dose rate at European Gaza

hospital 50

Figure (4.6) The equivalent radiation dose rate at Abu Yousef Al Najjar

Martyr hospital 50

Figure (4.7) The equivalent radiation dose rate at Kamal Adwan Martyr

hospital 51

Figure (4.8) The equivalent radiation dose rate at Al Aqsa Martyrs

hospital 52

Figure (4.9) The equivalent radiation dose rate at Abdel Aziz Rantessi

Martyr hospital 53

Figure (4.10) The equivalent radiation dose rate at Al Naser Pediatric

hospital 54

Figure (4.11) The equivalent radiation dose rate at Beit Hanoun hospital 55

Figure (4.12) The equivalent radiation dose rate at control panels 56

Figure (4.13) The equivalent radiation dose rate at corridors 57

Figure (4.14) The equivalent radiation dose rate at patient waiting rooms 58

Figure(4. 15) The equivalent radiation dose rate at dark rooms 59

Figure (4.16)

Directional equivalent radiation dose rate and at one meter

from the X-ray tube in basic X-ray and mammography

rooms

60

Figure (4.17) Directional equivalent radiation dose rate and at one meter

from the X-ray tube in fluoroscopy and CT scan rooms 61

Figure (4.18) Participants percentage according to their occupation 65

Figure (4.19) Participants percentage according to their sex 66

Figure (4.20) Participants percentage according to their age groups 66

Figure (4.21) Participants percentage according to their academic 67

xi

qualifications

Figure (4.22) Participants percentage according to their practical

experience 68

Figure (4.23) Participants percentage according to their distribution at the

hospitals 68

Figure (4.24) Participants percentage according to their dealing with

radio-diagnostic machines 69

Figure (4.25) Participants percentage according to their daily work hours

in radio-diagnostic rooms 69

Figure (4.26) Participants response about the availability of personal

radiation protection devices items 70

Figure (4.27) Participants response to radiation protection awareness

items 73

Figure (4.28) Participants response to radiation protection practices items 77

Figure (4.29) Participants response about availability of radiation

protection advisors 81

Figure (4.30) Participants response about availability of personal

radiation exposure monitoring devices 81

Figure (4.31)

Participants response about using of personal radiation

exposure monitoring device during their work in radio-

diagnostic rooms

82

Figure (4.32)

Participants response about receiving guidance about the

proper handling with the personal radiation exposure

monitoring device

82

Figure (4.33) Participants response about safety officers interest with the

devices measurements 83

Figure (4.34) Participants response about availability of new device when

the devices collect to measure of radiation dose 83

Figure (4.35) Participants response about the reasons for lack of personal

radiation exposure monitoring devices 84

xii

List of Annexes

Annex No. Annex Page

Annex (1) Sample size calculator 116

Annex (2) A permission from the Ministry of Health to perform the

study in the governmental hospitals 117

Annex (3) A consent from all participants to ensure their voluntary

participation 118

Annex (4) Arabic version of questionnaire 119

Annex (5) English version of questionnaire 123

Annex (6) Certificate of radiation survey meter (OD-01) calibration 127

Annex (7) The equivalent radiation dose rate measurements 128

Annex (8) Radio-diagnostic machines and rooms specifications data

sheet 135

Annex (9) The questionnaire analysis tables 141

xiii

List of Abbreviations

ALARA As Low As Reasonable Achievable

ANOVA Analysis Of Variance

CT Compute Tomography

DNA DeoxyriboNucleic Acid

EPA Environmental Protection Agency

HW Equivalent radiation dose for whole body

IAEA International Atomic Energy Agency

ICRP International Commission on Radiological Protection

IR Ionizing Radiation

kVp kilovolts peak (unit to describe X-ray tube voltage)

mA milliAmpere (unit to describe X-ray tube current)

MOH Ministry Of Health

MRI Magnetic Resonance Imaging

mSv milliSievert

NCRP National Council on Radiation Protection

PCBS Palestinian Central Bureau of Statistics

SPSS Statistical Package of Social Science

Sv Sievert (unit of effective dose)

UNRWA United Nations Relief and Work Agency

UNSCEAR United Nations Scientific Committee on the Effects of Atomic

Radiation

WHO World Health Organization

xiv

List of Glossary

Diagnostic radiology: the use of X-rays to diagnose disease or injury, or

provide imaging information for medical purposes.

X-ray: Ionizing electromagnetic radiation emitted by an atom when it has been

bombarded with electrons.

Diagnostic X-ray machines: any electronic device that has fast-moving

electrons is a potential source of ionizing radiation.

Radio-diagnostic worker: any person who is employed in diagnostic radiology,

whether full time, part time or temporarily, by an employer, and who has

recognized rights and duties in relation to occupational radiological protection.

Dose: a general term used to refer to the amount of energy absorbed by tissue

from ionizing radiation.

Equivalent dose: a measure of dose in organs and tissues which takes into

account the type of radiation involved. The unit of equivalent dose is J kg-1

, with

the special name Sievert (Sv).

Sievert (Sv): the special name for the SI unit of equivalent dose, effective dose,

and operational dose quantities. The unit is joule per kilogram (J/kg).

Workload: can be classified as quantitative (the amount of work to be done),

workload is a measure of the X-ray tube use.

Stochastic effects: are those in which the probability of the effect occurring

depends on the amount of radiation dose, this type of effects increases as a

radiation dose increases.

1

Chapter 1

Introduction

1.1 Overview

Ionizing radiation has always been a part of the human environment. Natural

background radiation comes from two primary sources: cosmic radiation and

terrestrial sources. The worldwide average background dose for a human being is

about 2.4 milliSievert (mSv) per year (UNSCEAR, 2008). Man-made sources also

contribute to our continuous exposure to ionizing radiation. Ionizing radiation is

radiation with enough energy so that during an interaction with an atom, it can

remove tightly bound electrons from the orbit of an atom, causing the atom to

become charged or ionized. Ionizing radiation has been putting to use in diagnosis of

various diseases and treatment since its discovery in 1895 by Wilhelm Conrad

Rontgen (WHO, 2009).

The use of radiation in medicine has led to major improvements in the diagnosis and

treatment of human diseases. Diagnostic X-rays are the largest man made sources of

radiation exposure to the population contributing to about 14% of the total annual

exposure worldwide from all sources. Although diagnostic X- ray provides great

benefits, but its use carries some risks of developing cancer (Mehta, 2005).

Monitoring of radiation doses received by staff in radiology department is a great

importance (Okaro et al., 2010). The purpose of a radiation monitoring programmed

is to identify all sources of radiation exposure within an operation area, to assess the

level of radiation exposure of the employee and members of the public so that timely

detection of changes in radiation parameters which may lead to increase the

exposures and to produce sufficient information for optimization purpose

(Olowookere et al., 2009).

The decrease in radiation dose of patients and medical staff undergoing diagnostic X-

ray has a significant value. Medical imaging has led to rapid increases in a number of

high dose X-ray examinations performed with significant consequences for

2

individual patient doses and for collective dose to the population as a whole.

Therefore, it is important to make regular assessments of the magnitude of these

large doses in each country (Gonzalez et al., 2004).

The radiological protection principles in practical field, the optimization of

protection and the individual dose limitation should be continuously performed. Dose

limitation for occupationally exposed individuals is necessary to reduce the level of

risk and ensures safety for workers. Knowledge and education have strong direct

effects in technical protection against health hazards associated with radiation

exposures (Mojiri and Moghimbeigi, 2008). It is advisable that assessing radiation

doses received by radiology workers at periodic intervals will ensure their

occupational safety (Ujah et al., 2012).

personal radiation monitoring is essential to ensure that dose limits for staff are not

exceeded. The accepted effective annual dose limits for occupational staff as

reported by the International Commission on Radiological Protection (ICRP) in 1977

was 50 mSv. Public should not be exposed to more than an average of 1 mSv per

year. A downward review was done in 1991 and an effective annual dose limit of 20

mSv was adopted as an average for a period of five years, with the further provision

that the effective dose should not exceed 50 mSv in any single year. The downward

review of annual dose limit was adopted in order to put a stricter control over the use

of ionizing radiation in medicine and minimize possible hazards, especially the

stochastic effects (Ibitoye et al., 2011).

To the best of our knowledge, there is no clear cut off evidence such a work has been

previously performed in Gaza governorates. Therefore, this study was conducted to

measure the ionizing radiation level inside and outside the radio-diagnostic rooms

and evaluation of radiation protection measures at governmental hospitals of Gaza

governorates.

3

1.2 Problem Statement

Recently, tremendous development has taken place in the radio-diagnostic field at

governmental Gaza governorates hospitals. Newer modalities are being applied in

hospitals and latest radiological machines are recently obtained. Besides, there is a

noticeable increase year after year in the frequency of radiological procedures. This

quantitative increase may have a positive impact on the health service system of the

country, but the lack of control can cause serious problem especially radiation hazard

to the radiation workers as well as public (Abbas, 2014, Personal communication).

Due to the increase of the demand on radio-diagnostic examinations, this leads to

increase the exposure of radio-diagnostic workers and patients to ionizing radiation

doses. Long term of ionizing radiation exposures may lead to biological changes and

health problems such as cancer, heritable effects and tissue reactions. Radiation

protection measures evaluation is essential to ensure that dose limits for radio-

diagnostic workers not exceed the permissible limits.

Therefore, this study should be taken seriously into consideration, so as ensure the

safety for a workers and public in governmental hospitals of Gaza governorates. This

would provide helpful recommendations for persons in charge to avoid or reduce the

exposure of workers and the public to medical ionizing radiation.

1.3 Significance

- No previous research is available about ionizing radiation levels inside and

outside of radio-diagnostic rooms at governmental hospitals at Gaza governorates.

- Ionizing radiation protection has been the concern of national and international

bodies. This is due to the potential hazardous effects associated with ionizing

radiation if not properly controlled and long term of ionizing radiation exposures

that lead to biological changes and health problems.

4

- Due to the increase of the frequency of radio-diagnostic procedures year after

year, this leads to increase the ionizing radiation doses to radio-diagnostic workers

and patients.

- In Gaza governorates hospitals, there is no radiation protection program, lack of

clear information about radiation protection measures and guidelines. Therefore,

the study results will help in implementing modification to alleviate risk factors.

In addition, to develop an action plan and new management strategies for

radiation protection enhancements and provide clear information to the decision

makers.

1.4 Justification

Measuring of the equivalent radiation dose rate at different locations in the radio-

diagnostic rooms at the selected nine hospitals. In addition obtain information about

of radio-diagnostic machines and rooms specifications.

Through the study we will get information about the availability of personal radiation

protection devices, awareness and practices regarding radiation protection issues and

evaluation of personal radiation exposure monitoring process as a dependent

variables. However, the socio-demographic and work related factors among radio-

diagnostic workers are independent variables.

The study results also help the planners and decision makers to modify the future

plans regarding radiation protection to be more effective and valuable in improving

the radiation protection knowledge among the radio-diagnostic workers in

governmental hospitals at Gaza governorates.

5

1.5 Objectives

1.5.1 General objective

The general objective of present study is to measure of ionizing radiation level inside

and outside of radio-diagnostic rooms to assess whether yearly equivalent radiation

dose received by the radio-diagnostic workers and public are within the dose limits

recommended by ICRP or not and evaluation of radiation protection measures at

governmental Gaza governorates hospitals.

1.5.2 Specific objectives

1. To identify the dangerous locations in radio-diagnostic centers.

2. To identify the availability of radiation protection devices in the radio-

diagnostic centers.

3. To measure the level of radio-diagnostic workers awareness and practices about

radiation protection issues.

4. To evaluate the personal radiation exposure monitoring process.

1.6 Context of the study

The study was conducted in governmental Gaza governorates hospitals. Therefore,

the context of the study involves some information about the place of study which

include the selected nine governmental hospitals and radio-diagnostic services in

these hospitals. In addition, information about the demographic, population,

socioeconomic, political variables and environmental status in Palestine.

6

1.6.1 Radio-diagnostic services in governmental hospitals of Gaza

governorates

In this section, we display details about the selected nine governmental hospitals and

radio-diagnostic centers according to the Ministry of Health (MOH) records (2013).

The Ministry of Health provides radio-diagnostic services mainly through eleven

hospitals from thirteen hospitals.

All of the eleven hospitals provide Ultrasound (U/S), routine X-ray, while four of

these hospitals have CT scan units, three hospitals have mammography units and

only two hospitals have panorama units. Magnetic Resonance Imaging (MRI) which

is a non-ionizing imaging unit is not available expect in one hospital.

According to the records of hospitals directorate general, about 554529 radio-

diagnostic procedures were done in 2013; of them 438016 routine X-ray procedures

and 2276 fluoroscopy procedures, 26407 CT scan procedures, 1474 panorama

procedures and 564 mammography procedures. This is a highly burden to the

workers and diagnostic machines. Thus, we have selected a nine governmental

hospitals in order to measure the equivalent radiation dose rate in different locations

in radio-diagnostic rooms. Figure (1.1), illustrates Gaza Strip map and the selected

nine governmental hospitals locations.

1. Radio-diagnostic services in Al Shifa Medical Complex

Al Shifa Medical Complex is located in Gaza city, Gaza governorate. It includes

three hospitals: the surgery hospital, internal medicine hospital and obstetrics and

women hospital. The total clinical capacity is about 500 beds. Radio-diagnostic

center in Al Shifa Medical Complex includes: six basic X-ray, one CT scan, two

fluoroscopy, one mammography, one panorama, three portable C-Arm and some of

portable X-ray machines. This center provides approximately 169969 medical

imaging procedures per year. Fifty medical radiographers and fourteen radiologists

working in the center.

7

2. Radio-diagnostic services in Nasser Medical Complex

Nasser Medical Complex is located in Khan Younis city, Khan Younis governorate.

It contains two hospitals: Nasser and Mubarak hospitals. It is provides medical,

surgery, radiological, children and obstetrics and women services. The total clinical

capacity about 258 beds. Radio-diagnostic center in Nasser Medical Complex

includes: two basic X-ray, one CT scan, one mammography, one fluoroscopy, one

panorama, one portable C-Arm and some of portable X-ray machines. This center

provides approximately 82241 medical imaging procedures per year. Twenty eight

medical radiographers and six radiologists working in the center.

3. Radio-diagnostic services in European Gaza hospital

The European Gaza hospital is located in Khan Younis city, Khan Younis

governorate. It provides medical, surgical, pediatric and radiological services. The

total clinical capacity is about 207 beds. Radio-diagnostic center in European Gaza

hospital includes: two basic X-ray, one CT scan, one mammography, one

fluoroscopy, one fluoroscopic lithotripsy, two portable C-Arm and some of portable

X-ray machines. This center provides approximately 66980 medical imaging

procedures per year. Twenty seven medical radiographers and eight radiologists

working in the center.

4. Radio-diagnostic centers in Abu Yousef Al Najjar hospital

Abu Yousef Al Najjar Martyr hospital is located in Rafah governorate, southern

borders of Gaza Strip. It provides medical, surgical, pediatric and radiology services.

The total clinical capacity is 40 beds. Radio-diagnostic center in Abu Yousef Al

Najjar hospital includes: two basic X-ray, one fluoroscopy, one portable C-Arm and

some of portable X-ray machines. This center provides approximately 43628 medical

imaging procedures per year. Sixteen medical radiographers and three radiologists

working in the center.

8

5. Radio-diagnostic services in Kamal Adwan Martyr hospital

Kamal Adwan Martyr hospital is located in Jabalya refugee camp, North Gaza

governorate. It provides surgical, pediatrics, radiological and medical services. The

total clinical capacity is about 73 beds. Radio-diagnostic center in Kamal Adwan

Martyr hospital includes: two basic X-ray, one fluoroscopy machine, two Portable C-

Arm and some of portable X-ray machines. This center provides approximately

70733 medical imaging procedures per year. Sixteen medical radiographers and three

radiologists working in the center.

6. Radio-diagnostic services in Al Aqsa Martyrs hospital

Al Aqsa Martyrs hospital is located in Dier El Balah city, Mid-Zone governorate. It

provides medical, surgical, pediatric, radiological and women obstetrics services, the

clinical capacity is about 103 beds. Radio-diagnostic center in Al Aqsa Martyrs

hospital includes: one basic X-ray, one fluoroscopy, two portable C-Arm and some

of portable X-ray machines. This center provides approximately 53967 medical

imaging procedures per year. Sixteen medical radiographers and five radiologists

working in the center.

7. Radio-diagnostic services in Abdel Aziz Rantessi Martyr Pediatric hospital

Abdel Aziz Rantessi Martyr Pediatric hospital is located in Gaza city, Gaza

governorate. It provides specialized medical services for children. The total clinical

capacity of current operating stage is about 49 beds. Radio-diagnostic center in

Abdel Aziz Rantessi Martyr pediatric hospital includes: one fluoroscopy, one CT

scan and some of portable X-ray machines. This center provides approximately

12377 medical imaging procedures per year. Eleven medical radiographers and two

radiologists working in the center.

9

8. Radio-diagnostic services in Al Naser Pediatric hospital

Al Naser Pediatric hospital is located in Gaza city, Gaza governorate. It provides

pediatric services. The total clinical capacity is about 151 beds. Radio-diagnostic

center in Al Naser hospital includes: one basic X-ray and one fluoroscopy and some

of portable X-ray machines. This center provides approximately 21654 medical

imaging procedures per year. Twelve medical radiographers and three radiologists

working in the center.

9. Radio-diagnostic services in Beit Hanoun hospital

Beit Hanoun hospital is located in Beit Hanoun, North governorate. It provides

surgical, pediatric and medical services, the total clinical capacity is about 36 beds.

The clinical capacity is a total of 500 beds. Radio-diagnostic center in Beit Hanoun

hospital includes: one basic X-ray machine and some of portable X-ray machines.

This center provides approximately 16710 medical imaging procedures per year.

Eight medical radiographers and radiologists working in the center.

10

Figure (1.1): Gaza Strip map and the selected nine governmental hospitals locations

(The source: this map prepared by the researcher)

11

1.6.2 Demographic context

Palestine has an important geographical and strategic location in Middle East.

Palestine is surrounded by Lebanon, Syria, Egypt, and Mediterranean Sea. The total

surface area of the historical Palestine is about 27.000 Km2 (Palestine, MOH, 2006).

Palestine has been occupied in 1948 by Israel and the two remaining parts are

separated geographically (West Bank [WB] and Gaza Strip [GS]) after the war in

1967 (Palestine, MOH, 2006).

Gaza Strip an elongated zone located on the southeastern coast of Palestine with

coordination of Latitude N 31° 26' 25" and Longitude E 34° 23' 34". The area is

bounded by the Mediterranean in the west, the 1948 cease-fire line in the north and

east and by Egypt in the south. The total area of the Gaza Strip was 365 km2 with

approximately 40 km long and the width varies from 8 km in the north to 14 km in

the south (UNEP, 2003).

1.6.3 Gaza Strip population

Gaza governorates is a highly crowded populated area, where approximately

1,853,000 people live in 365 km2, of them 49.33% males and 50.67% females. The

estimated density is 4,000 people per square kilometer distributed across five

governorates. Gaza Governorates are classified into five governorates: North Gaza

governorate, Gaza governorate which is the biggest governorate, Mid-Zone

governorate, Khan Younis governorate and Rafah governorate. Table (1.1),

illustrated the distribution of people into Gaza governorates. The majority of people

live in refugee camps (PCBS, 2014).

This high population density in Gaza Strip increases the over load on the hospitals

care which stress on the great need for proving the diagnostic radiology services in

governmental hospitals of Gaza governorates.

12

Table (1.1): Population distribution in Gaza governorates [PCBS, 2014]

Governorate Population number Percentage

North Gaza 302,000 16.3%

Gaza 700,000 37.8%

Mid-Zone 260,000 14%

Khan Younis 360,000 19.4%

Rafah 231,000 12.5%

Total 1,853,000 100%

1.6.4 Socioeconomic and political context

The Palestinian economy refers to the economy of Palestinian territory, including

GS, WB and East Jerusalem (PCBS, 2009). Due to the recent political changes that

facing the GS, a very bad socio-economic situations is happened. This gives rise a

profoundly negative impact on the public health and access to basic health services.

Nowadays, 80% of families in GS currently depend on humanitarian aid. This

decline results from exceptional levels of poverty and the inability of a large majority

of the population to provide basic food (Human Rights Council, 2013). Thus, the

overall bad economic status of the Palestinians in GS increasing the load on the

governmental hospitals to provide secondary care especially in case of emergency

and violence.

1.6.5 Environmental status

Palestinian environment is experiencing from serious threats such as (Poor quality

and quantity of the water, depletion of natural resources, destruction of the land and

soil erosion, air pollution and noise, pollution of the coast and marine environment,

decline of the natural environment and biodiversity, distortion of the landscape and

threat of Palestinian heritage and historical legacy). However, handling of hazardous

waste and infectious waste mixed up with solid waste is a critical problem which

causes environmental and health risks in the Palestinian Territories (UNEP, 2013).

13

The ignorance of the ongoing environmental issues throughout the years of

occupation, which is the main reason of many environmental disasters.

Environmental problems are aggravated because of the frequent Israeli closures of

the West Bank and the Gaza Strip; they cause disabling economic and population

activities and paralyzing production and construction tools, which increases pollution

problems in every city and village in the West Bank and Gaza Strip (Palestine News

& Info Agency - WAFA, 2014).

1.7 Cancer in Palestine

Cancer is a leading cause of death in all parts of the world, the disease has caused the

deaths of 7.6 million people (about 13% of all deaths) in 2013, the world records

annually more than 11 million new cases of cancer (IARC, 2014).

Palestinian Ministry of Health confirmed that the incidence of cancer in the

Palestinian territories within the global average. The number of cancer cases

recorded in the years 1998 and 1999 in the Gaza Strip and the West Bank and East

Jerusalem, reached 3474 case where the score in the occupied Palestinian territories

more than 1,700 new cases of cancer each year, and is the incidence of cancer is 11

per cent among children of the total number of new cases recorded annually in

Palestine. Cancer considered as a leading cause of death in the Palestinian territories.

In the year 2010 cancers formed the third cause of death in Palestine (MOH, 2013).

The new cancer cases in the Palestinian territories between the 2005 and 2010 were

estimated about 1623 case, with incidence rate of 43.1 cases per 100.000 people, of

whom 49.2 cases per 100.000 people in West Bank and 32.7 cases per 100,000

people in the Gaza Strip (MOH, 2013).

Ministry of Health reported that, since 1998, established the Palestinian Ministry of

Health at the time the National Cancer Registry, where, it is clear from this record, it

is recorded annually among children under the age of 15 years, about 65 children as

new patients with cancer, noting that 49 per cent of the population in the Gaza Strip

14

under the age of 15 years, so has the incidence of cancer among children aged less

than 15 years in the Gaza Strip, 13.2 per 100 thousand inhabitants (15.5 for males

and 10.9 for females). While the number of deaths from cancer among children under

the age of 15 years in the Gaza Strip, about 30 cases a year, which accounted for 9

per cent of the annual total of deaths registered in the Gaza Strip as a result of cancer.

More than 50% of the new cases registered in Palestine are in the age group of 60

years and older

The trachea , bronchus and lung cancer is the highest cause to deaths among cancer

mortality. The incidence of cancer is higher for female than male. The breast cancer

is the highest among female Palestinian population and lung cancer is the highest

among male Palestinian population (MOH, 2014).

The rate of incidence of cancer in the Hashemite Kingdom of Jordan, for example, to

64 cases per 100 thousand inhabitants. While estimated number of people diagnosed

with cancer in Egypt by about one hundred thousand patients a year (WHO, 2013).

15

Chapter 2

Literature Review

2.1 Introduction

In this chapter, we present the study conceptual framework, then a discussion of the

different issues about ionizing radiation such as radiation sources, types of

individuals’ exposure, ionizing radiation dose and units, medical use of ionizing

radiation, radiation protection principles and techniques, ionizing radiation

monitoring and biological effects of ionizing radiation. In the last section of this

chapter, we present many studies related to ionizing radiation leakage evaluation and

radiation protection measures in radio-diagnostic centers.

2.2 Conceptual framework

Based on the review of available literature, we have designed the conceptual

framework. This is used to guide the research process and to make research finding

more meaningful. A schematic representation of the framework of the present study

is mentioned in figure (2.1). The tools of the study included radiation survey meter

(OD-01) were used to measure the equivalent radiation dose rate at different

locations in the radio-diagnostic rooms and the data sheet information collected from

radio-diagnostic machines and rooms in nine selected governmental Gaza

governorates hospitals. In addition, the questionnaire were used to obtain information

about the availability of personal radiation protection devices, awareness and

practices regarding radiation protection issues and evaluation of personal radiation

exposure monitoring process as a dependent variables. However, the socio-

demographic and work related factors among radio-diagnostic workers are

independent variables.

Ionizing radiation: is radiation with enough energy remove tightly bound

electrons from the orbit of an atom, causing the atom to become charged or

ionized (WHO, 2009).

16

Radiation protection: is the science of protecting the human population and the

environment from the harmful effects of ionizing radiation. This includes both

particle radiation and high energy electromagnetic radiation (Radiation protection

manual, 2010).

Safety measures: the measures taken when working with sources of ionizing

radiation to reduce the total dose from all types of ionizing radiation to maximum

permissible dose (Directive Council, 1996)

Radio-diagnostic centers: a places that offers diagnostic services to medical

profession or general public (Brant and Helms 2012).

Governmental hospitals: are hospitals affiliated with the Palestinian Ministry of

Health administratively, financially and technically; they provide health services

to all members of the community who have health valid insurance card (MOH,

2014).

Awareness: is the capacity to acquire, retain and use information; a mixture of

comprehension, experience, discernment and skill (Badran, 1995).

Device: is any physical item that can be used to achieve a goal, especially if the

item is not consumed in the process. Radiation protection devices are a tools made

of lead used to protect patients and staffs from ionizing radiation include: aprons,

thyroid shields, eyewear, lead curtains, and gloves (Klein et al., 2009).

Practice: means the application of rules and knowledge that leads to action.

Good practice is an art that is linked to the progress of knowledge and technology

and it’s executed in an ethical manner (Badran, 1995).

personal radiation exposure monitoring: is an important safety precaution in

the practice of radiography. Its main purpose is to measure radiation dose received

17

by radiology personal, which can indicate that radiation doses received are within

permissible limits, verify that facilities for radiation protection are adequate and

show that radiation protection techniques are acceptable (The University of

Western Australia, 2010).

Figure (2.1): Schematic representation of the study framework

Ionizing radiation leakage and radiation protection

measures in radio-diagnostic centers at

governmental Gaza governorates hospitals

Socio-demographic and work related factors

Age, sex, occupation, academic qualification,

experience, type of machine and daily work

hours

Practices Devices Awareness

Personal radiation

exposure monitoring

18

2.3 Ionizing radiation

Ionizing radiation (IR) is electromagnetic radiation that has sufficient energy to

remove electrons from atoms (WHO, 2009). Ionization results in the production of

negatively charged free electrons and positively charged ionized atoms (EPA, 2007).

IR can be classified into two categories: photons (X-ray and γ- radiation) and

particles (α and β particles and neutrons) (UNSCEAR, 2006).

X-ray is a form of short wavelength electromagnetic radiation which will penetrate

all organs of the body and are a significant external radiation hazard. The energy of

the X-ray photons is an important factor in determining the magnitude of the external

radiation hazard (Burnham, 2001). Most X-rays have a wavelength in the range of

0.01 to 10 nanometers, corresponding to frequencies in the range 30 petahertz to

30 exahertz (3×1016

Hz to 3×1019

Hz) and energies in the range 100 eV to 100 keV

X-ray is emitted by electrons, they can be generated by an X-ray tube, a vacuum

tube that uses a high voltage to accelerate the electrons released by a hot cathode to a

high velocity. The high velocity electrons collide with a metal target, the anode,

creating the X-rays (Whaites et al., 2002).

In contrast, artificial radiation sources have only been introduced in the last 100

years and although many benefits and it has been realized that exposure to these

sources can be harmful to us (IAEA, 2007).

2.4 Natural ionizing radiation sources

Throughout history, human beings are exposed to natural radiation. It is impossible

to decide whether this radiation has been harmful or beneficial to the human species

(IAEA, 2007). Radioactive material is found throughout nature in soil, rocks, water,

air, and vegetation from which it is inhaled and ingested into the body. Humans also

receive external exposure from radioactive materials that remain outside the body

and from cosmic radiation from space (UNSCEAR, 2008).

19

Ionizing radiation is present naturally in the environment from cosmic and terrestrial

sources. Cosmic radiation primarily consists of positively charged ions from protons

to iron and larger nuclei derived sources outside our solar system. This radiation

interacts with atoms in the atmosphere to create an air shower of secondary radiation,

including X-rays, protons, alpha particles, electrons, and neutrons (Feng, 2002). The

second source of natural IR is the terrestrial radiation "earth radiation'' which

includes radiation from the soil, rocks, and building materials such as radionuclides

in granite, stones, sandstone, limestone, where its amount varies geographically

(NAS, 2006).

Radon is a radioactive gas that emanates from the ground. Radon and its isotopes,

parent radionuclides, and decay products all contribute to an average inhaled dose of

1.26 mSv/yr. Radon is unevenly distributed and varies with weather, such that much

higher doses apply to many areas of the world, where it represents a significant

health hazard (UNSCEAR, 2008). Through decay of radon, it produces α and β

radiations. It enters homes through the cracks in floors and walls or building

materials which may contain radio nuclides (WHO, 2004).

2.5 Artificial ionizing radiation sources

People are also exposed to artificial radiation from medical treatments and activities

involving radioactive material. Radioisotopes are produced as a by-product of the

operation of nuclear reactors, and by radioisotope generators like cyclotrons. Many

man-made radioisotopes are used in the fields of nuclear medicine, biochemistry, the

manufacturing industry and agriculture (UNSCER, 2006).

Medical use of IR in both diagnosis and therapy has been widespread since the

discovery of X-rays by Wilhelm Conrad Roentgen in 1895, and radioactive sources

have been used in radiotherapy since 1898. Advances in the latter half of the 20th

century increased the use of medical radiation, and some newer techniques,

particularly radiotherapy, computed tomography, positron emission tomography, and

20

interventional radiation involving fluoroscopy, use higher radiation doses than do

standard diagnostic X-rays. Radiation therapy may involve use of external beams of

radiation, typically high-energy X-rays 4 to 50 MeV and low-energy cobalt-60

gamma rays 1-2 MeV (UNSCEAR, 2006).

Several industrial processes use ionizing radiation. Industrial radiography uses

gamma radiation to examine welded joints in structures. In the oil industry, gamma

radiation or neutron sources are used to determine the geological structures in a bore

hole (NCRP, 1989).

Ionizing radiation is also used to sterilize products and irradiate foods to kill bacteria

and parasites. Military uses of materials and processes that emit X-radiation and

gamma radiation include the production of materials for nuclear weapons and the

testing and use of nuclear weapons (IARC, 2000).

2.6 Types of individual exposure to ionizing radiation

The ICRP refers to three types of exposure individual; occupational exposure is the

exposure of a person in the workplace and mainly as a result of the work they

perform; medical exposure is the exposure of a person as part of a medical diagnosis

or treatment; public exposure is the exposure of a person by means other than

occupational or medical exposure (ICRP, 2008).

2.7 Ionizing radiation dose and units

The radiation dose is the amount of energy absorbed in the body from radiation

interactions. Early non quantitative measures of dose, based on skin erythema, were

replaced by measures of exposure [e.g. the ability of X-rays to ionize air, measured

in roentgens (R)] and measures of absorbed dose [e.g. energy absorption, measured

initially in radiation absorbed dose (Rad), and more recently in Gray (Gy)] (Hall and

Giaccia, 2006).

21

Different types of radiation may produce different biological effects and the

magnitude of the effect can vary according to the rate at which radiation is received

(dose rate). The dose rate is a primary factor in determining the biological effects of

a given absorbed dose. For example, as the dose rate is reduced and the exposure

time extended, the biologic effect of a given dose is generally reduced. Relative

biological effectiveness, which denotes the ability of a given type of radiation to

produce a specific biological outcome compared with X-rays or gamma rays, is taken

into account by the Sievert (Sv), a metric for biological equivalent dose that can be

used to measure mixed types of radiation exposure (ICRP, 1991 and ICRP, 2007).

The effective dose is the sum of the equivalent doses to each tissue and organ

exposed multiplied by the appropriate tissue weighting factor or, in other words, the

whole body dose of X-rays that would have to be delivered to produce the same

carcinogenic risk as the partial dose that was delivered. This quantity provides an

easy assessment of overall risk and makes the comparison of risks much simpler.

Although effective dose is emphasized in many surveys because this metric is related

to the risk of carcinogenic effects, effective dose cannot be measured and cannot be

used for individual risk assessment. Only absorbed dose to a given tissue or organ

can be used for estimating cancer risks (ICRP, 1991 and ICRP, 2007).

2.8 Medical uses of ionizing radiation

Ionizing radiation has two very different uses in medicine for diagnosis and therapy.

Both are intended to benefit patients and, as with any use of radiation, the benefit

must outweigh the risk (IAEA,2007).

2.8.1 Radio-therapy

Radiation therapy use high energy ionizing radiation to shrink tumors and kill cancer

cells. X-ray, gamma ray , and charged particles are types of radiation used for cancer

treatment. The radiation may be delivered by a machine outside the body called

external-beam radiation therapy, or it may come from radioactive material placed in

22

the body near cancer cells called internal radiation therapy, also called brachytherapy

(Lawrence et al., 2008).

2.8.2 Radio-diagnostic

Diagnostic radiography involves the use of both ionizing radiation and non-ionizing

radiation to create images for medical diagnoses (Bushberg et al., 2001).There are a

variety of imaging techniques such as nuclear medicine, X-ray radiography,

computed tomography (CT) scan, fluoroscopy, mammography, dental X-ray,

interventional radiology, ultrasound and magnetic resonance imaging (MRI) to

diagnosis of diseases (CSPH, 2006 and UNSCEAR, 2000).

2.8.2.1 Nuclear medicine

In diagnostic nuclear medicine, radiopharmaceuticals are given to patients where it

is administered either by injection, inhalation or ingestion. The type of

radiopharmaceutical is chosen according to the examined organ or tissue. These

radiopharmaceuticals emit γ rays which are detected by Gamma camera such as

sodium iodide and give a picture about the examined organ (Shrimpton, 2001,

Burnham, 2001, IAEA, 2004).

2.8.2.2 Diagnostic X-ray

Diagnostic X-ray increase the risk of developmental problems and cancer in those

exposed (Santis et al., 2007; Hall and Brenner, 2008 and Brenner, 2010).The amount

of absorbed radiation depends upon the type of X-ray examination and the body part

involved. CT scan and fluoroscopy entail higher doses of radiation than do plain X-

ray (Hall and Brenner , 2008).

Fluoroscopy is an imaging technique commonly used by physicians or radiation

therapists to obtain real-time moving images of the internal structures of a patient

through the use of a fluoroscope (Balter et al., 2010). Fluoroscopic examinations also

23

vary according to the types of exams. Most of the fluoroscopy examinations give an

effective dose higher than that for radiography examinations. Barium meal, which is

an examination for stomach, gives an effective dose of about 3 mSv. Barium enema

which is an examination for the large bowl, gives a higher effective dose of about 7

mSv (Hart and Wall, 2002), it is equal to the exposure to natural IR through 2 to 3

years (FDA, 2007).

Computed tomography scan (CT) is a medical imaging modality where tomographic

images or slices of specific areas of the body are obtained from a large series of two-

dimensional X-ray images taken in different directions. These cross-sectional images

can be combined into a three-dimensional image of the inside of the body and used

for diagnostic and therapeutic purposes in various medical disciplines (Herman and

Gabor, 2009). CT scan examinations expose patients to dose larger than any other

diagnostic radiology examinations (Golding and Shrimpton, 2002).

The effective dose to the spinal cord from a CT scan of the chest is about 5 mSv, and

the absorbed dose is about 14 mGy (Caon et al., 2000). A head CT scan (1.5 mSv, 64

mGy) that is performed once with and once without contrast agent, would be

equivalent to 40 years of background radiation to the head (Shrimpton et al., 2001).

Dosage due to dental X-rays varies significantly depending on the procedure and the

technology (film or digital). A single dental X-ray of human results in an exposure of

0.5 to 4 mRem. A full mouth series may therefore result in an exposure of up to 6

(digital) to 18 (film) mSv, for a yearly average of up to 40 mRem (Muller, 2010).

Mammograms require very small doses of radiation. The risk of harm from this

radiation exposure is extremely low, usually around 0.4 mSv to examine the human

breast, while the average annual dose from food is 0.3 mSv, the average yearly

background dose is 2.4 mSv (Biller, 2014).

24

2.9 Radiation protection

Radiation protection is defined as the science and practice of reducing harm to

human beings from radiation. In all radiological activities it is important to have

some idea of the risk associated with the use of ionizing radiation (IAEA, 2007).

Occupational radiation protection measures are necessary for all individuals who

work in the diagnostic imaging departments, radiology staffs require appropriate

monitoring continuously by common personal dosimeters like film badge and

thermo-luminescence dosimeter. They must also receive education and training

appropriate to their jobs and protect by tools and equipment (Rahman et al., 2008).

The accepted effective annual dose limits for occupational staff as reported by the

International Commission on Radiological Protection (ICRP) in 1977 was 50 mSv.

Public should not be exposed to more than an average of 1 mSv per year. A

downward review was done in 1991 and an effective annual dose limit of 20 mSv

was adopted as an average for a period of five years, with the further provision that

the effective dose should not exceed 50 mSv in any single year. The downward

review of annual dose limit was adopted in order to put a stricter control over the use

of ionizing radiation in medicine and minimize possible hazards, especially the

stochastic effects (Ibitoye et al., 2011).

2.9.1 Radiation protection principle

The radiation protection principles of justification, optimization and dose limitation

are applied to radiation protection in medicine (Street et al., 2009).

2.9.1.1 Justification

The referring medical practitioner is responsible for ensuring that a diagnostic

procedure involving ionizing radiation is necessary for a patient’s care and that the

radiation dose from the procedure is expected to do more good than harm, a concept

25

designated as justification by the ICRP (ICRP, 2007). Justification and

appropriateness of medical exposures will help reduce the imaging costs and the dose

received by the patient. However, studies under taken in some countries (Oikarinen

et al., 2009; Brenner and Hricak, 2010).

2.9.1.2 Optimization

The radiological medical practitioner is responsible for ensuring that the radiological

procedure provides images adequate for diagnosis and treatment while keeping the

radiation dose as low as reasonably achievable (ALARA), a concept designated as

optimization by the ICRP (ICRP, 2007). Dose optimization recognizes the potential

risk of any radiation and emphasizes the need for appropriate dose management for

all imaging procedures (Balter and Moses, 2007 and Stecker et al., 2009).

2.9.1.3 Individual dose limits

All medical applications of ionizing radiation must be managed in such a way that

radiation doses to occupationally exposed persons and members of the public do not

exceed the dose limits. Dose limits do not apply to the exposure of patients as part of

their diagnosis or treatment (Street et al., 2009).

2.9.2 Radiation protection techniques

There are three basic methods that control the amount of radiation dose received

from a source. Radiation exposure can be managed by a combination of these

methods: the first is the exposure time; reducing the time of an exposure is an

important method for reducing the exposure to ionizing radiation. The second

radiation protection method relates to the distance between the source of radiation

and the exposed individual, where the Radiation intensity decreases sharply with

distance, according to an inverse-square law. The third method which helps in

reducing the received dose for both patient and the staff is the shielding, which is a

material, as lead, that attenuates radiation when it is placed between the source of

26

radiation and the exposed individual. Hence, shielding strength or "thickness" is

conventionally measured in units of g/cm2. The radiation that manages to get through

falls exponentially with the thickness of the shield. In X-ray facilities, walls

surrounding the room with the X-ray generator may contain lead sheets, or the

plaster may contain barium sulfate. Almost any material can act as a shield from

gamma or X-rays if used in sufficient amounts (Lawrence, 2008 and Occupational

Safety and Health council, 2006).

2.9.3 Radiation monitoring

Radiation monitoring is an important safety precaution in the practice of

radiography. It does not in itself provide protection against ionizing radiations. Its

main purpose is to measure radiation dose received by radiology personnel, which

can indicate that radiation doses received are within permissible limits, verify that

facilities for radiation protection are adequate and show that radiation protection

techniques are acceptable (The University of Western Australia, 2010).

2.9.3.1 Personal radiation monitoring in radio-diagnostic centers

Monitoring of radiation doses received by staff in radiology department is of great

importance in efforts to protect themselves from the effect of excessive radiation

during and after radiological examinations of patients (Okaro et al., 2010). It is

advisable that assessing radiation doses received by radiology workers at periodic

intervals will ensure their occupational safety. That is the radiations exposure to a

staff are within the internationally accepted safe limits (Ujah et al., 2012).

The common devices recommended for measuring of dose rate of radiation received

by radiation workers are; Thermo-luminescence dosimeters (TLD), film badges and

pocket ionization dosimeters, etc. Okpala (2004) reported that every radiology

worker is expected to wear dosimeters always while working. The dosimeter

readings are kept as records for every staff for the purpose of evaluating their

27

radiation history and possible risks that would be involved. These records help in

improving radiation practices in radiology department.

Radiation badges are essential monitoring gadgets that must be applied and received

before starting work involving radiation exposure. Also, personal dosimetric record

and monitoring are integral parts of radiography practice in the world (Washington

State University, 2000). Dosimetric records are kept and are required to be disclosed

when workers change jobs (Jean, 1998).

2.9.3.2 Ensuring effective radiation protection of medical staff

Radiation protection programmed (RPP) is one means of implementing occupational

radiation protection by the adoption of appropriate management structures, policies,

procedures and organizational arrangements. For medical staff in X-ray imaging,

topics would include the need for local rules and procedures for personal to follow,

arrangements for the provision of personal protective tools, a programmed for

education and training in radiation protection, arrangements for individual

monitoring, and methods for periodically reviewing and auditing the performance of

the RPP (IAEA, 2006).

2.9.4 Personal radiation protection devices

Personal protective devices include aprons, thyroid shields, eyewear, lead curtains,

and gloves. Protective aprons with thyroid shields are the principal radiation

protection devices for radiology workers. They should be employed at all times. The

vest or skirt configuration is preferred by many operators in order to reduce the risk

of musculoskeletal back injury (Klein et al., 2009). This wrap-around style is

typically 0.25 mm lead-equivalent so that, when worn, the double thickness

anteriorly provides 0.5 mm lead equivalence. Operators and staff who work in the

radiology on a regular basis should be provided with properly fitted aprons, both to

reduce ergonomic hazards and to provide optimal radiation protection (Detorie et al.,

2007).

28

Aprons should be inspected fluoroscopically on an annual basis to detect

deterioration and defects in the protective material (Christodoulou et al., 2003).

Because of the ergonomic hazards of personal protective tools (particularly leaded

aprons), attempts to reduce the fatigue and injury associated with wearing heavy

protective apparel have been made (Klein et al., 2009).

The principal disadvantage of leaded eyeglasses is their weight and discomfort. In

general, the operator’s hands should be kept out of the primary radiation beam.

Leaded gloves may seem useful for radiation protection on those rare occasions

when the operator’s hands must be in the primary radiation beam, but they do not

provide protection in this situation. Because of the increased dose when any

shielding is placed in the primary beam, and the false sense of security that these

gloves provide, protective gloves can result in increased radiation dose to the hand

when the gloved hand is in the primary beam, leaded gloves are not recommended in

this situation. The best way to protect the operator’s hands is to keep them out of the

radiation field. Leaded gloves may be of benefit if the operator’s hands will be near,

but not in, the primary radiation beam (Wagner and Mulhern, 1996).

2.9.5 Radiation protection training

Education and training should be implemented to radiation protection in practice, and

most countries have regulatory requirements for such training. In X-ray imaging,

personal need training not only in occupational radiation protection, but also

inpatient radiation protection as the latter can influence occupational exposure

(European Commission, 2000).

2.10 The use of radiation for medical exposure

The use of radiation in medical applications continues to increase worldwide. Latest

UNSCEAR estimates suggest that there are about 4 billion X-ray examinations per

year, worldwide (UNSCEAR, 2008). Table (2.1), displays the time evolution through

29

two decades, from 1988 to 2008, of the number of medical radiological procedures

and the effective dose per capita, worldwide.

As is clearly seen, the number of radiological procedures more than doubled whilst

the annual effective dose per inhabitant almost doubled. Similar but more

pronounced trend scan be seen in the report NCRP-160 (NCRP, 2009), for the USA,

that pinpoints a significant increase of the population exposure to ionizing radiation

due to the medical applications of ionizing radiation, namely CT, nuclear medicine,

and interventional procedures.

In the USA the number of prescribed CT scans grew by approximately10% per

annum from the 1990s until the middle of the last decade (Bfs, 2010) pinpointing the

major role played by the increasing frequency of CT exams in the significant

increase of the mean effective dose per inhabitant.

Table (2.1): Time evolution of the number of radiological procedures, collective dose

and annual dose per capita, worldwide (UNSCEAR, 2008).

UNSCEAR

Report

No. of

examinations

(Billion)

Collective Dose

(Million man*Sv)

Annual dose

"per capita"

(mSv)

1988 1.38 1.8 0.35

1993 1.6 1.6 0.3

2000 1.91 2.3 0.4

2008 3.1 4.0 0.6

More people are exposed to ionizing radiation from medical practice than from any

other human activity, and in many cases, the individual doses are higher. In countries

with advanced healthcare systems, the annual number of radiological diagnostic

procedures approaches or exceeds 1 for every member of the population

(UNSCEAR, 2000). Furthermore, doses to patients for the same type of examination

differ widely between centers, suggesting that there is considerable scope for

management of patient dose (UNSCEAR, 2000). The use of radiation for medical

exposure of patients contributes over 95% of man-made radiation exposure and is

only exceeded world-wide by natural background as a source of exposure

(UNSCEAR, 2000).

30

Overall, medical exposure has increased since the UNSCEAR, (2000) evaluation,

largely due to the rapid increase in the utilization of computed tomography (CT),

both in industrialized and in developing countries (ICRP, 2006 and ICRP, 2007).

Worldwide, the estimated number of medical and dental radiographic machines is

approximately 2 million. While it is difficult to estimate the number of

occupationally exposed medical workers, UNSCEAR, (2000) estimated that there are

more than 2.3 million monitored medical radiation workers.

2.11 Biological effects of ionizing radiation

Almost twenty years after the initial discovery of X-rays by Wilhelm Conrad

Roentgen in 1895, the Drosophila geneticist Herman Muller demonstrated that

ionizing radiation causes mutations in living organisms. In the 80 years since that

discovery, the biological and genetic consequences of exposure to ionizing radiation

(IR) have been investigated. The biological effects of IR exposure are mediated

through direct damage to biomolecules (e.g., energy directly deposited on the

molecule) or indirectly through the formation of Reactive Oxygen Species (ROS)

(Muller, 1927).

The biological effects of radiation can be grouped into two types: Stochastic effects

(cancer and heritable effects) and Deterministic effects (tissue reactions) (ICRP,

2007).

The first type is stochastic effects (no threshold dose): are those in which the

probability of the effect occurring depends on the amount of radiation dose, this type

of effects increases as a radiation dose increases. So, there is no threshold dose for

the stochastic effect. Stochastic effects can cause cancer, or have influence on gene-

material affecting future generations (NOHSC, 2002 and EPA, 2009).

The second type is deterministic effects (threshold dose): are those effects resulting if

the effect only results when many cells in an organ or tissue are killed, the effect will

31

only be clinically observable if the radiation dose is above some threshold. The

magnitude of this threshold will depend on the dose rate (i.e. dose per unit time),

linear energy transfer of the radiation, the organ or tissue irradiated, the volume of

the irradiated part of the organ or tissue, and the clinical effect of interest. These

effects occur because of large number of killed cells which cannot be compensated.

The degree of damage (severity) increases the more the threshold value is exceeded

(ICRP, 2007 and EPA, 2009).

The single largest contributor of manmade radiation is the medical profession. The

effects of ionizing radiation on a given population are generally divided into two

categories, acute and chronic. The acute effects are considered to be those which

happen in the immediate post irradiation periods, i.e. from the time of radiation

exposure up to 6 months to a year post exposure. Acute effects are generally the

result of long radiation exposure delivered to the whole body, or at least a major port

of it, in average short time, on the other hand the chronic effects of radiation results

from relatively low exposure levels delivered over long periods of time. Therefore

long time effects of low doses seems to be the main risk factor and that might results

from occupational exposure (Morgan, 2003).

2.12 Previous studies related to this research

A survey of Giri et al. (2007) “Radiation measurement at X-ray centers of a few

hospitals in Kathmandu city, Nepal". Radiation was measured in X-ray room of 13

different hospitals, fluoroscopy room of 2 hospitals and CT scan room of 1 hospital

in Kathmandu City, Nepal, using a portable radiation measuring instrument.

Measurement was performed during the daytime. The background radiation was

measured before the machines were switched on in respective rooms. Subsequently

after the exposure to the radiation, the fall out radiation was measured in 4 different

corners of the radiation facility room of different hospitals. The unit of measurement

was in count per minute and converted in milliSievert per year (mSv/yr). The

findings show increased exposure and in some instances very high levels of

unintentional exposure to radiation.

32

Oluwafisoye et al. (2009) conducted an environmental monitoring survey and quality

control test of X-ray diagnostic facilities of a large Nigerian hospital. The

environmental monitoring in this study was carried out using calibrated radiation

equipment. Questionnaires were also used to elicit information from the most senior

personal of the hospital. The study was carried out at the X-ray unit of the Jon-Ken

hospital, Lagos (private hospital). The results show that the facilities for safety were

grossly inadequate and the dose rates of 4.0 μSv/hr and 5.0 μSv/hr were recorded at

the reception and outside the entrance door respectively. The dose rates at the

adjacent ultrasound scan room and waiting lobby are at least a factor of 40 higher

than the background dose rate each, indicating higher health risk to the visitors and

personnel at the hospital. The results recommended to improve on the safety of the

patient and personnel were sent to the management of the X-ray unit of the hospital.

Nevertheless, follow-up studies indicate improved facilities and safety measures.

A recent study conducted by Abu Draz (2009) aimed to evaluate the radio-

technologists knowledge, attitudes and practices about radiation protection in the

eleven governmental hospitals which provide radiological services in Gaza Strip,

Palestine. Close ended structured questionnaire containing 69 questions had been

distributed among 135 radio-technologists through face to face interview. The study

showed that, the mean of knowledge was 9.5 (out of 20) while the mean attitude was

16.5 (total scores 20) and that of practice was 5.6 (total scores 18). Of studied radio-

technologists only 4.5% obtained high knowledge scores and about 87.9% have high

attitude scores while none of the study participants achieved a high practice scores.

The study has indicated that, the radio-technologists have high concern toward

radiation protection, but they have inadequate knowledge while their proper practices

were not adequate toward radiation health hazards.

Adejumo et al. (2012) evaluated compliance to radiation safety standard amongst

radiographers in radio-diagnostic centers in South West, Nigeria. The study carried

out in some selected private diagnostic centers and government hospitals. One

hundred radiographers from public and private radio-diagnostic centers administered

33

questionnaires on compliance rate of safety standard as described by national and

international commission on ionizing radiation. The result reveals high compliance

rate in majority of radio-diagnostic centers located in south west Nigeria.

Conclusively, this study showed that radiographers working in both private and

public establishments in south west, Nigeria were been monitored and they strictly

followed the radiation protection standard rules to be within radiation workers dose

limits.

The radiation survey conducted by Adhikari et al. (2012) for diagnostic radiology

was done in 28 different hospitals around Kathmandu and different parts of Nepal by

which include forty four X-ray equipment, ten CT scans, two mammography and two

catheterization laboratory to assessment of the radiation protection in medical uses of

ionizing radiation. Questionnaire for radiation workers were also used; radiation dose

levels were measured and an inventory of availability of radiation equipment made.

A corollary objective of the study was to create awareness in among workers on

possible radiation health hazard and risk. It was also deemed important to know the

level of understanding of the radiation workers in order to initiate steps towards the

establishment of Nepalese laws, regulation and code of radiological practice in this

field. The radiation workers who have participated in the questionnaire represent

more than 50% of the radiation workers working in this field in Nepal. we can say

that around 70% of the radiation workers are aware of radiation safety issue. Almost

all X-ray, CT and mammogram installations were built according to protection

criteria and hence found safe. Around 65% of the radiation workers have never been

monitored for radiation.

A survey of Ali (2013) was conducted in Iraqi Kurdistan region hospitals to evaluate

the environmental monitoring. The quality control test of X-ray facilities of

Kurdistan region hospitals was carried out. Data on the number of diagnostic

procedures using x-ray examination in year 2010- 2011 in four governmental

hospitals. Questionnaires were also used to elicit information from the most senior

personal of the hospital. The results show that the facilities for safety were grossly

inadequate and the dose rates of 11.75 μSv/hr and 10.48 μSv/hr, recorded at Place for

34

standing radiographic respectively. The dose rates at the Behind X-ray door room at

least 3.123 μSv/hr indicating higher health risk to the visitors and personnel at the

hospital. The results suggested to improve on the safety of the all staff of the X-ray

unit, patient and personnel were sent to the management of the X-ray unit of the

hospital.

Younis et al. (2014) evaluated radiation protection from radio diagnostic departments

in Erbil hospitals. Data on the number of diagnostic procedures using X-ray

examinations in five hospitals were collected. The Nuclear Radiation Meter was used

to measure radiation leakage. Questionnaire was also used to elicit information from

the most senior personnel of the hospital. The finding showed that the facilities for

safety were grossly inadequate and the dose rates of 16.4 μSv/hr and 20 μSv/hr,

recorded at places for paramedics and technician room respectively. A dose rate in

front of window of the monitor room was 113 μSv/hr and in the reception was

20μSv/hr indicating higher health risk to the paramedic, visitors and personnel at the

hospital. Radiation protection facilities in the radiological departments of Erbil

hospitals are in general poor including both public & private sectors indicating high

health risk to the paramedics, visitors and personnel at the hospitals.

Since, there is no clear cut of evidence that such a work have been done in Gaza

Strip. We present here the measurements of equivalent radiation dose rate in different

locations in radio-diagnostic rooms at a selected governmental Gaza governorates

hospitals. In addition, a questionnaire used to obtain information from the radio-

diagnostic workers in order to improve the radiation protection safety measures.

35

Chapter 3

Methodology

3.1 Introduction

In this chapter, we describe the methodology used in the present work, including the

study design, study population, sample size, location of the study, study instruments

and techniques and data analysis. Ethical considerations were also taken into

consideration through conducting the research. In addition, the obstacles and

limitations that encountered the researcher through conducting the research are also

mentioned.

3.2 Study design

The present study is a practical and descriptive analytical cross sectional study, based

on the analysis of data collected from the radiation survey meter. The data sheet

information collected from radio-diagnostic machines and rooms are also analyzed.

In addition, a questionnaire are distributed to the workers who have been working in

nine selected governmental Gaza governorates hospitals.

3.3 Study population

The target population of this study is the radio-diagnostic workers who have been

working at radio-diagnostic centers. This estimated approximately 185 medical

radiographers and 45 radiologists distributed at nine governmental hospitals

according to the MOH records (Abbas, 2014, Personal communication).

3.4 Sample size

The sample size was calculated by using sample size calculator from the survey

system on the web, with confidence level of 95% and confidence interval of 5. The

calculated sample size was 144 of the 230 radio-diagnostic workers (Annex, 1). We

36

decided to give rise this number to 182 in order to increase the response rate and to

compensate the uncertainties.

3.5 Locations of the study

The study was carried out in radio-diagnostic centers at nine selected governmental

Gaza governorates hospitals including: Al Shifa Medical Complex, Nasser Medical

Complex, European Gaza hospital, Abu Yousef Al Najjar Martyr hospital, Kamal

Adwan Martyr hospital, Al Aqsa Martyrs hospital, Abdel Aziz Rantessi Martyr

hospital , Al Naser pediatric hospital and Beit Hanoun hospital.

The hospitals were selected because of their large and diverse of their radio-

diagnostic services.

3.6 Ethical considerations

A permission from the ministry of health has been obtained to perform the study in

the governmental hospitals (Annex, 2). A consent from all participants to ensure their

voluntary participation (Annex, 3).

3.7 Study instruments

Three ways were applied to assess the status of ionizing radiation dose rate and

radiation protection measures in radio-diagnostic centers at governmental Gaza

governorates hospitals, namely:

3.7.1 Radiation survey meter

The radiation survey has been carried out to measure the radiation dose rate at

different locations in the radio-diagnostic rooms at nine selected governmental Gaza

governorates hospitals.

37

Radiation survey meter (OD-01) that designed by Step – Sensortechnik und

ElektronikPockauGmbH, Germany. Figure (3.1) displays the radiation survey meter

that used throughout the measurements. The calibration of the survey meter (OD-01)

is performed according to ISO 9001 TUV Quality Management System Certification,

headquartered in Munich, Germany by using Co-60 (photon energy 1.2 MeV), see

annex (annex, 6).

Radiation survey meter used for measurements of ambient and directional equivalent

dose of pulsed radiation fields and dose rate of X-rays, gamma and beta radiation.

Figure (3.1): Radiation survey meter (OD-01)

3.7.2 Radio-diagnostic machines and rooms specifications

Data sheets are also used to obtain information about radio-diagnostic machines and

rooms. The information was taken from medical equipment engineering department

in ministry of health and from the head of radio-diagnostic center. The data sheet

includes information about: name of hospital, radio-diagnostic room number,

manufacturer of machine, model of machine, status of machine, date of machine

installation, type of machine working (constant or portable), (electronic or manual),

(film processing digital or analogue), dimensions of radio-diagnostic room in cm,

width of the room walls in cm, material of the room walls, material of the control

panel wall, thickness and high of lead lining the room walls, the distance between the

38

radiation source and control panel, thickness of lead lining the room doors and

number of radiological procedures in the radio-diagnostic room per day. For more

details see (annex, 8).

3.7.3 Questionnaire interview

An interview was also done for filling the questionnaire that designed for matching

the study needs. All interviews were conducted face to face by the researcher

personally. During the survey the interviewer explained any of the questions that

were not clear. The questionnaire was based on the questions of a previous study

with some modifications (Abu Draz, 2009). The validity of the questionnaire was

tested by six specialists in the fields of radiology, medical physics, public health and

statistics.

The questionnaire content validity had been built in pilot study before starting real

data collection. It was served as a pre-test for the questionnaire to check the

ambiguity in the question statements and the time taken to complete the

questionnaire. Twenty radio-diagnostic workers were chosen to participate in the

pilot study. They were selected by the convenience method from the hospitals that

have been previously identified. Slight modifications were also done on the

questionnaire in corporation with the academic supervisors.

The questionnaire content reliability and internal consistency determined by using

Cronbach's Alpha in SPSS. The reliability of the second part items of the

questionnaire relating to the availability of personal radiation protection devices

equal 0.6. While the reliability of the third part items of the questionnaire relating to

awareness of radio-diagnostic workers about radiation protection issues equal 0.731.

In addition, the reliability of the fourth part items of the questionnaire relating to

practices of radio-diagnostic workers about radiation protection issues equal 0.751.

39

The questionnaire originally was constructed in English language (Annex, 4), and

then translated into Arabic language except some medical terms remained in English

(Annex, 5).

The questionnaire consists of five parts and includes the following:

Part one: consisted of eight questions about socio-demographic factors and related

work information. This includes: age, sex, occupation, academic qualification, years

of experience, name of hospital, type of radio-diagnostic machines who use it, and

daily work hours inside the radio-diagnostic rooms.

Part two: consisted of ten questions related to the availability of radiation protection

devices in the radio-diagnostic centers. This contains (lead apron, gonad shield, lead

curtains, lead shields or barrier, thyroid shields, lead glass, lead gloves, breast

shields, radiation warning signs and caution lights).

Part three: consisted of eighteen questions to measure the level of radio-diagnostic

workers awareness about radiation protection issues. This also gives some

information about the general understanding of radiation protection issues.

Part four: consisted of fifteen questions related to describe of radio-diagnostic

workers practices about radiation protection issues.

Part five: consisted of six questions to evaluate the personal radiation exposure

monitoring process.

3.8 Study techniques

3.8.1 Locations of measurements

To measure the equivalent radiation dose rate, specific locations were selected

according to radio-diagnostic rooms design and machines types. These locations are:

electrical zero balancing value, under the X-ray tube when X-ray directly fall on the

40

survey meter probe (directional dose), at one meter distance from the X-ray tube by

closing the tube collimators, at control panel, at corridor outside the X-ray room

(door closed), at dark room and behind the chest stand wall. For CT scan the

measurements also conducted at door near the control panel (door closed), in

additional to patient waiting rooms.

3.8.2 The workload

In this study the radiation level at each location was calculated using the workload.

The National Council on Radiation Protection and Measurements (NCRP report no. 49)

workloads could be used throughout this work. However, the NCRP workloads

might be more or less than the workloads at some of those rooms. For this reason,

can be calculated the workloads in each radio-diagnostic room to simulate the real

workloads in radio-diagnostic rooms at governmental Gaza governorates hospitals,

see (Annex, 7).

Workload is a measure of the X-ray tube use and is a number of electrons hitting X-

ray tube anode. It varies greatly with assumed maximum kVp of X -ray unit. It is

usually a gross overestimation (ICRP, 2007).

Workloads according to NCRP report no.49 are: for basic X-ray unit: 1000

mA.min/week, for fluoroscopy unit: 750 mA.min/week and for CT scan unit:

28.000 mA.min/week at 100 kVp. It is also noticed that spiral CT scan units or multi-

slice CT scan could have higher workloads. In addition, for mammography unit: 700

mA.min/week at 30 kVp.

The radiation level at each location in one week was calculated using the workload

mA.min/week (= mAs/60), the current workload in each room could be calculated as:

Workload = ∑ (𝐦𝐀. 𝐦𝐢𝐧)𝐢

i.Ni

Where (Ni) is the examination number of kind i and (mA.min) used techniques for

examination kind i (Adhikari, 2012).

41

3.8.3 The equivalent radiation dose rate

In order to calculate the radiation level in different locations, we have considered the

different characteristic parameters of radiation like kilo-Volt (kV), milli-Ampere

(mA) and time (s).

In basic X-ray, the radiation parameters taken to evaluate radiation level were about

100 kVp in voltage, 1 s in time (t), and tube current (I) was 100 mA, to give high

energy of radiation. Figure (3.2), displays the radiation parameters at X-ray machine

control of panel. In CT scan, the radiation parameters taken to evaluate radiation

level were about 100 kVp in voltage, 1 s in time (t), and tube current (I) was 210 mA.

In fluoroscopy, the radiation parameters taken to evaluate radiation level were about

100 kVp in voltage, tube current (I) was 3 mA. In mammography, the radiation

parameters taken to evaluate radiation level were about 30 kVp in voltage, 1 s in time

(t), and tube current (I) was 50 mA.

Figure (3.2): The radiation parameters were taken in basic X-ray machine

The measurements were performed during the daytime between 8 AM to 2 PM. The

electrical zero balancing was recorded before the radio-diagnostic machines were

switched on in respective rooms to verify the electrical zero of the measuring device.

42

Figure (3.3), illustrates the reference phantom was used as a scattering medium to

simulate physiological characteristics of patient body. The Measurements behind the

chest stand wall was done without a patient or a phantom and the distance between

X-ray tube and chest stand equal 180 cm. As shown in figure (3.4), the

measurements were conducted by using Source Image Distance (SID) is equal 100

cm.

The unit of measurements was in milliSievert per hour (mSv/hr) and converted in

milliSievert per year (mSv/year).

The equivalent radiation dose rate to whole body at each location (HW) in unit of

(mSv

week ) was calculated using:

𝐇𝐰 (mSv

week) = 𝐑 (

mSv

min) .

𝟏

𝐈𝐦(mAm) . 𝐖𝐨𝐫𝐤𝐥𝐨𝐚d (

mA.min

week)

Where (R) is the radiation dose rate reading in each location in unit of (mSv/min),

(Im) is the maximum continuous tube current possible in mA units at kVpmax and

workload in units of (mA.min

week) (Adhikari, 2012).

Figure (3.3): The reference phantom was used as a scattering medium

43

Figure (3.4): Source Image Distance (SID) is equal 100 cm

3.9 Limitation of the study

During the implementation of the study we faced some of limitations such as:

1. This study conducted only in governmental hospitals in Gaza governorates, not

primary care clinics, UNRWA or private centers, so the results can only be

generalized on this sector.

2. Lack of cooperation of Radiation Protection Department in Energy and Human

Resources Authority.

3. At some centers, it is doubtful whether the given mA or kV are actually correct

as shown in control panel because there is no measuring/verifying equipment

and no quality control program to maintain the quality of the equipment.

4. Some of radio-diagnostic machines out of services during the period of study

conducting, which led to the inability of measuring the ionizing radiation

leakage in these rooms.

44

3.10 Statistical tools and data analysis

Data checked, coded, entered and analyzed using SPSS 20 (Statistical

Package for the Social Science Inc. Chicago, Illinois USA, version 20)

statistical package.

We would utilize the following statistical tools:

Frequency .

Descriptive analysis (means and standard deviation "S.D").

Tabular and Graphical display.

Independent Samples T-test.

Analysis of Variance "ANOVA".

45

Chapter 4

Results and Discussion

4.1 Introduction

In this chapter, we presented the main results of the study based on the outcomes of

the statistical analyses and it includes two parts:

1. The results of the equivalent radiation dose rate that measured at different

locations in the radio-diagnostic rooms at the selected nine hospitals. It also

contains the radio-diagnostic machines and rooms specification data sheet

information.

2. The results of the questionnaire information analysis which includes: distribution

of the participants according to their socio-demographic characteristics and work

related information, evaluation of availability of radiation protection devices,

measure of radio-diagnostic workers awareness and practices level regarding

radiation protection issues and evaluation of the personal radiation exposure

monitoring process.

In the present work, we conducted the independent samples t- test, frequency and

one-way analysis of variance (ANOVA). These tests detect the difference between

the availability of personal radiation protection devices, awareness and practices

level regarding radiation protection issues and evaluation of personal radiation

exposure monitoring process as a dependent variables. However, the socio-

demographic and work related factors among radio-diagnostic workers are

independent variables.

46

Part one

4.2 The equivalent radiation dose rate measurements in radio-diagnostic

centers at the selected nine hospitals

The radiation survey has been carried out in radio-diagnostic centers at nine selected

governmental Gaza governorates hospitals to measure the radiation dose rate at

different locations in the radio-diagnostic rooms.

The accepted effective annual dose limits for occupational staff as reported by the

International Commission on Radiological Protection (ICRP) in 1991 was 20 mSv as

an average for a period of five years, with the further provision that the effective

dose should not exceed 50 mSv in any single year. Public should not be exposed to

more than an average of 1 mSv per year.

4.2.1 The measurements at Al Shifa Medical Complex

Figure (4:1): The equivalent radiation dose rate in basic X-ray rooms at Al Shifa

Medical Complex

Figure (4.1), shows that the equivalent radiation dose rate that measured at corridor

during closing the door, at patient waiting room and behind the chest stand wall in

the most of basic X-ray rooms are found higher than the reference limit for public

0

0.5

1

1.5

2

2.5

3

3.5

4

At control panel

At dark room

At corridor (doorclosed)

At Patient waitingroom

Behind the cheststand wall

(Hw)

mS

v/y

r

roo

m n

o. 2

Basic X-ray

room no. 6

Basic X-ray

room no. 7

Basic X-ray

emergency

room

Basic X-ray

out clinic

room no. 1

Basic X-ray

out clinic

room no. 2

1.1

mS

v/y

r

1.1

mS

v/y

r

1.7

mS

v/y

r

1.9

5 m

Sv/y

r

1.3

mS

v/y

r

1.2

mS

v/y

r

1.8

mS

v/y

r

0.9

mS

v/y

r

1.4

m

Sv/y

r

1.6

mS

v/y

r

2

.2 m

Sv/y

r

1.9

mS

v/y

r

1.8

m

Sv/y

r

1.2

mS

v/y

r

2.0

1 m

Sv/y

r

1

.9 m

Sv/y

r

3.8

mS

v/y

r

1.8

mS

v/y

r

2

.01

mS

v/y

r

2

.1 m

Sv/y

r

47

exposure (1 mSv/yr).These results indicate that the door leads to basic X-ray rooms,

patient waiting room walls and chest stand wall were not efficiently lead lined.

However the measurements at control panels and dark rooms are within the accepted

annual dose limits for occupational staff (20 mSv/yr).

Figure (4.2), exhibits the measured values at corridor during closing the door and at

patient waiting room in fluoroscopy and CT scan rooms suggests very high

exceedance compared reference limit for public exposure. These results indicate that

the fluoroscopy and CT scan rooms were not efficiently lead lined and the radiation

protection is not commensurate with the fluoroscopy and CT scan radiation dose.

There is an obvious health risk of radiation exposure for all persons who visiting

these rooms. These problems should be corrected immediately and installing

adequate protection.

While if we look at the equivalent radiation dose rate that measured at control panels

and at door of the control panels during closing the door, we find that these doses are

high but remain in the permissible limit for radiology workers. However there is an

impending risks of chronic occupational exposure to the workers.

Figure (4.2): The equivalent radiation dose rate in fluoroscopy and CT scan rooms at

Al Shifa Medical Complex

0

2

4

6

8

10

12

14

16

At control panel

At door of the controlpanel (door closed)

At corridor (closed door)

At patients waitingroom

CT scan room Fluoroscopy

room no. 2

(Hw)

mS

v/y

r

roo

m n

o. 2

Fluoroscopy

room no. 1

12

.3 m

Sv/y

r

9.4

mS

v/y

r

14

.2 m

Sv/y

r

7.1

mS

v/y

r

13

.2 m

Sv/y

r

8.2

mS

v/y

r

9.4

m

Sv/y

r

8.1

mS

v/y

r

10

.7 m

Sv/y

r

13

.2 m

Sv/y

r

48

4.2.2 The measurements at Nasser Medical Complex

Figure (4.3), illustrates that the values of equivalent radiation dose rate that measured

in the basic X-ray machines rooms are within the permissible limits for radio-

diagnostic workers and public.

The equivalent radiation dose rate is also measured at different locations in

mammography room, it is clearly the mammography room is very safe and built

according to protection criteria.

Figure (4.3): The equivalent radiation dose rate in basic X-ray and mammography

rooms at Nasser Medical Complex

Figure (4.4), exhibits the equivalent radiation dose rate at corridor during closing the

door and at patient waiting room in fluoroscopy room were found (5.4 mSv/yr and 6

mSv/yr) respectively. This means that the values at these locations are four times

higher than the permissible limits for the public. The equivalent radiation dose that

measured at control panel was (10.9 mSv/yr) which is also high but not exceed the

permissible occupational limits. The results indicates that this room is not efficiently

lead lined or protected well. This would give health risk due to radiation exposure.

The equivalent radiation dose rate values in CT scan room show that the equivalent

radiation dose rate at corridor during closing the door was about (1.7 mSv/yr).

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

At control panel

At dark room

At corridor (doorclosed)

Behind the cheststand wall

Portable X-ray room no. 1

(Hw)

mS

v/y

r

Basic X-ray

room no. 2

Mammography

room no. 3

Basic X-ray

Out clinic room

0.1

mS

v/y

r

0.2

mS

v/y

r

0.4

mS

v/y

r

0.1

6

mS

v/y

r

0.0

3 m

Sv/y

r

1.4

mS

v/y

r

0.0

5 m

Sv/y

r

0.0

5 m

Sv/y

r

0.2

mS

v/y

r

0.9

mS

v/y

r

0.1

mS

v/y

r

0.2

mS

v/y

r

0.4

m

Sv/y

r

0.2

mS

v/y

r

0

.4 m

Sv/y

r

49

Certainly, this is higher than the reference limit for public exposure (1 mSv/yr).This

result indicates that the doors that lead to the CT scan room and patient waiting room

are also in need for protection. However the other measurements were estimated

within the accepted annual dose limits for occupational staff (20 mSv/yr).

Figure (4.4): The equivalent radiation dose rate in fluoroscopy and CT scan rooms at

Nasser Medical Complex

4.2.3 The measurements at European Gaza hospital

Figure (4.5), shows the equivalent radiation dose rate that measured at the different

locations in basic X-ray rooms are within safe limits for radio-diagnostic workers

and public. The radiation survey in these rooms show that it is built safe according to

safety criteria.

The equivalent radiation dose rate in fluoroscopy room (ESWEL), shows the

radiation dose rate that measured at corridor during closing the door and patient

waiting room was about (2.5 mSv/yr), which is about more than 1.5 times higher

than the reference limit for public exposure (1 mSv/yr).This result indicates that the

doors that lead to the fluoroscopy room and patient waiting room was not efficiently

protected. This high dose rate could mean a higher health risk to the unsuspecting

supportive personnel such as nurses, hospital attendants and the visitors. Such dose

rate could pose more serious problem to a pregnant women. The measurements at

0

2

4

6

8

10

12

At control panel

At the entrance of controlpanel (no door)

At corridor (door closed)

At patient waiting room

(Hw)

mS

v/y

r

Fluoroscopy room no. 4

CT scan room no. 5

0.8

mS

v/y

r

1.7

m

Sv/y

r

6.3

mS

v/y

r

5.9

mS

v/y

r

6 m

Sv/y

r

5.4

mS

v/y

r

10

.9 m

Sv/y

r

50

control panel and at door of the control panel during closing the door were (3.4

mSv/yr) are within the accepted annual dose limits for occupational staff (20

mSv/yr).

Figure (4.5): The equivalent radiation dose rate at European Gaza hospital

4.2.4 The measurements at Abu Yousef Al Najjar Martyr hospital

Figure (4.6): The equivalent radiation dose rate at Abu Yousef Al Najjar Martyr

hospital

Figure (4.6), shows that the equivalent radiation dose rate that measured at different

locations in basic X-ray rooms are within the permissible limits for radio-diagnostic

0

0.5

1

1.5

2

2.5

3

3.5 At control panel

At dark room

At door of the control panel(door closed)

At corridor (door closed)

Behind the chest stand wall

At patient waiting roomBasic X-ray room no. 2

Basic X-ray room no. 4

Flouroscopy room

0

1

2

3

4

5

6

7

At control panel

At dark room

At corridor(door closed)

Behind the chest stand wall

Basic X-ray room no. 2

Fluoroscopy room no. 2

Basic X-ray emergency room

(Hw)

mS

v/y

r

0.3

mS

v/y

r

2 m

Sv/y

r

6.7

mS

v/y

r

2.5

mS

v/y

r

5 m

Sv/y

r

0.1

7

mS

v/y

r

0.6

mS

v/y

r

0.1

mS

v/y

r

0.3

mS

v/y

r

0.2

mS

v/y

r

0

.2 m

Sv/y

r

(Hw)

mS

v/y

r

roo

m n

o. 2

2.5

mS

v/y

r

3.4

mS

v/y

r

3.4

mS

v/y

r

0.2

mS

v/y

r

0.1

6 m

Sv/y

r

0.2

mS

v/y

r

2.2

mS

v/y

r

0.1

mS

v/y

r

0.1

mS

v/y

r

0.2

mS

v/y

r

0.1

mS

v/y

r

2.5

mS

v/y

r

51

workers and public. Whereas, there is a huge radiation dose at corridor during

closing the door in the fluoroscopy room, and gives (6.7 mSv/yr).These result

indicates that the door that leads to this room should be protected well. There is an

obvious health risk of radiation exposure for all persons who visiting this room. It is

interesting to note that there were no leakages experienced in the other locations

within this room, the equivalent radiation dose rate at control panel and dark room

are within the accepted annual dose limits for occupational staff, were about (5

mSv/yr and 2.5 mSv/yr) respectively. Some rooms will be fitted with more than one

X- ray tub, shielding calculations must consider the total radiation dose from the two

tubes (IAEA, 2007).

4.2.5 The measurements at Kamal Adwan Martyr hospital

Figure (4.7): The equivalent radiation dose rate at Kamal Adwan Martyr hospital

As show in figure (4.7), the equivalent radiation dose rate measured at corridor

during closing the door in basic X-ray rooms were within the reference limit for

public exposure (1 mSv/yr) except in the basic X-ray in room no. 2, the value gives

(2.4 mSv/yr). This result indicates that the door leads to this room was not efficiently

lead lined. However, the measurements at control panels and at dark rooms are

within the accepted annual dose limits for occupational staff.

0

1

2

3

4

5

6

7

8

9

At control panel

At dark room

At corridor (door closed)

Behind the chest stand wall

Basic X-ray

room no. 2 Basic X-ray

Emergency room Basic X-ray

room no.3

Fluoroscopy room no. 3

(Hw)

mS

v/y

r

roo

m n

o. 2

4.0

3 m

Sv/y

r

0

.8

mS

v/y

r

0.7

mS

v/y

r

2.3

mS

v/y

r

2

.4 m

Sv/y

r

0.9

mS

v/y

r

7.5

mS

v/y

r

6

.7 m

Sv/y

r

8.4

mS

v/y

r

0.4

mS

v/y

r

0

.5 m

Sv/y

r

0.9

mS

v/y

r

0.5

mS

v/y

r

52

The measured values in fluoroscopy room show that there is a huge radiation dose at

corridor during closing the door. This result indicates that the door leads to the

fluoroscopy room was not efficiently lead lined. It is also noticed that the equivalent

radiation dose at control panel and at dark room are within the accepted effective

annual dose limits for occupational staff.

4.2.6 The measurements at Al Aqsa Martyrs hospital

Figure (4.8): The equivalent radiation dose rate at Al Aqsa Martyrs hospital

As show in figure (4.8), the measured equivalent radiation dose rate at different

locations in basic X-ray rooms are also found within the permissible limits for radio-

diagnostic workers and public.

However, the measured values in the fluoroscopy room we found there is a huge

radiation dose at corridor during closing the door gives (10.1mSv/yr). This result

indicates that the door that leads to the fluoroscopy room was not efficiently lead

lined. There is an obvious health risk of radiation exposure for persons who visiting

this room. Radiation leakages experienced in the other locations within this room are

within the accepted annual dose limits for occupational staff, the equivalent radiation

dose rate at control panel and at dark room gives (7.7 mSv/yr and 6.7 mSv/yr).

0

2

4

6

8

10

12

Basic X-rayroom no. 1

Basic X-rayroom no. 2

Flouroscopyroom no. 2

At control panel

At dark room

At radiodiagnostic workersroom

At corridor (door closed)

Behind the chest stand wall

(Hw)

mS

v/y

r

roo

m n

o. 2

6.7

mS

v/y

r

1

0.1

mS

v/y

r

7.6

mS

v/y

r

0.1

mS

v/y

r

1.4

mS

v/y

r

0

.5 m

Sv/y

r

0.2

mS

v/y

r

0.5

mS

v/y

r

0.2

mS

v/y

r

2.0

1 m

Sv/y

r

0.2

mS

v/y

r

53

4.2.7 The measurements at Abdel Aziz Rantessi Martyr Pediatric hospital

Figure (4.9): The equivalent radiation dose rate at Abdel Aziz Rantessi Martyr

hospital

The results in figure (4.9), show that the measured radiation dose rate at corridor

during closing the door in fluoroscopy room is about (3.4 mSv/yr) and reflects a

huge radiation dose compared with reference limit for public exposure (1 mSv/yr).

These results indicate that the X-ray room was not efficiently lead lined and the

radiation protection is not commensurate with the fluoroscopy radiation doses. There

is an obvious health risk of radiation exposure for persons who visiting this room.

However, the measured values at control panel and at dark room remain in the

permissible limit for radio-diagnostic workers.

The measured values in CT scan room, show that the measured dose rate at patient

waiting room is about more than three times higher than the reference limit for public

exposure (1 mSv/yr).Whereas, the measured values at control panel and at door of

the control panel during closing the door are found high but remain in the

permissible limit for radio-diagnostic workers. These results reveals that the radio-

diagnostic center should be carefully shielded out.

0

1

2

3

4

5

6

7

At control panel

At dark room

At door of the controlpanel (door closed)

At corridor (door closed)

At patients waiting room

Fluoroscopy room no. 1

CT scan room no. 2

(Hw)

mS

v/y

r

roo

m n

o.

2

4.7

mS

v/y

r

4

.03

mS

v/y

r

6.3

mS

v/y

r

3.7

mS

v/y

r

4.2

mS

v/y

r

3.4

mS

v/y

r

54

4.2.8 The measurements at Al Naser Pediatric hospital

As shown in figure (4.10), the equivalent radiation dose rate that measured at

corridor during closing the door in basic X-ray room is found slightly beyond the

reference dose limit of 1 mSv/yr. It is interesting to note that the equivalent radiation

dose rate at control panel, at dark room are within the accepted annual dose limits

(20 mSv/yr).

Figure (4.10): The equivalent radiation dose rate at Al Naser Pediatric hospital

4.2.9 The measurements at Beit Hanoun hospital

Figure (4.11), depicts the measured radiation dose rate values at different locations

are found within the permissible limits for occupational stuff and public. The

radiation survey in this room shows that it is built safe according to safety criteria.

0

0.5

1

1.5

2

At control panel

At dark room

At corridor (door closed)

Behind the chest stand wall

(Hw)

mS

v/y

r

roo

m n

o. 2

Basic X-ray

room no. 1

room no. 2

0.5

mS

v/y

r

0.3

mS

v/y

r

1.0

08 m

Sv/y

r

1.9

mS

v/y

r

55

Figure (4.11): The equivalent radiation dose rate at Beit Hanoun hospital

4.3 The equivalent radiation dose rate at the different locations

The selected radio-diagnostic centers include: basic X-ray, fluoroscopy, CT scan and

mammography machines. The equivalent radiation dose rate were measured at the

different locations at those centers. These locations are: directional under the X-ray

tube, one meter distance from the X-ray tubes, control panels, dark rooms, corridors,

patient waiting rooms and behind the chest stand walls.

4.3.1 The equivalent radiation dose rate at control panels

The measured values of equivalent radiation dose rate at control panels are carried

out in radio-diagnostic rooms at nine selected hospitals shown in figure (4.12). The

results could be accepted and remain within permissible limit for occupational stuff.

We have also noticed that the CT scan room at Al Shifa Medical Complex ranked the

first in term of the highest radiation dose rate, and gives (14.2 mSv/yr). Then

followed by fluoroscopy room at Nasser Medical Complex, and gives (10.9 mSv/yr).

In addition , the higher values at control panels for basic X-ray rooms found in

emergency room at Kamal Adwan hospital and at emergency room at Al Shifa

0

0.2

0.4

0.6

0.8

1

1.2

1.4

At control panel

At dark room

At corridor (door closed)

Behind the chest standwall

Basic X-ray

room no. 1

(Hw)

mS

v/y

r

roo

m n

o. 2

0.3

mS

v/y

r

0.2

mS

v/y

r

0.3

mS

v/y

r

1.3

mS

v/y

r

56

hospital, and gives ( 4.03 mSv/yr and 3.8 mSv/yr) respectively. The lowest radiation

dose rate at control panel found in mammography room at Nasser Medical complex.

Figure (4.12): The equivalent radiation dose rate at control panels

4.3.2 The equivalent radiation dose rate at corridors

Figure (4.13), illustrates the measured values at corridors during closing the doors in

thirty radio-diagnostic rooms at nine selected hospitals. The results showed that the

values at CT scan , fluoroscopy, and some of basic X- ray rooms are higher than the

reference limit for public exposure and indicate that the doors that leads to these

rooms should be efficiently lead lined. Clearly, there is a health risk of radiation

0

2

4

6

8

10

12

14

16

At control panels

Mam

mo

graph

y, roo

m n

o. 3

at Nasser

Basic X

-ray, roo

m n

o. 2

at Al A

qsa

Basic X

-ray, roo

m n

o. 2

at Euro

pean

Gaza

Basic X

-ray, roo

m n

o. 2 at A

l Najjar

Basic X

-ray, ou

t clinic ro

om

at Nasser

Po

rtable X

-ray, roo

m n

o.1

at Nasser

Basic X

-ray roo

m n

o. 3

at Kam

al Aw

dw

an B

asic X-ray, ro

om

no

. 1 At B

eit Han

ou

n B

asic X-ray, o

ut clin

ic roo

m n

o.1

at Al sh

ifa B

asic X-ray, ro

om

no

. 2 at Nasser

Basic X

-ray, roo

m n

o. 6 at A

l Shifa

Basic X

-ray, roo

m n

o. 1 at A

l Naser

Basic X

-ray roo

m n

o. 7

at Al Sh

ifa B

asic X-ray, ro

om

no

. 1 at Al A

qsa

Basic X

-ray, emergen

cy roo

m at A

l Najjar

Basic X

-ray, roo

m n

o. 4 at Eu

rop

ean G

aza B

asic X-ray, o

ut clin

ic roo

m n

o. 2

at Al Sh

ifa B

asic X-ray, ro

om

no

. 2 at Kam

al Ad

wan

ESWEL, flu

oro

scop

y roo

m at Eu

rop

ean G

aza B

asic X-ray, em

ergency ro

om

at Al Sh

ifa B

asic X-ray, em

ergency ro

om

at Kam

al Ad

wan

Fluo

rosco

py, ro

om

no

. 1 at A

l Ran

tessi Flu

oro

scop

y, roo

m n

o.2

at al Najjar

CT scan

, roo

m n

o. 5

at Nasser

CT scan

, roo

m n

o. 2

at Al R

antessi

Fluo

rosco

py, ro

om

no

. 3 A

t Kam

al Ad

wan

Fluo

rosco

py, ro

om

no

. 2 at A

l Aq

sa Flu

oro

scop

y, roo

m n

o.2

at Al Sh

ifa Flu

oro

scop

y, roo

m n

o. 1

at Al Sh

ifa Flu

oro

scop

y, roo

m n

o. 4

at Nasser

CT scan

roo

m at A

l Shifa

(Hw)

mS

v/y

r

roo

m n

o. 2

0.2

mS

v/y

r

3.4

mS

v/y

r

3.8

mS

v/y

r

4.0

3 m

Sv/y

r

4.7

m

Sv/y

r

5.0

4 m

Sv/y

r

5.9

mS

v/y

r

6.3

m

Sv/y

r

7.6

mS

v/y

r

7.6

mS

v/y

r

8.2

mS

v/y

r

10

.9 m

Sv/y

r

1

0.7

mS

v/y

r

14

.2 m

Sv/y

r

0.2

mS

v/y

r

1.8

mS

v/y

r

1.9

mS

v/y

r

1.9

5 m

Sv/y

r 2

.02

mS

v/y

r

2

.01

mS

v/y

r

2.2

m

Sv/y

r

2

.2 m

Sv/y

r

2.3

mS

v/y

r

1.3

m

Sv/y

r

0.4

mS

v/y

r

0.9

mS

v/y

r

0.3

mS

v/y

r

0.4

mS

v/y

r

0.3

mS

v/y

r

1.4

mS

v/y

r

1.4

mS

v/y

r

57

exposure for people who visiting this rooms. Certainly, this would give notice to the

stakeholders for an adequate protection. However, the measured values for the rest

rooms were found within the permissible limits and the lowest radiation dose rate

was found in mammography room at Nasser Medical Complex.

Figure (4.13): The equivalent radiation dose rate at corridors

4.3.3 The equivalent radiation dose rate at patient waiting rooms

Figure (4.14), exhibits the measured values at patient waiting rooms in nine radio-

diagnostic rooms at nine selected hospitals. The results could be described the most

of equivalent radiation dose rate are higher than the reference limits for public

exposure. The results showed that the values in patient waiting room at CT scan

room at Al Shifa Medical complex are the higher compared the reference limit for

public exposure and indicate that the doors that leads to these rooms should be

0

2

4

6

8

10

12

14

At corridors

Mam

mo

graph

y, roo

m n

o. 3

at Nasser

Po

rtable X

-ray, roo

m n

o. 1

at Nasser

Basic X

-ray, roo

m n

o. 2

at Euro

pean

Gaza

Basic X

-ray, roo

m n

o. 4

at Euro

pean

Gaza

Basic X

-ray, roo

m n

o. 1

at Al A

qsa

Basic X

-ray, roo

m n

o. 1

At B

eit Han

ou

n

Basic X

-ray, emergen

cy roo

m at A

l Najjar

Basic X

-ray, ou

t clinic ro

om

at Nasser

Basic X

-ray, roo

m n

o. 2

at Al A

qsa

Basic X

-ray, roo

m n

o. 3

at Kam

al Ad

wan

Basic X

-ray, roo

m n

o. 2

at Al N

ajjar B

asic X-ray, em

ergen

cy roo

m at K

amal A

dw

an

Basic X

-ray, roo

m n

o. 2

at Nasser

Basic X

-ray, roo

m n

o. 1

at Al N

aser B

asic X-ray, ro

om

no

. 7 at A

l Shifa

Basic X

-ray roo

m n

o. 6

at Al Sh

ifa

Basic X

-ray, emergen

cy roo

m at A

l Shifa

Basic X

-ray, ou

t clinic ro

om

no

.1 at A

l shifa

Basic X

-ray, ou

t clinic ro

om

no

. 2 at A

l Shifa

B

asic X-ray ro

om

no

. 2 at K

amal A

dw

an

ESWEL, flu

oro

scop

y roo

m at Eu

rop

ean G

aza

Fluo

rosco

py, ro

om

no

. 1 at A

l Ran

tessi Flu

oro

scop

y, roo

m n

o.4

at Nasser

CT scan

, roo

m n

o. 5

at Nasser

Fluo

rosco

py, ro

om

no

. 3 A

t Kam

al Ad

wan

Fluo

rosco

py, ro

om

no

.2 at al N

ajjar Flu

oro

scop

y, roo

m n

o.2

at Al Sh

ifa

Fluo

rosco

py, ro

om

no

. 1 at A

l Shifa

Fluo

rosco

py, ro

om

no

. 2 at A

l Aq

sa

CT scan

roo

m at A

l Shifa

(Hw)

mS

v/y

r

roo

m n

o.

2 8.1

mS

v/y

r

10

.08

mS

v/y

r

12

.3 m

Sv/y

r

1.8

mS

v/y

r

1.9

mS

v/y

r

1.1

2 m

Sv/y

r

1

.01

mS

v/y

r

0

.9 m

Sv/y

r

0

.8 m

Sv/y

r

0

.6 m

Sv/y

r

0

.5 m

Sv/y

r

0

.5 m

Sv/y

r

0

.4 m

Sv/y

r

0

.3 m

Sv/y

r

0

.3 m

Sv/y

r

0

.2 m

Sv/y

r

0

.2 m

Sv/y

r

0

.1 m

Sv/y

r

0

.09

mS

v/y

r

0

.05

mS

v/y

r

2.5

mS

v/y

r

2.0

2 m

Sv/y

r

2.4

mS

v/y

r

4.0

3 m

Sv/y

r

5.4

mS

v/y

r

6.3

mS

v/y

r

6.7

mS

v/y

r

6.7

mS

v/y

r

7.1

mS

v/y

r

1.7

mS

v/y

r

58

efficiently lead lined. However, the lowest radiation dose rate was found in patient

waiting room at CT scan room at Nasser Medical Complex.

Figure (4.14): The equivalent radiation dose rate at patient waiting rooms

4.3.4 The equivalent radiation dose rate at dark rooms

Figure (4.15), describes the measured values in twenty first dark rooms at nine

selected hospitals. It is noticed that the dark rooms near the fluoroscopy rooms

ranked the first in terms of the highest radiation dose rate.

0

2

4

6

8

10

12

14

At patient waiting rooms

CT scan

, roo

m n

o. 5

at Nasser

Basic X

-ray, roo

m n

o. 7 at A

l Shifa

Basic X

-ray, roo

m n

o. 6 at A

l Shifa

ESWEL, flu

oro

scop

y roo

m at Eu

rop

ean G

aza C

T scan, ro

om

no

. 2 at A

l Ran

tessi Flu

oro

scop

y, roo

m n

o. 4

at Nasser

Fluo

rosco

py, ro

om

no

.2 at A

l Shifa

Fluo

rosco

py, ro

om

no

. 1 at A

l Shifa

CT scan

roo

m at A

l Shifa

(Hw)

mS

v/y

r

roo

m n

o. 2

13

.2

mS

v/y

r

9.4

mS

v/y

r

9.4

mS

v/y

r

6.0

5 m

Sv/y

r

4.2

mS

v/y

r

2.5

mS

v/y

r

1.2

mS

v/y

r

1.1

2 m

Sv/y

r

0.8

mS

v/y

r

59

Figure (4. 15): The equivalent radiation dose rate at dark rooms

4.3.5 Directional equivalent radiation dose rate and at one meter from the

X-ray tube in basic X-ray and mammography rooms

Figure (4.16), illustrates the difference between the directional radiation dose rate

and the radiation dose rate at one meter distance from the X-ray tube by closing the

collimators in basic X-ray and mammography machines. This indicates to the

importance of using radiation protection techniques such as the distance from the X-

ray source and X-ray beam collimators.

All X-ray tubes have some radiation leakage, there is only 2-3 mm lead in the

housing. Radiation leakage is limited in most countries to 1 mGy/hr at 1 meter, so

this can be used as the actual leakage value for shielding calculations (ICRP, 2007).

0

2

4

6

8

10

At dark rooms

(Hw)

mS

v/y

r

0.1

1 m

Sv/y

r

0

.06

mS

v/y

r

0.2

mS

v/y

r

0.2

mS

v/y

r

0

.2 m

Sv/y

r

0.2

mS

v/y

r

0.2

mS

v/y

r

0.3

mS

v/y

r

0.4

mS

v/y

r

0.7

mS

v/y

r

0.9

mS

v/y

r

1.2

m

Sv/y

r

1.4

mS

v/y

r

1.8

mS

v/y

r

2.0

2 m

Sv/y

r

2.5

mS

v/y

r

3.4

mS

v/y

r

6.7

mS

v/y

r

8.4

mS

v/y

r

0.2

mS

v/y

r

0

.16

mS

v/y

r

Mam

mo

graph

y roo

m n

o.3

at Nasser

Po

rtable X

-ray, roo

m n

o.1

at Nasser

Basic X

-ray ,roo

m n

o. 2 at A

l Najjar

Basic X

-ray, roo

m n

o. 2 at N

asser

Basic X

-ray, emergen

cy roo

m at A

l Najjar

Basic X

-ray, roo

m n

o. 1 at A

l Aq

sa

Basic x-ray, o

ut clin

ic roo

m at N

asser

Basic X

-ray, roo

m n

o. 1

At B

eit Han

ou

n

Basic X

-ray, roo

m n

o. 4 at Eu

rop

ean G

aza

Basic X

-ray, roo

m n

o. 2

at Euro

pean

Gaza

Basic X

-ray, roo

m n

o. 1 at A

l Naser

Basic X

-ray, roo

m n

o. 3 at K

amal A

dw

an

Basic X

-ray, emergen

cy roo

m at K

amal A

dw

an

Basic X

-ray, roo

m n

o. 2 at K

amal A

dw

an

Basic X

-ray , ou

t clinic ro

om

no

.1 at A

l shifa

Basic X

-ray, roo

m n

o. 2

at Al A

qsa

Basic X

-ray, ou

t clinic ro

om

no

. 2 at A

l Shifa

Basic X

-ray, emergen

cy roo

m at A

l Shifa

Fluo

rosco

py, ro

om

no

.2 at al N

ajjar

Fluo

rosco

py, ro

om

no

. 1 at A

l Ran

tessi

Fluo

rosco

py, ro

om

no

. 2 at A

l Aq

sa

Fluo

rosco

py, ro

om

no

. 3 A

t Kam

al Ad

wan

0.0

3 m

Sv/y

r

60

The directional radiation dose rate in basic X-ray machine in room no. 2 at Kamal

Adwan martyr hospital was about (162.9 mSv/yr), while the radiation leakage at one

meter distance from the X-tube by closing the collimators about (4.4 mSv/yr).This

reflects the importance of using the distance from the X-ray source and X-ray tube

collimators to protect the patients and their escorts.

Figure (4.16): Directional equivalent radiation dose rate and at one meter from the X-

ray tube in basic X-ray and mammography rooms

-10

10

30

50

70

90

110

130

150

170

Directional dose rate

At one meter from the X-ray tube by closing the collimators

Mam

mo

grap

hy, ro

om

no

. 3 at N

asser

Po

rtable X

-ray, ro

om

no

.1 at N

asser

Basic X

-ray, ro

om

no

. 2 at E

uro

pean

Gaza

Basic X

-ray, e

merg

ency ro

om

at A

l Najjar

Basic X

-ray, ro

om

no

. 3 at K

amal A

dw

an

Basic X

-ray, ro

om

no

. 2 at A

l Aq

sa

Basic X

-ray, ro

om

no

. 1 at A

l Naser

Basic X

-ray, ro

om

no

. 1 A

t Beit H

ano

un

Basic X

-ray, ro

om

no

. 7 at A

l Sh

ifa

Basic X

-ray, ro

om

no

. 2 at A

l Najjar

Basic X

-ray, e

merg

ency ro

om

at A

l Sh

ifa

Basic X

-ray, o

ut clin

ic roo

m n

o. 2

at Al S

hifa

Basic X

-ray, o

ut clin

ic roo

m n

o.1

at Al sh

ifa

Basic X

-ray. ro

om

no

. 1 at A

l Aq

sa

Basic X

-ray, ro

om

no

. 2 at N

asser

Basic X

-ray, ro

om

no

. 6 at A

l Sh

ifa

Basic X

-ray, o

ut clin

ic roo

m at N

asser

Basic X

-ray, ro

om

no

. 4 at E

uro

pean

Gaza

Basic X

-ray, e

merg

ency ro

om

at K

am

al Ad

wan

Basic X

-ray, ro

om

no

. 2 at K

amal A

dw

an

(Hw)

mS

v/y

r

roo

m n

o. 2

10

5.3

mS

v/y

r

29

.1m

Sv/y

r

30

.7 m

Sv/y

r

52

.1 m

Sv

/yr

4

6.6

mS

v/y

r

55

.6 m

Sv/y

r

58

.8 m

Sv/y

r

64

.4 m

Sv/y

r

67

.8 m

Sv/y

r

79

.1 m

Sv/y

r

83

.6 m

Sv/y

r

98

.8 m

Sv/y

r

10

3.7

mS

v/y

r

10

6.5

mS

v/y

r

10

7.2

mS

v/y

r

10

7.5

mS

v/y

r

12

8.7

m

Sv/y

r

15

0.4

mS

v/y

r

15

4.9

mS

v/y

r

16

2.9

mS

v/y

r

0.3

mS

v/y

r

6

.7 m

Sv/y

r

0

.5 m

Sv/y

r

2.6

mS

v/y

r

0.9

m

Sv/y

r

1.7

mS

v/y

r

0.6

mS

v/y

r

2.0

1m

Sv/y

r

2.4

mS

v/y

r

4.2

mS

v/y

r

3.2

mS

v/y

r

1.1

mS

v/y

r

2.5

mS

v/y

r

1.2

mS

v/y

r

2.7

mS

v/y

r

1.5

mS

v/y

r

4.4

mS

v/y

r

0.7

mS

v/y

r

0.8

mS

v/y

r

0.4

mS

v/y

r

61

4.3.6 Directional equivalent radiation dose rate and at one meter from the

X-ray tube in fluoroscopy and CT scan rooms

Figure (4.17): Directional equivalent radiation dose rate and at one meter from the X-

ray tube in fluoroscopy and CT scan rooms

The measurements are also performed for both fluoroscopy and CT scan machines at

the selected hospitals. Figure (4.17), describes the deference between the directional

radiation dose rate and the radiation dose rate at one meter distance from the X-ray

tube by closing the collimators in fluoroscopy rooms.

The difference between the directional radiation dose rate in CT scan machine at Al

Shifa Medical complex (1338.12 mSv/yr), and the radiation dose rate at one meter

distance from the X-ray tube (752.976 mSv/yr), refers to a huge radiation dose

inside the CT scan rooms during imaging the patient. This high dose rate indicates a

-200

300

800

1300

1800

2300

Directional dose rate

At one meter from X-ray tube

CT scan

, roo

m n

o. 5

at Nasser

Fluo

rosco

py, ro

om

no

. 4 at Nasser

CT scan

, roo

m n

o. 2

at Al R

ante

ssi

Fluo

rosco

py, ro

om

no

. 1 at A

l Ran

tessi

ESWEL, flu

oro

scop

y roo

m at Eu

rop

ean G

aza

CT scan

roo

m at A

l Shifa

Fluo

rosco

py, ro

om

no

.2 at al N

ajjar

Fluo

rosco

py, ro

om

no

. 2 at A

l Aq

sa

Fluo

rosco

py, ro

om

no

. 3 A

t Kam

al Ad

wan

Fluo

rosco

py, ro

om

no

. 2 at A

l Shifa

Fluo

rosco

py, ro

om

no

. 1 at A

l Shifa

(Hw)

mS

v/y

r

roo

m n

o. 2

12

.6

mS

v/y

r

16

.1 m

Sv/y

r

26

2.5

mS

v/y

r

60

6.1

mS

v/y

r

89

9.1

mS

v/y

r

98

3.8

mS

v/y

r

98

7.8

mS

v/y

r

12

90

.2 m

Sv/y

r

13

38

.1 m

Sv/y

r

13

38

.1 m

Sv/y

r

13

67

.5 m

Sv

/yr

15

72

.5 m

Sv/y

r

21

09

.7 m

Sv/y

r

22

96

.9 m

Sv/y

r

48

3.5

mS

v/y

r

17

.6 m

Sv/y

r

14

8.7

mS

v/y

r

75

2.9

8 m

Sv

/yr

17

.6

mS

v/y

r

18

.5 m

Sv/y

r

41

.2 m

Sv/y

r

45

.7 m

Sv

/yr

62

high health risk to the unsuspecting supportive persons such as nurses, hospital

attendants and patient escorts. Such dose rate could pose more serious problem to a

pregnant women. So, it is importance of evacuating the CT scan room from the

patient escorts before giving the X-ray dose.

For more details about the equivalent radiation dose rate measurements in radio-

diagnostic centers, see annex (7).

4.4 Specifications of radio-diagnostic machines and rooms at the selected

hospitals

Data sheet information were collected and analyzed for all radio-diagnostic machines

and rooms that available in the selected hospitals. The information was taken from

medical equipment engineering department in ministry of health and from the head

of radio-diagnostic center. Most of these machines are analogue, this leads to

increase the possibility of X-ray images repeating. Thereby leads to increase the

work load in those rooms.

The analysis shows the presence of thirty-five radio-diagnostic machines in the

radio-diagnostic centers. Most of these machines are installed recently, working

electronically and constant except one of them is a portable and nine of them out of

services.

The results of analysis show that all of radio-diagnostic rooms space less than the

ideal X-ray rooms space, that should not be less than 36 m2 according to (NCRP,

report no. 147). The recommended distance between the X-ray machine and control

panels have not been achieved in some rooms such as: emergency basic X-ray room

at Al Shifa Medical Complex, fluoroscopy room at Nasser Medical Complex, basic

X-ray room no. 4 at European Gaza hospital, emergency basic X-ray room at Abu

Yousef Al Najjar Martyr hospital, basic X-ray in emergency room and fluoroscopy

room at Kamal Adwan Martyr hospital, basic X-ray room at Al Naser Pediatric

hospital and basic X-ray room at Beit Hanoun hospital.

63

The thickness and materials of the X-ray rooms walls (20 cm and cement)

respectively. The thickness and height of lead lining of room walls (2 mm and 200-

210 cm) respectively. The thickness of lead lining the room doors (2 mm), this is in

conformity with safety standards. However, we found that the wall of the control

panel in some rooms made of wood lined with lead thickness 2 mm, this is not

compatible with ALARA principle.

For more details about the radio-diagnostic machines and rooms data sheet, see

annex (8).

These findings are consistent with the study of Giri et al. (2007), which was

conducted to measure of radiation at X-ray centers of a few hospitals in Kathmandue

city, Nepal. Their results revealed that the maximum radiation level noted at 4

different corners of radiation machine room was considered for the purpose of

statistical analysis.

These findings are also in line with Younis et al. (2014), which was conducted to

evaluation of radiation protection in radio-diagnostic departments in Erbil hospitals,

his results showed that the facilities for safety were grossly inadequate at places for

paramedics and technician room. Dose rates in front of window of the monitor room

and in the reception indicating higher health risk to the paramedic, visitors and

personnel at the hospital.

The results in the present work could be described in consistent with Adhikari et al.

(2012),which was conducted to evaluate the status of radiation protection at different

hospitals in Nepal. They observed the maximum calculated equivalent radiation level

(HW) is 0.006 mSv/week, which is within the safe limit. Radiation dose level

measurement, was also done at patient waiting area and inside the dark room. In

addition, leakage radiation test was performed by closing the collimators and reading

were obtained at one meter distance from the tube. There is a leakage in almost all

units which is not good in view of protection of the patients and average reading was

64

0.0075 mSv/week. Dose level at different reference point around CT scan unit shows

a maximum value of 0.057 mSv/week at door near the control console. Radiation

survey around the mammogram unit shows that all the area is very safe and built

according to protection criteria.

Furthermore, Ali (2013), study which conducted in X-ray diagnostic facility of

hospitals in Iraqi Kurdistan region. The results show that the facilities for safety were

grossly inadequate and the dose rates at the behind X-ray door room indicating

higher health risk to the visitors and personnel at the hospital. Similar results were

found in the study of Oluwafisoye et al. (2009), which was conducted in X-ray

diagnostic facility of a large Nigerian hospital. The results revealed that the dose rate

measured at the patient waiting room was far above the background radiation dose

rate, while at the reception, the dose rate was greater than the background dose rate

by factor of 20 mSv/yr. This high dose rate indicates a higher health risk to the

unsuspecting supportive personnel such as nurses, hospital attendants and visitors.

In brief, our results and findings are consistent and adequate with the results of

previous studies that above mentioned. This reveals the presence of ionizing

radiation leakage in different locations in radio-diagnostic centers and suggested to

be remediated.

65

Part two

4.5 The questionnaire contents analysis

Our study consists of 182 radio-diagnostic workers from nine selected hospitals,

where a questionnaire were distributed to obtain information for matching the study

needs. The questionnaire includes five parts as follows.

4.5.1 Socio-demographic and work related information

The first part of the questionnaire contained eight items about the socio-demographic

and work related information of participants who completed the questionnaire. The

results reveals an information about the participants percentage according to the

following items:

i. Participants occupation

Figure (4.18), shows 79.1% (n=144) of participants are medical radiographers and

20.9% (n=38) are radiologists.

Figure (4.18): Participants percentage according to their occupation

Radiologists

Medical radiographers

20.9%

79.1%

66

ii. Participants sex

There is a wide variation in sex of radio-diagnostic workers, where 76.1% (n=144) of

the study participants are males and 23.9% (n=43) females as illustrated in figure

(4.19). This result indicates that the most of radio-diagnostic workers are males and

this is attributed to the community culture towards women who working in radiology

field and their fear from transmitting the risk of radiation to their future generations.

A pproximatlely180 participant answered this question.

Figure (4.19): Participants percentage according to their sex

iii. Participants age groups

Figure (4.20): Participants percentage according to their age groups

0%

10%

20%

30%

40%

50%

60%

70%

80%

Male Female

76.1%

23.9%

Par

tici

pan

ts p

erce

nta

ge

0%

10%

20%

30%

40%

50%

From 20-29years

From 30-39years

From 40-49years

More than 50years

Par

tici

pan

ts p

erce

nta

ge

8.3%

21%

46.4%

24.3%

67

The study shows that the participants ages were between 30 and 39 years which

formulates 46.4% (n=84) of the participants. Figure (4.20), illustrates the percentage

of participates due to their ages. This indicates that the radio-diagnostic population

are young labors.

iv. Participants academic qualifications

About 174 participants out of 182 participants answered this question and gives a

result as illustrated in figure (4.21).

Figure (4.21): Participants percentage according to their academic qualifications

v. Participants practical experience

It is also about 178 participants from 182 persons answered the question related to

the practical experience. Figure (4.22), shows that the study population was

categorized into four groups according to their practical experience and refers that

most of the radio-diagnostic workers have sufficient practical experience in radio-

diagnostic field.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Diploma Bachelor Higher degrees

Par

tici

pan

ts p

erce

nta

ge

9.2% 8%

82.8%

68

Figure (4.22): Participants percentage according to their practical experience

vi. Participants distribution at the hospitals

Figure (4.23): Participants percentage according to their distribution at the hospitals

Clearly, it is found that the largest number of study participants from Al Shifa

Medical Complex, who formulates 31.3% (n=57) of the study participants. However,

the lowest number of study participants from Abdel Aziz Rantessi hospital who

formulates 4.9% (n=9) of the participants. Participants distribution in other hospitals

are illustrated in figure (4.23).

This result is not a surprise since the participants proportions depend on the number

of radio-diagnostic workers in each hospital, where Al Shifa Medical Complex is a

major one.

0%

5%

10%

15%

20%

25%

30%

35%

40%

1-4 years 5-9 years 10-14 years 15-20 years

36%

27%

19.1% 18% P

arti

cip

ants

per

cen

tage

0%5%

10%15%20%25%30%35%

Par

tici

pan

ts p

erce

nta

ge 31.3%

8.8% 9.3% 11%

15.9%

5.5% 6.6% 6.6% 4.9%

69

vii. Participants dealing with radio-diagnostic machines

As shown in figures (4.24). Basic X-ray machines is the most common used, which

formulates 83% (n=151) of participants. While 14.8% (n=27) of participants used

with mammography machines. We find that this result is reasonable because the

basic X-ray machines are the most prevalent in terms of the number and use in the

hospitals. Whereas, the dealing with the mammography machines restricted to

females workers.

Figure (4.24): Participants percentage according to their dealing with radio-

diagnostic machines

viii. Participants daily work hours in radio-diagnostic rooms

Figure (4.25): Participants percentage according to their daily work hours in radio-

diagnostic rooms

0

50

100

Radio-diagnosticmachines

0%

20%

40%

1-2 hours2-3 hours

3-4 hours4-5 hours

More than5 hours

14.8% 24.2%

58.8% 44%

83%

41.8%

8%

34.1% 27.8%

18.2% 11.9%

%

%

%

70

Most of radio-diagnostic workers that formulate 34.1% (n=60) working between 3

and 4 hours inside the radio-diagnostic rooms per day, while 27.8% (n=49) of the

participants working between 2 and 3 hours per day. Figure (4.25) exhibits the

participant percentage concerning daily work hours in radio-diagnostic rooms.

For more details about the socio-demographic and related work factors of the study

participants, see table no. (1) in annex (9).

4.5.2 Participants response to availability of personal radiation protection

devices items

The second part of the questionnaire contained ten items that reflects the current

level of availability of personal radiation protection devices and warning signs in

radio-diagnostic centers. The results about the availability of such devices in radio-

diagnostic centers according to the participants response are illustrated in figure

(4.26).

Figure (4.26): Participants response about the availability of personal radiation

protection devices items

0%10%20%30%40%50%60%70%80%90%

100%

Ava

ilab

ility

of d

evic

es

pe

rce

nt.

95.6%

41.8%

75.8%

26.4%

40.1%

22.5% 20.9% 15.9%

5.5% 7.1%

35.2%

71

The personal radiation protection devices are the principal for radiology workers

(Klein et al., 2009). A visible warning sign and caution light required to alert

individuals to radiological conditions (Radiation protection manual, 2010). However,

according to the participants knowledge, it is about 35.2% of personal radiation

protection devices are available in the radio-diagnostic centers at governmental Gaza

governorates hospitals.

As it displays in the figure (4.26), the maximum rate about the availability of

personal radiation protection devices specified to lead aprons and thyroid shields by

95.6% (n=174) and 75.8% (n=138) respectively. The minimum rate that related to

the availability of personal radiation protection devices specified to lead curtains,

breast shields and gonad shields by 5.5% (n=10), 7.1% (n=13) and 15.9% (n=29)

respectively.

In addition, There are a few participants have no idea about the availability of

personal radiation protection devices in radio-diagnostic centers such as lead

curtains, lead barriers and breast shields by 20.3% (n=37), 9.3% (n=17) and 7.7%

(n=14) respectively.

The percentage of participants who know that the lead glass available in radio-

diagnostic centers was about 41.8% (n=76). However, less percentage of participants

reported the availability of radiation warning signs and caution lights respectively.

These findings are in line with results of a study which was conducted by Adejumo

et al. (2012) in South West Nigeria. Their results revealed that some radiation

protection devices are available in large proportion in radio-diagnostic centers such

as: lead apron 96%,caution lights 98%, lead glass 19% and shield lead shields/barrier

77%. However, other radiation protection devices are available in low proportion in

radio-diagnostic centers such as: lead gloves 19%, breast shields 19%, lead curtains

36% and thyroid shields 24%.

72

In addition, these results are in an agreement with the study of Mojiri and

Moghimbeigi (2011) which conducted in various hospitals in Hamadan city, Iran.

They observed that different percent of radiographers awareness about the existence

of personal radiation protective devices in radiology centers, where that lead apron,

radiation signs and gonad shields are available in radiology centers by 98.6%, 80.3%

and 78.9% respectively. While lead glass, lead gloves and thyroid shields are

available in radiology centers by 28.2%, 35.2% and 67.6% respectively. In addition,

These findings are in adequate with Younis et al. (2014) which conducted to

radiation protection evaluation from radio-diagnostic departments in Erbil hospitals.

They showed that the facilities for safety were grossly inadequate at places for

paramedics and technician room.

For more details about the response of study participants to the availability of

personal radiation protection devices items, see table no. (2), in annex no. (9).

4.5.3 Participants response to awareness items about radiation protection

issues

The third part of the questionnaire contained eighteen items to measure the current

level of radio-diagnostic workers awareness about radiation protection issues.

Descriptive statistics include mean and percentage; where yes answers reflecting the

level of study participants awareness about radiation protection issues.

According to the results displayed in figure (4.27), about 74.8% of participants have

awareness toward radiation protection issues. This result indicates that the majority

of radio-diagnostic workers in governmental Gaza governorates hospitals have

relatively adequate awareness regarding radiation protection issues. This would not

surprise us since there is an educational lectures established recently in governmental

Gaza governorates hospitals regarding radiation protection and safety issues. Despite

this result is obtained, there is a dare need to increase the radio-diagnostic workers

awareness about some of radiation protection issues, which will be mentioned later.

73

Figure (4.27): Participants response to radiation protection awareness items

Clearly, the radio-diagnostic workers have a relatively well awareness about

radiation protection techniques. The highest value of percentage of participants who

know that short radiation exposure time during radiological examinations leads to

less patient radiation dose, and gives 97.8% (n=178). The participants awareness

about increase the distance from the radiation source to double the received dose will

be reduced to its half was about 74.2% (n=135).The rest either they said the opposite

or they did not know. While those who know that the thickness of the X-ray room

wall, which is exposed to primary X-rays should be 2 mm based on the principle of

ALARA about 64.3% (n=117) of participants response.

The item about the recommended distance between the X-ray source and radiology

workers is two meter have the lowest percentage of participants awareness and gives

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74

about 33.5% (n=61) of participants. Then it is followed by the item about radiation

dose limits for pregnant women which worked in radiation field and gives about

36.8% (n=67) of participants. Only 49.5% (n=90) of participants knew that the ideal

space for X-ray room should not be less than 36 m2, the ceiling height of 3.6 m and

the exterior windows must have a height of 2.2 m above the X-ray room floor. These

findings revealed that the radio-diagnostic workers in governmental hospitals in

Gaza governorates have limited awareness about specific radiation protection issues

in spite of their work in a radio-diagnostic field.

In the items regarding awareness about the annual average dose over five years

should not exceed (20 mSv) for occupational exposure, the responses were almost

68.7% (n=125) are aware of the annual average dose. While 19.8% (n=36) did not

aware that and 11.5% (n=21) said the opposite. About 58.8% (n=107) are aware on

public should not be exposed to more than an average of (1 mSv per year). Clearly

that the radio-diagnostic workers in governmental Gaza governorates hospitals have

inadequate awareness regarding permissible radiation dose limits in spite of their

work in a radio-diagnostic field.

Participants awareness was relatively high in a few issues. Most of them aware that

periodic maintenance for X-ray room walls, doors and radiation protection devices

should be tested to ensure their efficiency with a percentage of about 96.7% (n=176).

While only 2.2% (n=4) of them answered the opposite and 1.1% (n=2) they did not

know. Regarding the maintenance and calibration for X-ray machines must be

periodically performed to prevent radiation leakage by 95.6% (n=174). However,

about 95.1% (n=173) know that the protection of the patient and the public from

unnecessary radiation during radiological examinations are the responsibility of

radiology staff, while about 1.1% (n=2) of participants have no idea, and 3.8% (n=7)

said the opposite. Almost 94.5% (n=172) aware that the error in the selection of

appropriate kilovolts due to technical error or malfunction in the X-ray machine

leads to excessive radiation dose to the patient.

75

Approximately 94.0% (n=171) of the participants responded that the radio-diagnostic

workers should be involved in the X-ray machines purchase. The participants

awareness about the use of collimation during radiography has a great benefit in

reducing patient dose were about 93.4% (n=170) of the study participants. These

results indicate that the majority of the participants have positive awareness

regarding the numerous radiation protection issues.

In comparison of our results with others due to awareness level. There is an

agreement with the study of Mojiri and Moghimbeigi (2011) which was conducted in

various hospitals in Hamadan city, Iran. They revealed that the medical

radiographers have a good awareness about radiation protection issues. The same

results have been reported in the study of Amirzadeh and Tabatabaee (2005) in Iran

which was conducted to evaluate the awareness of employees about radiation

protection in Shiraz hospitals.

In comparison with other study performed by Adejumo et al. (2012) to evaluate the

compliance to radiation safety standard amongst radiographers in radio-diagnostic

centers in south west, Nigeria. The study reported that about 98% of respondents

have good knowledge of radiation protection issues.

The same results have been also reported in the study of Shah et al. (2007) which

conducted in Campus Peshawar, Pakistan, to assess the radiation protection

awareness levels in medical radiation technologists. They observed that the radiation

awareness knowledge levels in the sample group varied widely with a range of

median score of 75%. In addition, these findings are in line with Adhikari et al.

(2012) which conducted to evaluate the status of radiation protection at different

hospitals in Nepal. They observed that around 70% of the radiation workers are

aware of radiation safety issue.

However, the present work disagrees with the results of Abu Draz (2009) which

showed that the level of radiation protection knowledge among radio-technologists in

governmental hospitals in Gaza governorates almost 47.41%. This value indicates

76

that the majority of radio-technologists haven't high knowledge regarding radiation

protection issues of that time. These variations can be attributed to the educational

lectures established recently in governmental Gaza governorates hospitals that

regarding about radiation protection and safety issues.

There is also an disagreement with results reported in Mutyabule and Whaites (2002)

in Uganda. and in that of Salti and Whaites (2002) in Syria. This disagreement with

our results may be due to the difference in the cultures among various communities.

For more details about the response of study participants to awareness items about

radiation protection issues, see table no. (3), in annex no. (9).

4.5.4 Participants response to practices items about radiation protection

issues

The fourth part of the questionnaire contained fifteen items describe current level of

radio-diagnostic workers practices about radiation protection issues.

The results in figure (4.28), illustrates that, in spite the fact that 74.8% of participants

have awareness about radiation protection issues, but it is only about 53.4% of

participants follows the radiation protection practices. This result is surprising and

alarming. Clearly it seems unsatisfactory and indicates that the approximately half of

participants have negative practices toward radiation protection issues.

The statistical strength of these relationships are in line with the study carried out by

Slechta and Reagan (2008) which conducted to examination of factors related to

radiation protection practices in American society of radiologic technologists. They

reported that the mean scores for knowledge and compliance with safety practices

were 82% and 72%, respectively.

77

Figure (4.28): Participants response to radiation protection practices items

At the present work, the results of participants practices regarding of radiation

protection issues during their work in the radio-diagnostic centers, have shown the

majority of the participants 94.0% (n=171) stand behind the lead barrier when give

the radiation dose. However, 73.6% (n=134) of participants used the X-ray tube

collimation during the radiography in order to reduce patient surface that exposed to

X-ray, this means the radio-diagnostic workers interested in protecting themselves

and their patients from ionizing radiation. Also 74.7% (n=136) of participants make

sure that the X-ray door is closed during the examination. These results reflect that

the study participants follows some of positive radiation protection practices.

When the radio-diagnostic workers were asked if they explain the radiological

examination instructions to the patient before the exam, just about 52.2% (n=95) of

participants answered yes. While low percentage of participants don’t protect patient

escorts who holds the child during the radiological examination were about 31.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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tici

pan

ts p

ract

ices

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t.

34

.6%

36

.3%

3

6.8

%

52

.2%

55

.5%

59%

66

.5%

67

.6%

73

.6%

74

.7%

76

.4%

94%

31

.3%

25

.8%

16

.5%

53

.4%

78

(n=57). In addition, about 67.6% of participants wear and use the radiation protection

devices in order to protect themselves from ionizing radiation. We found only about

16.5% (n=30) of participants use the gonadal shield to protect the patients gonads

even if the doctor did not ask to protect these organs. This results may be due to only

15.9% of participants reported the availability of gonadal shield in radio-diagnostic

centers.

Approximately 55.5% (n=101) of participants reported that they asked the patient

escorts to evacuate the X-ray room before giving the X-ray dose. We also found that

this result is un satisfactory when compared with participants awareness about

radiation protection issues. This result reflects that the study participants follow

some of negative practices toward radiation protection issues.

The responses related to item about radiation protection course, show less than half

of radio-diagnostic workers have participated in a radiation protection course

(34.6%). Similar studies such as Mojiri and Moghimbeigi (2011) which was

conducted in in various hospitals in Hamadan city, reported that there less than half

of the technicians have participated in a radiation protection course (43.7%). In

comparison with the other study performed by Noohi (2009) in Kerman (Iran)

revealed that half of the radiographers in diagnostics radiology centers have

participated in a radiation protection course (50%).

Regarding responses to using of portable X-ray items, only 66.5% (n=121) of

participants take the necessary precautions to protect patient escorts and other

patients in the room when using the portable X-ray machine. When the participants

were asked if they keep the recommended distance from the radiation source, a

relatively high percentage of participants 76.4% (n=139) answered positively.

When the participants were asked if they believe that your radio-diagnostic centers

conformity with the safety and radiation protection standards, the responses were

55.5% (n=101) response negatively. While 36.3% (n=66) answered positive and

8.2% (n=15) answered don’t know. The importance of this study was to determine

79

whether the radio-diagnostic centers safe or not. This result contradict by Adejumo et

al. (2012) study, which reported that 65% of radiographers believe that there is a

radiation safety in the workplace. This disagreement possibly because of differences

in the design, construction and lead lined of X-ray rooms.

When the participants were asked if they participants interested in maintenance

conducting for X-ray machines when the defect related with radiation protection,

59.0% (n=109) answered yes. While about 58.8% (n=107) of participants show

carelessly to check the radiology center when there is suspicion of radiation leakage.

However, about 50.5% (n=92) of participants answered that the administration does

not respond to the demands of workers related to check the X-ray rooms to make

sure of their safety. This result is highly associated with opinion of 64.9% of

participants that the negligence in radiation protection issues caused by the lack of

radiation safety officer to provide the service.

These results are agreement with the study of Abu Draz (2009) which showed that

the level of radiation protection practices among radio-technologists in governmental

hospitals in Gaza governorates was about 45%. Clearly, this result indicates that the

majority of radio-technologists have low practices level regarding radiation

protection issues..

This result is also adequate with Tavakoli et al. (2003) which was conducted in Iran,

who revealed that the medical students in Birjand University of medical sciences

have low level of practices regarding radiation protection.

For more details about the responses of study participants to practices items about

radiation protection issues, see table no. (4), in annex no. (9).

80

4.5.5 Participants response to personal radiation exposure monitoring

process items

The fifth part of the questionnaire contained seven items to evaluate current level of

personal radiation exposure monitoring process.

Descriptive statistics include mean and percentage were carried out. According to the

study results, just about 29.9% of study participants have positive evaluation toward

personal radiation monitoring process. This result indicates that the majority of

radio-diagnostic workers in governmental Gaza governorates hospitals undergoes to

radiation risks. Certainly, this cannot be purposely assessed and corrective measures

will become difficult.

These results are in an agreement with the study of Iortile et al. (2013), the study has

revealed that the levels of monitoring the absorption of radiation by radiology

workers in most hospitals surveyed in Makurdi metropolis are very poor. These

findings are in line with Okaro et al. (2010) study which reported that personal

radiation monitoring radio-diagnostic centers in South Eastern Nigeria is abysmally

poor.

i. Availability of radiation protection adviser

The results in figure (4.29), show that the radiation protection advisers or supervisors

are not available in the radio-diagnostic centers surveyed. About 95.6% (n=174) of

study participants don't have radiation protection adviser in radio-diagnostic centers.

This result agrees with the results of Okaro et al. (2010) which conducted to

evaluation of personal radiation monitoring in radio-diagnostic centers in south

eastern Nigeria, which showed that radiation protection advisers are hardly available

in the centers surveyed. They were found only in four centers when ideally they

should be in every radiology centers.

81

Figure (4.29): Participants response about availability of radiation protection

advisors

ii. Availability of personal radiation exposure monitoring devices

As shown in figure (4.30), about 60.4% (n=111) of study participants have a personal

radiation exposure monitoring device.

Figure (4.30): Participants response about availability of personal radiation exposure

monitoring devices

iii. Use of personal radiation exposure monitoring devices during their work in

radio-diagnostic rooms

As shown in figure (4.31), about 55% (n=61) of participants who have personal

radiation exposure monitoring device use this device during their work in radio-

diagnostic rooms. While 31.5% (n=35) of participants sometimes use this device.

About 13.5% (n=15) of participants who have personal radiation exposure

monitoring device don’t use this device during their work in radio-diagnostic rooms.

Yes

No

Yes

No

Participants response

95.6%

4.4%

60.4%

39.6%

82

.

Figure (4.31): Participants response about using of personal radiation exposure

monitoring device during their work in radio-diagnostic rooms

iv. Receive of guidance about using the devices

As shown in figure (4.32), the most of participants who have a dosimeter don't

receive guidance about the proper handling with the personal radiation exposure

monitoring devices, this represents about 75.7% (n=84) of participants.

Figure (4.32): Participants response about receiving guidance about the proper

handling with the personal radiation exposure monitoring device

v. Safety officers interest with the devices measurements

As shown in figure (4.33), there are a big problem in personal radiation exposure

monitoring process, majority of the participants 64.9% (n=72) believe that the

measurements results doesn’t take into consideration by the safety officers.

0%

20%

40%

60%

Yes Sometimes No

Per

cen

tage

of

resp

on

se

0%

20%

40%

60%

80%

YesNo

55%

13.5%

31.5%

24.3%

75.7%

83

Figure (4.33): Participants response about safety officers interest with the devices

measurements

vi. Availability of another personal radiation exposure monitoring device

As shown in figure (4.34), there is no one of radio-diagnostic workers receive a new

personal radiation exposure monitoring device when the devices collect to measure

of radiation dose.

Figure (4.34): Participants response about availability of new device when the

devices collect to measure of radiation dose

vii. The reasons for lack of these devices

As shown in figure (4.35), there are a miscellaneous reasons advanced by the study

participants about the negligence in personal radiation exposure monitoring process.

Majority of participants 64.9% (n=63) believe that there is no radiation safety officer

to provide the service. While about 57.7% (n=56) believe that another reason was put

0%

20%

40%

60%

80%

YesNo

Per

cen

tage

of

resp

on

se

Yes 0%

No 100%

100%

Participants response

64.9%

35.1%

84

forward by the participants. This is due to the carelessly of hospital management, that

represent about 57.7% (n=56). Another opinion reports that there is lack of fund to

purchase these devices and this represents about 32.0% (n=31). Finally, 24.7%

(n=24) of participants believe that the radio-diagnostic workers do not request the

dosimeters.

Figure (4.35): Participants response about the reasons for lack of personal radiation

exposure monitoring devices

Almost similar reasons with different in ratios were found in the Iortile et al. (2013)

study, which conducted in Makurdi Metropolis, and reported the percentages of

7.5%, 17.5%, 10%, 32.5% and 32.5% for various reasons as: unavailability of

radiation safety officers, lack of funds, radiology workers do not request for personal

radiation monitoring, hospital management do not provide for it and others,

respectively.

In addition, almost similar reasons with different values were found in the Okaro et

al. (2010) study, which conducted in South Eastern Nigeria. They reported that about

(9.8%) of participants believe that there is no radiation safety officer to provide the

service, (14%) of participants reports that there is lack of funds, (4.9%) of

participants believe that the radiographers do not request for personal radiation

monitoring and (41.5%) of participants believe that the hospital management do not

provide for it in its budget. However, about (29.2%) of participants reports other

reasons for lack of these devices.

0

20

40

60

80No radiation safety officer toprovide the service

Carelessly of hospitalmanagement

Lack of fund to purchasethese devices

Radiology workers do notrequest these devices

64.9%

24.7%

32%

57.7% %

%

%

%

%

85

The results of present work agree with the safety policies and procedures manual on

radiation safety conducted in Washington State University (2000). This manual

reported that the employees should receive a radiation monitoring device for

monitoring radiation exposure.

In addition, our results are found in line with Okaro et al. (2010) study who show

that personal radiation monitoring is available only in a few hospitals and in most

cases does not cover all the radiographers on employment. This finding agrees with

the result of a previous survey which carried by Okpala (2004) which covered 28 X-

ray centers in two states of south eastern Nigeria. The survey result showed that

radiation monitoring was almost non-existent in the centers. Furthermore, the

obtained results are in line with Younis et al. (2014) who carried out his work in

radio-diagnostic departments in Erbil hospitals. His results revealed that the personal

monitoring (TLD badges) were not provided in the majority of departments. Our

results are also agrees well with Adhikari et al. (2012) which conducted to evaluate

the status of radiation protection at different hospitals in Nepal, which observed the

personal monitoring for radiation workers cannot be easily determined. This is due to

around 65% of radiation workers are not monitored for radiation exposure owing

insufficient of monitoring devices.

In comparison with the other study performed similar results were found in the study

of Ali (2013) which was conducted in X-ray diagnostic facility of hospitals in Iraqi

Kurdistan region, and its results revealed that the personal monitoring (TLD badges)

were not provided for radiographers.

Our results, also give a good agreement with Iortile et al. (2013) study, which

observed that personal radiation monitoring is available only in one hospital. This

indicates that, radiation monitoring devices are not easily provided in most of radio-

diagnostic centers of hospitals.

Clearly, a poor level of personal radiation exposure monitoring is found in the

present work. This is due to radiation monitoring insufficient to cover all the radio-

86

diagnostic workers, where the results shows that the devices are available for only

60.4% (n=110) of study participants. Rosenbloom (2007), revealed in his article that

the risk level from radiation exposure could not be assessed perfectly. Since we are

in dare need for a sensitive devices for radiation exposure monitoring.

For more details about the responses of study participants to evaluation of personal

radiation exposure monitoring process items, see table no. (5), in annex no. (9)

4.6 The relationship between the independent variables and the

participants response to radiation protection issues

The independent samples t-test, frequency, one-way analysis of variance (ANOVA),

mean and the standard deviation were carried out and developed in order to meet the

study purpose.

Therefore, the relationship between the level of availability the personal radiation

protection devices, awareness and practices regarding radiation protection issues and

evaluation of personal radiation exposure monitoring process as a dependent

variables. However, the socio-demographic and work related factors for workers as

independent variables will be discussed in the following section.

i. Age effect

The radio-diagnostic workers who participated in this study were categorized into

four groups according to their age groups as mentioned previously. The following

table (4.1), shows the results of dependent variable throughout the participants

according to their age groups.

87

Table (4.1): The dependent variables according to participants age

Items Age No. Mean Std. F Sig.

Availability of

devices

From 20-29 years 44 40.00 21.67

2.024

0.112

From 30-39 years 84 34.29 19.59

From 40-49 years 38 30.26 15.85

More than 50 years 15 39.33 18.31

Awareness

From 20-29 years 44 73.61 14.68

2.18

0.092

From 30-39 years 84 74.07 14.26

From 40-49 years 38 74.42 14.47

More than 50 years 15 83.70 9.73

Practices

From 20-29 years 44 53.03 21.23

4.721

0.003

From 30-39 years 84 49.05 21.45

From 40-49 years 38 55.44 25.66

More than 50 years 15 72.00 18.55

Radiation

monitoring

From 20-29 years 44 23.11 26.22

2.879

0.037

From 30-39 years 84 33.93 25.67

From 40-49 years 38 25.00 26.78

More than 50 years 15 41.11 33.85

The above table illustrates that age group between 20 and 29 years has the highest

mean value (40). This means that the participants in this age group recorded highly

availability of personal radiation protection devices in the radio-diagnostic centers.

While the age group between 40 and 49 years has the lowest mean value (30.26).

According to one-way variance (ANOVA) analysis, (P value=0.112), there are no

statistically significant differences between availability and age groups. Clearly that

the calculated p-value is greater than the significant level which is equal 0.05 (p-

value > 0.05).This indicates that there is no effect of age groups on the evaluation of

the availability of personal radiation protection devices in radio-diagnostic centers.

So, the null hypothesis that there is no differences between the evaluation of the

availability of radiation protection devices in radio-diagnostic centers and their age

groups is accepted and the researcher hypothesis is rejected.

Regarding the awareness items. It is noticed that the age group more than 50 years

has higher awareness than the other age groups, and gives mean value (83.70).

88

Moreover, there is no statistically significant differences among age groups and

participants awareness (p-value=0.092). So, the null hypothesis "there is no

relationship between the awareness of radio-diagnostic workers about radiation

protection issues and their age groups is accepted and the researcher hypothesis

rejected. This result may be attributed to the older age radio-diagnostic workers are

more careful about their health, while the younger workers careless. This result are in

line with Su, et al., (2000) study result, which observed there is a significant

difference shown between radiation safety knowledge and the growth of the age and

the career period of radiological technologists who work at medical centers in

Taiwan.

Regarding the practices items. According to one-way variance (ANOVA) analysis,

(P value=0.003), the results reflect there is a difference in the practices mean among

the radio-diagnostic workers according to their age groups. The highest mean value

(72) was for age group more than 50 years, while the lowest mean value (49.05) was

for age group between 30 and 39 years. So, the alternative hypothesis that there is

statistically significant relationship between the participants practices regarding

radiation protection and their age groups is accepted.

Regarding the evaluation of personal radiation exposure monitoring process items.

Clearly that there is a statistically significant difference according to the participants

age groups (p-value=0.037), this difference is highest among radio-diagnostic

workers with age groups more than 50 years, with mean value (41.11). The lowest

mean (23.11) is among age group between 20 and 29 years. This is logical result and

reflects that the new employees are not included in the personal radiation exposure

monitoring process. So, the alternative hypothesis that there is statistically significant

relationship between the radio-diagnostic workers evaluation of monitoring process

and their age groups is accepted.

89

ii. Sex effect

As shown in Table (4.2), the mean of availability of personal radiation protection

devices among participants males (34.67) is slightly more than females (36.28).

According to one-way variance (ANOVA) analysis, (p-value=0.636), there are no

statistically significant differences due to their sex. So, the null hypothesis that there

is no relationship between the evaluation of the availability of personal radiation

protection devices and their sex is accepted and the researcher hypothesis is rejected.

Regarding the awareness items. The mean of awareness among participants males

(74.53) is slightly less than females (75.19). According to one-way variance

(ANOVA) analysis, (p-value=0.791), there is no relationship between the awareness

of radio-diagnostic workers regarding radiation protection and their sex. So, the null

hypothesis that there is no relationship between the awareness of radio-diagnostic

workers regarding radiation protection issues and their sex is accepted and the

researcher hypothesis is rejected. These findings are in line with Su et al., (2000)

study results, there is no significant difference shown between radiation safety

knowledge and gender of radiological technologists who work at medical centers in

Taiwan.

Regarding the practices items. The results demonstrate that there is a slight

difference in the mean of participants due to their sex. The practices mean among

males (52.99) slightly higher than females (53.18). According to one-way variance

(ANOVA) analysis, there are no relationship between the participants practices

regarding radiation protection and the sex. So, the null hypothesis that there are no

relationship between the practices of radio-diagnostic workers regarding radiation

protection issues and their sex is accepted and the researcher hypothesis is rejected.

Regarding the evaluation of personal radiation exposure monitoring process items.

The results reflect that the mean among males (29.56) is slightly less than among

females (32.17). According to one-way variance (ANOVA) analysis, (p-

value=0.584), there is no relationship between the evaluation regarding personal

90

radiation monitoring process and the gender of radio-diagnostic workers. So, the null

hypothesis that there is no relationship between the evaluation regarding personal

radiation monitoring process and their sex is accepted and the researcher hypothesis

is rejected.

Table (4.2): The dependent variables according to participants sex

Items Sex No. Mean Std. t Sig.

Availability of

devices

Male 137 34.67 18.87 -0.474

0.636

Female 43 36.28 21.05

Awareness Male 137 74.53 14.72 -0.266

0.791

Female 43 75.19 12.32

Practices Male 137 52.99 23.25 -0.047

0.963

Female 43 53.18 21.01

Radiation

monitoring

Male 137 29.56 27.34 -0.548

0.584

Female 43 32.17 26.82

iii. Occupation effect

As shown in table (4.3), the mean of availability of personal radiation protection

devices among medical radiographers (35.83) is slightly higher than that among

radiologists (32.63). According to one-way variance (ANOVA) analysis, (p-

value=0.368 ). There are no statistically significant differences in the evaluation of

the availability of personal radiation protection devices due to their occupation. So,

the null hypothesis that there is no relationship between the evaluation of the

availability of personal radiation protection devices and their occupation is accepted

and the researcher hypothesis is rejected.

Regarding the awareness items. The mean of awareness among medical

radiographers (75.96) is slightly higher than that among radiologists (70.32).

According to one-way variance (ANOVA) analysis, (p-value=0.029).There is a

statistically significant relationship between radio-diagnostic workers awareness

toward radiation protection issues due to their occupation. So, the alternative

hypothesis that there is a statistically significant relationship between the radio-

91

diagnostic workers awareness regarding radiation protection issues and their

occupation is accepted.

Regarding the practices items. Clearly that the radiation protection practices mean

among medical radiographers (54.86) is higher than among radiologists (48.07).

According to (p-value=0.104). There are no statistically significant differences. So,

the null hypothesis that there is no statistically significant relationship between the

radio-diagnostic workers practices regarding radiation protection issues and their

occupation is accepted and the researcher hypothesis is rejected.

Regarding the evaluation of personal radiation exposure monitoring process items.

The medical radiographers have a highest mean (35.88), while the radiologists have a

lowest mean (8.77). According to (p-value=0.000). There are a highly statistically

significant differences. So, the alternative hypothesis that there is statistically

significant relationship between the radio-diagnostic workers evaluation regarding

personal radiation exposure monitoring process and their occupation is accepted.

Table (4.3): The dependent variables according to participants occupation

Items Occupation No. Mean Std. t Sig.

Availability of

devices

Radiologist 38 32.63 17.96 -0.902

0.368

Medical radiographer 144 35.83 19.84

Awareness Radiologist 38 70.32 15.30 -2.199

0.029

Medical radiographer 144 75.96 13.73

Practices Radiologist 38 48.07 25.94 -1.635

0.104

Medical radiographer 144 54.86 21.89

Radiation

monitoring

Radiologist 38 8.77 16.32 -5.952

0.000

Medical radiographer 144 35.88 26.76

iv. Academic qualification effect

As show in table (4.4), the results reflect some differences between the means of

availability of personal radiation protection devices among radio-diagnostic workers

due to their academic qualification. The mean of radio-diagnostic workers who have

92

bachelor degrees (36.11) is slightly higher than the mean for those who have higher

degree (35.71) and those who have diploma is (31.25). According to (p-

value=0.648). There are no statistically significant differences. So, the null

hypothesis that there is no relationship between the evaluation of the availability of

personal radiation protection devices among radio-diagnostic workers and their

academic qualification is accepted and the researcher hypothesis is rejected.

Regarding the awareness items. The results demonstrate that there is slightly

differences in the mean of radio-diagnostic workers awareness between those who

have diploma (78.13), those who have higher degree (75.00) and those who have

bachelor degrees (74.50). According to (p-value=0.631). There is no relationship

between the awareness level regarding radiation protection issues and the academic

qualification of radio-diagnostic workers. So, the null hypothesis that there is no

statistically significant relationship between the radio-diagnostic workers awareness

level regarding radiation protection issues and their academic qualification is

accepted and the researcher hypothesis is rejected. There is an agreement with Abu

Draz (2009) study, which revealed that there is no statistically significant difference

in knowledge level due to the educational level of radio-technologists in

governmental Gaza governorates hospitals.

Regarding the practices items. According to one-way variance (ANOVA) analysis,

(p-value=0.008). Clearly that there is a statistically significant difference in the radio-

diagnostic workers practices according to their academic qualification. So, the

alternative hypothesis there is a statistically significant relationship between the

radio-diagnostic workers practices regarding radiation protection issues and their

academic qualification is accepted. This result may be attributed to the quality of

education materials and curriculum given to the three different groups. This result is

also commensurate with the level of radiation protection awareness of each group as

mentioned above.

Regarding the evaluation of personal radiation exposure monitoring process items.

The mean of radio-diagnostic workers who have diploma (47.92) is higher than those

93

who have bachelor degrees (30.09) ) and those who have higher degree (20.24).

According to (p-value=0.013). There is statistically significant difference. So, the

alternative hypothesis there is relationship between the evaluation regarding personal

radiation exposure monitoring process among radio-diagnostic workers and their

academic qualifications is accepted and the researcher hypothesis is rejected.

Table (4.4): The dependent variables according to participants academic qualification

Items Education No. Mean Std. F Sig.

Availability of

devices

Diploma 16 31.25 19.28 0.435

0.648

B.Sc. 144 36.11 20.11

Higher degree 14 35.71 16.51

Awareness

Diploma 16 78.13 10.44 0.462

0.631

B.Sc. 144 74.50 14.68

Higher degree 14 75.00 14.25

Practices

Diploma 16 70.42 19.62 4.967

0.008

B.Sc. 144 52.04 22.32

Higher degree 14 55.24 23.45

Radiation

monitoring

Diploma 16 47.92 27.13 4.433

0.013

B.Sc. 144 30.09 26.76

Higher degree 14 20.24 25.47

v. Practical experience effect

From table (4.5), The availability of personal radiation protection devices differs

according to the participants practical experience. The radio-diagnostic workers who

have between 15 and 19 years of practical experience have a highest mean value

(39.47) , while the lowest mean value (30.83) for those who have between 10 and 14

years. According to the one-way (ANOVA) test results (p-value=0.287).This

indicates that, there is no relationship between level of evaluation of the availability

of radiation protection devices among radio-diagnostic workers and their practical

experience years. So, the null hypothesis that there is no relationship between level

of evaluation of the availability of radiation protection devices among the radio-

94

diagnostic workers and their years of practical experience is accepted and the

researcher hypothesis is rejected.

Regarding the awareness items. The radio-diagnostic workers who have more than

20 years of practical experience have a highest mean value (81.48), while the lowest

mean value (71.09) for those who have between 5 and 9 practical experience years.

According to the one-way (ANOVA) test results (p-value=0.017). There is a

statistically significant difference in the radio-diagnostic workers awareness level

due to their years of practical experience. So, the alternative hypothesis that there is a

relationship between the radio-diagnostic workers awareness level regarding

radiation protection issues and their practical experience years is accepted and the

researcher hypothesis is rejected.

There is an agreement with Mojiri and Moghimbeigi (2011) study result, which was

conducted in various hospitals in Hamadan city. The result revealed that there is a

statistically significant relationship between the work experiences and awareness of

radiation protection. The low experiences workers have less information about

radiation protection issues.

In addition, this result in line with Su et al. (2000) study result, which observed there

is a significant difference was shown between radiation safety knowledge and years

of practical experience of radiological technologists who work at medical centers in

Taiwan. Radiation safety knowledge of the college level for radiological

technologists is significant better than the junior college level ones.

Regarding the practices items. The radio-diagnostic workers who have more than 20

years of practical experience have a highest mean value (75.11), while the lowest

mean value (47.19) for those who have between 5 and 9 years of practical

experience. According to the one-way (ANOVA) test results (p-value=0.000).There

is a highly statistically significant difference in the radio-diagnostic practices due to

their practical experience years. So, the alternative hypothesis that there is a

statistically significant relationship between the radio-diagnostic workers practices

95

regarding radiation protection issues and their years of practical experience is

accepted. This result may be attributed to long-term of occupational radiation doses

for those who have more than 20 years of work. So, this group of radio-diagnostic

workers has become more concerned about the health impacts from radiation

exposures than those who have less period of experience. Hence, they applied the

protection procedures more carefully to decrease the probability of radiation risks on

their health.

Regarding the evaluation of personal radiation exposure monitoring process items.

The radio-diagnostic workers who have more than 20 years of practical experience

have a highest mean value (48.89), while those who have between 1 and 4 years of

practical experience have the lowest mean value (13.54). This result is surprising and

alarming. It should be strongly recommended to improve the personal radiation

exposure monitoring process for them. According to the one-way (ANOVA) test

results (p-value=0.000).There are a highly statistically significant differences in the

evaluation of personal radiation exposure monitoring process due to their practical

experience years. So, the alternative hypothesis that there is a statistically significant

relationship between the participants evaluation regarding personal radiation

exposure monitoring process and their years of practical experience is accepted.

Table (4.5): The dependent variables according to participants practical experience

Items Experience No. Mean Std. F Sig.

Availability of

devices

From 1-4 years 32 39.06 24.14

1.261

0.287

From 5-9 years 64 35.31 19.92

From 10-14 years 48 30.83 15.96

From 15-19 years 19 39.47 17.79

More than 20 years 15 32.00 16.56

Awareness

From 1-4 years 32 78.99 12.91

3.088

0.017

From 5-9 years 64 71.09 14.21

From 10-14 years 48 73.61 14.24

From 15-19 years 19 78.07 13.67

More than 20 years 15 81.48 13.55

Practices From 1-4 years 32 53.13 18.97 7.493 0.000

96

From 5-9 years 64 47.19 22.04

From 10-14 years 48 49.72 22.04

From 15-19 years 19 67.02 22.50

More than 20 years 15 75.11 19.76

Radiation

monitoring

From 1-4 years 32 13.54 20.93

5.414

0.000

From 5-9 years 64 32.29 25.70

From 10-14 years 48 30.21 25.65

From 15-19 years 19 33.33 31.43

More than 20 years 15 48.89 29.86

vi. Hospitals effect

From table (4.6), shows clear differences between the radio-diagnostic workers

evaluation of the availability of personal radiation protection devices according to

their hospitals. Abdel Aziz Rantessi Martyr Pediatric hospital obtain the highest

mean value (63.33), while Beit Hanoun hospital obtain the lowest mean value

(15.00). According to the one-way (ANOVA) test results (p-value=0.000), there are

highly statistically significant differences in the availability due to their hospitals. So,

the alternative hypothesis that there is a statistically significant relationship between

the evaluation of the availability of personal radiation protection devices and their

hospitals is accepted.

Regarding the awareness items. Al Naser Pediatric hospital obtain the highest mean

value (85.65), while Abdel Aziz Rantessi Martyr Pediatric hospital obtain the lowest

mean value (69.14). According to the one-way (ANOVA) test results (p-

value=0.028), there are a statistically significant differences in the awareness level

due to their hospitals. So, the alternative hypothesis that there is a statistically

significant relationship between the awareness level regarding radiation protection

issues and their hospitals is accepted.

These findings contradict the Su et al. (2000) study results, that revealed there is no

significant difference was shown between radiation safety knowledge and work place

of radiological technologists who work at medical centers in Taiwan. This difference

97

in the outcomes of the studies may be attribute to the existence of a difference in the

nature of work in hospitals between the two countries.

Regarding the awareness items. The mean of radio-diagnostic workers practices in

Al Naser Pediatric hospital (67.22) is higher than other hospitals. According to (p-

value=0.001). There is a highly statistically significant difference. So, the alternative

hypothesis that there is a relationship between the radio-diagnostic workers practices

regarding radiation protection issues is accepted and the researcher hypothesis is

rejected.

Regarding the evaluation of personal radiation exposure monitoring process items.

Abu Yousef Al Najjar Martyr hospital obtain the highest mean value (45.83), while

Nasser Medical Complex obtain the lowest mean value (24.71). According to the

one-way ANOVA test results (p-value=0.134),there is no relationship between level

of evaluation of personal radiation exposure monitoring process and their hospitals.

So, the null hypothesis that there is no relationship between the evaluation of

personal radiation exposure monitoring process among the radio-diagnostic workers

and their hospitals is accepted and the researcher hypothesis is rejected.

Table (4.6): The dependent variables according to participants hospitals

Items Hospital No. Mean Std. F Sig.

Availability of

devices

European Gaza hospital 16 31.25 10.25

8.337

0.000

Nasser Medical Complex 29 43.45 20.58

Abu Yousef Al Najjar hospital 12 22.50 6.22

Al Aqsa Martyrs hospital 20 34.00 11.42

Al Shifa Medical Complex 57 38.77 19.28

Abdel Aziz Rantessi hospital 9 63.33 11.18

Al Naser hospital 12 31.67 23.29

Kamal Adwan hospital 17 22.35 16.78

Beit Hanoun hospital 10 15.00 9.72

Awareness

European Gaza hospital 16 70.83 15.52 2.221

0.028

Nasser Medical Complex 29 71.26 13.03

Abu Yousef Al Najjar hospital 12 70.37 17.14

98

Al Aqsa Martyrs hospital 20 74.17 16.74

Al Shifa Medical Complex 57 78.36 12.93

Abdel Aziz Rantessi hospital 9 69.14 14.46

Al Naser hospital 12 85.65 14.88

Kamal Adwan hospital 17 73.53 8.68

Beit Hanoun hospital 10 71.67 13.21

Practices

European Gaza hospital 16 43.33 26.22

3.484

0.001

Nasser Medical Complex 29 42.76 21.49

Abu Yousef Al Najjar hospital 12 56.11 16.69

Al Aqsa Martyrs hospital 20 42.00 25.05

Al Shifa Medical Complex 57 59.53 21.19

Abdel Aziz Rantessi hospital 9 54.81 22.80

Al Naser hospital 12 67.22 13.77

Kamal Adwan hospital 17 56.08 19.73

Beit Hanoun hospital 10 63.33 25.39

Radiation

monitoring

European Gaza hospital 16 25.0 21.08

1.58

0.134

Nasser Medical Complex 29 24.71 28.74

Abu Yousef Al Najjar hospital 12 45.83 18.97

Al Aqsa Martyrs hospital 20 27.50 26.64

Al Shifa Medical Complex 57 26.90 28.65

Abdel Aziz Rantessi hospital 9 42.59 22.22

Al Naser hospital 12 38.89 32.05

Kamal Adwan hospital 17 27.45 25.65

Beit Hanoun hospital 10 43.33 26.29

vii. Daily work hours in radio-diagnostic rooms effect

The above table shows that the participants who work more than 5 hours have the

highest mean value (40). This means that the participants in this group is the most

recorded about the availability of personal radiation protection devices in their radio-

diagnostic centers. While the participants who work between 1 and 2 hours have the

lowest mean value (32.4). There are no statistically significant differences between

availability and daily work hours (P value=0.733). So, the null hypothesis that there

is no differences between the evaluation of the availability of radiation protection

99

devices in radio-diagnostic centers and their daily work hours is accepted and the

researcher hypothesis is rejected.

Regarding the awareness level items. It is clearly that the radio-diagnostic workers

who work between 2 and 4 hours have lowest mean value (72.3).While the radia-

diagnostic workers who work between 4 and 5 hours have a highest mean value

(80.7).This means that they have higher awareness level than the other groups.

Moreover, there is no statistically significant differences between the daily work

hours and participants awareness level (p-value=0.108). So, the null hypothesis

"there is no relationship between the awareness level of radio-diagnostic workers

about radiation protection issues and their daily work hours is accepted and the

researcher hypothesis is rejected .

Regarding the awareness items. Clearly that there is a statistically significant

difference in the radio-diagnostic workers practices according to their daily work

hours (p-value=0.008). This difference is high among radio-diagnostic workers who

work more than 5 hours (67.1), the lowest is among radio-diagnostic workers who

work between 2 and 4 hours (46.7). So, the alternative hypothesis there is a

statistically significant relationship between the radio-diagnostic workers practices

regarding radiation protection issues and their daily work hours is accepted .

Regarding the evaluation of personal radiation exposure monitoring process items.

The mean among participants who work between 4 and 5 hours is (35.9), slightly

more than other participants groups, where (p-value=0.048).This indicates there is no

statistically significant differences. So, the null hypothesis that there is no

relationship between the evaluation of personal radiation exposure monitoring

process and their daily work hours is accepted and the researcher hypothesis is

rejected.

100

Table (4.7): The dependent variables according to participants daily work hours in

radio-diagnostic rooms

Items Daily work hours No. Mean Std. F Sig.

Availability of

devices

From 1-2 hours 21 32.4 21.2

0.504

0.733

From 2-3 hours 49 36.9 22.7

From 2-4 hours 60 36.0 18.5

From 4-5 hours 32 33.1 17.5

More than 5 hours 14 40.0 15.2

Awareness

From 1-2 hours 21 74.6 13.6

1.928

0.108

From 2-3 hours 49 73.7 15.9

From 2-4 hours 60 72.3 14.8

From 4-5 hours 32 80.7 11.3

More than 5 hours 14 75.0 11.9

Practices

From 1-2 hours 21 56.2 20.5

4.192

0.003

From 2-3 hours 49 52.9 21.9

From 2-4 hours 60 46.7 21.7

From 4-5 hours 32 62.3 22.8

More than 5 hours 14 67.1 21.8

Radiation

monitoring

From 1-2 hours 21 31.0 29.5

1.002

0.408

From 2-3 hours 49 32.7 26.1

From 2-4 hours 60 25.6 27.7

From 4-5 hours 32 35.9 28.4

More than 5 hours 14 25.0 25.9

101

Chapter 5

Conclusion and Recommendations

5.1 Conclusion

In the present work, radiation level measurements for radio-diagnostic centers was

carried out in nine selected governmental hospitals at Gaza governorates. These

include: 19 basic X-ray, 8 fluoroscopy, 1 mammography and 3 CT scan machines.

The equivalent radiation dose rate were measured experimentally at different

locations in the radio-diagnostic rooms at the selected hospitals. These locations are:

directional dose rate , at one meter distance from the X-ray tube, at control panel, at

corridor outside the X-ray room, at dark room , behind the chest stand wall and at

patient waiting rooms. In addition, data sheets are used to obtain information about

the radio-diagnostic machines and rooms specifications.

In general, the results indicate that the fluoroscopy and CT scan rooms were not

efficiently lead lined and the radiation protection is not well organized. Since, the

measured values at corridors during closing the doors and at patient waiting rooms in

fluoroscopy and CT scan rooms suggests very high exceedance compared to the

reference limit for public exposure. Thus, it is noticed that a health risk of radiation

exposure for all persons who visiting these rooms. Also, the measured equivalent

radiation dose rate at control panels give high doses values, but remain in the

permissible limit for radiology workers. However, there is an impending risk of

chronic occupational exposure to the employees. In addition, we have noticed that

the CT scan room at Al Shifa Medical Complex ranked the first in term of the

highest radiation dose rate, and gives (14.2 mSv/yr). Then followed by fluoroscopy

room at Nasser Medical Complex, and gives (10.9 mSv/yr).

Moreover, the equivalent radiation doses rate that measured at a different locations in

basic X-ray and mammography rooms are found within the permissible limits for

radio-diagnostic workers and public. This indicates that these rooms are built safe

and well organized according to safety criteria. Also, the results suggest that the

102

importance of using radiation protection techniques such as the distance from the X-

ray source and X-ray beam collimators. Whereas, the recommended distance

between the X-ray machines and control panels have not been achieved in some

rooms.

A second part of this research is a questionnaire, which designed for matching the

study needs and 182 radio-diagnostic workers participated in the work. We

conducted the independent samples t-test, frequency and one-way analysis of

variance (ANOVA). These tests detect the difference between the availability of

personal radiation protection devices, awareness and practices level regarding

radiation protection issues and evaluation of personal radiation exposure monitoring

process as a dependent variables. However, the socio-demographic and work related

factors among radio-diagnostic workers are independent variables.

According to the results displayed in chapter four, the participants reported that

35.2% of personal radiation protection devices are available in the radio-diagnostic

centers at governmental Gaza governorates hospitals.

The results indicate unsatisfactory practices toward radiation protection issues, where

approximately half of participants have negative practices. In general, the results

revealed that there is an obvious poor of personal radiation exposure monitoring

process. There is also a statistically significant difference in the participants

awareness level due to their years of practical experience and occupation.

Overall, the results represented in this work reflect that majority of

participants believe there is no radiation safety officer to provide the service.

Therefore, there is a desperate need for rules, regulations and radiation

protection act in the field of radiation in medical field.

103

5.2 Recommendations

The outcome of the results in this research, the following recommendations

should be taken into account to improve the radiation protection measures

and reduce the radiation doses for the radio-diagnostic workers and public:

The basic radiation protection principles of Justification and Optimization

should be taken into consideration, in this period of rapid increase of

radio-diagnostic procedures following the availability of new machines.

The stakeholders should provide the radiation protection devices in all

radio-diagnostic centers in Gaza governorates hospitals.

Re-shielding the locations where the annual equivalent radiation dose

exceed of the permissible limits should be taken into consideration.

There is a dare need for rules, regulation and radiation protection act in

the field of radiation in medical field.

Conducting continuous training programs that may help in improving the

awareness of workers about radiation protection issues.

The hospitals should provide a radiation protection advisers for a routine

daily monitor the radiation protection measures, practices and inspection

of radiation dose rate levels in Gaza governmental hospitals.

Establishing radiation protection department in the country in order to

ensure the regular monitoring of radio-diagnostic workers doses.

Designing the radio-diagnostic centers according to the internationally

safety criteria.

104

5.3 Suggestions for future studies

The present study suggests to conduct further researches in West Bank

governorates hospitals, UNRWA and private radiology centers to measure

radiation leakage and evaluating the radiation protection measures.

105

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116

Annexes

Annex (1): Sample size calculator

Sample Size Calculator Terms: Confidence Interval & Confidence Level

The confidence interval (also called margin of error) is the plus-or-minus figure

usually reported in newspaper or television opinion poll results. For example, if you

use a confidence interval of 4 and 47% percent of your sample picks an answer you

can be "sure" that if you had asked the question of the entire relevant population

between 43% (47-4) and 51% (47+4) would have picked that answer.

The confidence level tells you how sure you can be. It is expressed as a percentage

and represents how often the true percentage of the population who would pick an

answer lies within the confidence interval. The 95% confidence level means you can

be 95% certain; the 99% confidence level means you can be 99% certain. Most

researchers use the 95% confidence level.

When you put the confidence level and the confidence interval together, you can say

that you are 95% sure that the true percentage of the population is between 43% and

51%. The wider the confidence interval you are willing to accept, the more certain

you can be that the whole population answers would be within that range.

For example, if you asked a sample of 1000 people in a city which brand of cola they

preferred, and 60% said Brand A, you can be very certain that between 40 and 80%

of all the people in the city actually do prefer that brand, but you cannot be so sure

that between 59 and 61% of the people in the city prefer the brand.

http://www.surveysystem.com/sscalc.htm

117

Annex (2): A permission from the Ministry of Health to perform the study in

the governmental hospitals

118

Annex (3): A consent from all participants to ensure their voluntary

participation

بسم هللا الرحمن الرحيم

السيد/ة المشارك:

تحية طيبة وبعد...

أدرس بكلية العلوم بالجامعةة اسالةيمية بةة ة و طمبطلةب للح ةو سامر سليم عبد أبو زرأنا الطالب

على درجة الماجسبير أقوم بإعداد بحث بعنوان:

تسرب اإلشعاع المؤين وإجراءات الوقاية من اإلشعاع في مراكز األشعة التشخيصية في مستشفيات "

"محافظات غزة الحكومية, فلسطين

"Ionizing radiation Leakage and Radiation Protection Measures in

Radio-Diagnostic Centers in Governmental Hospitals of Gaza

Governorates, Palestine"

إلةى قيةاس مسةبو اإل اسعةعام المةا ت والبعةرء إجةراقاإل الوقا ةة مةت اسعةعام و تهدف هذه الدراسذة

الخروج ببوصياإل تساعد صانعي القرار في تحسيت خططهم المسبقبلية المبعلقة بالوقا ة مت اسععام.

أرجو المشارطة في هذه الدراالة باسجابة على بعض األالئلة خةي المقابلةة البةي لةت تسةبةرر أط ةر مةت

دقيقة تقر با المشارطة طوعية و حق لك االمبنام عت إجابة أي الاا . 15

أرغب أن أنوه أن المعلوماإل البي الوء بم جمعها الةبكون م ةدر ةقةة والةر ة تامةة و الةوء تسةبخدم

فقط بةرض البحث العلمي وبدون ذطر أالماق لذلك أرجوا منك أن تكون اسجاباإل دقيقة.

على أي االبفسار مت طرفك.أنا مسبعد لإلجابة

هل توافق على المشارطة في هذه الدراالة؟

ال نعم

شكرا على حسن تعاونك

الباحث: سامر سليم أبو زر

0599309702جوال:

Samer_516@hotmail.comEmail:

119

Annex (4): Arabic version of questionnaire

-----رقم البسلسل:

أوال: األسئلة المتعلقة بالبيانات الديموغرافية و أخرى تتعلق بالعمل :

النة 50أط ر مت 49-40 39-30 29-20 العمر:

أن ى ذطر :الجنس

فني ت و ر طبي طبيب أخ ائي أععة المهنة:

دراالاإل عليابكالور وس دبلوم مبوالط المؤهل العلمي:

النة 20أط ر مت 19-15 14-10 9-5 4-1سنوات الخبرة العملية:

مسبشفى غ ة األوروبي مجمع ناصر الطبي مجمع الشفاق الطبي المستشفى الهي تعمل به:

مسبشفى مسبشفى عهداق األق ى مسبشفى الشهيد طما عدوان مسبشفى الشهيد أبو والف النجار

مسبشفى بيت حانون مسبشفى الن ر لألطفا الرنبيسي البخ ي لألطفا الشهيد عبد الع

-األجهزة التي عادة ما تعمل عليها:

-ray

عدد ساعات العمل اليومي داخل غرف األشعة التشخيصية:

الاعاإل 6أط ر مت 5-6 4-5 4 -3 2-3 1-2

ثانيا: األسئلة المتعلقة بتوفر أدوات الوقاية من اإلشعاع في القسم الهي تعمل به:

م أداة الوقاية من اإلشعاع

ال نعم

ال

أعرف

1 Lead Apron

2 Gonad shields

3 Lead curtains

4 Lead shields/barrier

5 Thyroid shields

6 Lead glass

7 Lead gloves

8 Breast shields

9 Radiation warning signs

10 Caution lights

120

ثالثا: األسئلة المتعلقة بقياس مستوى معرفة العاملين حول طرق الوقاية من اإلشعاع:

ال نعم السؤال مال

أعرف

1 الجرعة اسععاعية السنو ة المسموح بها للعامليت في مجا األععة هي

20 mSv/yr

1mSv/yrالجرعة اسععاعية المسموح بها للجمهور هي 2

3 حدود الجرعة اسععاعية للمرأة الحامل العاملة في مجا االععة هي

2mSv خي فبرة الحمل

4 والجمهور مت األععة الةير ضرور ة أةناق الفحوصاإل حما ة المر ض

اسععاعية قع على عاتق العامليت في مجا األععة

5

االبخدام طيلو فولت عالي أةناق إعطاق الجرعة اسععاعية ادي إلى ز ادة

في نفوذ ة الح مة اسععاعية البي تادي إلى تخفيض الجرعة الممب ة في

جسم المر ض

6 قل وقت البعرض لألععة أةناق الفحوصاإل اسععاعية فإن جرعة إذا

المر ض الوء تقل

7 إذا زادإل المسافة مت م در األععة إلى الضعف فإن جرعة المسبلمة الوء

تقل إلى الن ف

مبر 2المسافة الموصى ترطها بيت جهاز األععة والعامليت هي 8

9 أةناق الب و ر اسععاعي له فائدة طبيرة " "Collimationاالبخدام المحدد

في تقليل جرعة األععة للمر ض

واقي الرصاص جب فح ه بشكل دوري لبجنب حدوث أي تشققاإل فيه 10

11 primary x- ray roomالمك الرصاص في جدار غرفة األععة األولي

ALARAملي مبر بناق على مبدأ 2 جب أن كون

12 أبواب مت جهة واحدة أو مت جهبيت بطبقة مت الرصاص المكها جب تبطيت

ملي مبر1

13

3.6مبر مربع وارتفام السقف 36ال تقل عت المساحة الم الية لةرء أععة

مبر فور 2.2مبر وبالنسبة للنوافذ الخارجية جب أن كون ارتفاعها

مسبوى أرضية الةرفة

14 " جب أن Primary radiation barrierالحاج اسععاعي األولي"

مبر 2 كون على ارتفام

جب أن بم عمل صيانة و معا رة دور ة ألجه ة األععة لمنع البسرب 15

16 جب أن بم عمل فحص دوري لجدران و أبواب غرء األععة ووالائل

الوقا ة للبأطد مت طفاقتها

17 أجه ة األععة في عيت االعببار عند عرائها جب أخذ خبرة العامليت على

واعراطهم في مواصفاإل الشراق

الكيلو فولت المناالب الناتج عت خطأ الفني أو وجود عطل الخطأ في اخبيار 18

في جهاز األععة قد ادي إلى جرعة إععاعية زائدة للمر ض

121

حذول الوقايذذة مذذن ةالمتعلقذة بوفذذم ممارسذذات العذاملين فذذي مجذال األشذذعة التشخيصذذي ةرابعذا: األسذذئل

:اإلشعاع

خامسا: مجموعة أسئلة لتقييم عملية مراقبة التعرض الشخصي لإلشعاع المؤين:

. هل يوجد مشرف مختص في الوقاية من اإلشعاع في المستشفى الهي تعمل به؟1

ال نعم

. هل تملك جهاز قياس لمراقبة التعرض لإلشعاع ؟2

ال نعم

(7)اذا طانت االجابة ب )ال( فقط اجب عت الساا رقم

", هل تقوم باستخدامه أُثناء عملك في غرف األشعة؟ة " نعمإذا كانت اإلجاب .3

ال أحيانا نعم

أحيانا ال نعم السؤال م

هل عارطت في دوراإل حو الوقا ة مت اسععام؟ 1

هل تقوم ببوضيح تعليماإل الفحص اسععاعي للمر ض قبل ت و ره؟ 2

3 لبقليل collimationأةناق قيامك بالب و ر اسععاعي هل تقوم باالبخدام

الطح المر ض المعرض لإلععام؟

هل تقف خلف الحاج المرصص عند ت و رك للمر ض؟ 4

5 هل تقوم باالبخدام Gonadesفي حالة عدم احبواق طلب الطبيب ت و ر

Gonadal shield لحما ة هذه األعضاق؟

6 هل تقوم بإفراغ غرفة األععة مت مرافقي المر ض قبل اعطاق الجرعة

االععاعية؟

هل تبأطد مت إغير باب غرفة األععة جيدا أةناق الب و ر؟ 7

8 أةناق عملك باالبخدام جهاز أععة مبنقل هل تقوم بالحفاظ على المسافة

المطلوبة بينك وبيت م در األععة؟

9 باالبخدام جهاز أععة مبنقل هل تقوم بأخذ االحبياطاإل اليزمة أةناق عملك

لحما ة مرافقي المر ض والمرضى اآلخر ت داخل الةرفة؟

10 هل تقوم بارتداق و االبخدام أدواإل الوقا ة مت اسععام لحما ة نفسك مت

االععام؟

الب و ر؟هل تقوم بحما ة مرافق المر ض الذي قوم بب بيت الطفل أةناق 11

12 هل البق و أن طلبت فحص للموقع الذي تعمل به عند االعبباه بوجود تسر ب

لألععة؟

13 هل تهبم بإجراق ال يانة للجهاز في حا وجود خلل بعلق بالوقا ة مت

اسععام؟

14 هل تسبجيب اسدارة لمطالب العامليت سجراق فحوصاإل للبأطد مت اليمة

غرء األععة؟

15 هل تعبقد أن قسم األععة الذي تعمل به مطابق لمعا ير السيمة والوقا ة مت

اسععام؟

122

. هل تلقيت إرشادات من قبل مسئول الوقاية من اإلشعاع حول كيفية استخدام وحفظ جهاز قياس اإلشعاع؟ 4

ال نعم

. هل يتم أخه قياسات أجهزة مراقبة التعرض الشخصي لإلشعاع بعين االعتبار من قبل الجهات المختصة؟ 5

ال نعم

؟اإلشعاعية أخر عند تسليمك للجهاز القديم لقياس الجرعة جهاز قياس تسليمك. هل يتم 6

ال نعم

", إلى ما تعزو هها اإلهمال ؟إذا كانت اإلجابة "ال .7

غير مهبمة اسدارة عت الوقا ة مت اسععام مسئولةعدم وجود جهة

العامليت في مجا األععة ال طلبون هذه األجه ة لبوفير هذه األجه ة ةالمي انيعدم توفر

123

Annex (5): English version of questionnaire

Serial number:………..

Part one: The following questions about socio-demographic and related work

information:

Age: - - -

Sex:

Occupation: Medical radiographer

Academic qualification: ploma Bachelor higher degrees

Years of practical experience - - - -

15 years

Name of hospital

a Martyrs hospital

Types of your radio-diagnostic machines: Basic X-

-ray

Daily work hours in radio-diagnostic rooms:

- - - -

124

Part two: The availability of radiation protection devices in radio-diagnostic

center:

No idea

NO

Yes

Radiation protection devices No.

Lead Apron 1

Gonad shields 2

Lead curtains 3

Lead shields/barrier 4

Thyroid shields 5

Lead glass 6

Lead gloves 7

Breast shields 8

Radiation warning signs 9

Caution lights 10

Part three: Measure of the radio-diagnostic workers awareness level regarding

radiation protection issues:

No

idea No Yes Question No.

The annual average dose over five years should not

exceed 20 mSv for occupational exposure 1

Public should not be exposed to more than an average of

1 mSv per year 2

Radiation dose limits for pregnant woman who work in

radiation field is 2 mSv during pregnancy period 3

Protection of patient and public from unnecessary

radiation during radiological examinations are the

responsibility of radiology staff

4

Utilizing high kV during radiological examinations leads

to an increase the permeability of the radiation beam and

reduce the absorbed dose in the patient body

5

Short radiation exposure time during radiological

examinations, leads to less patient radiation dose 6

Increasing the distance from the radiation source to

double, leads to reduce the received dose to half 7

The recommended distance between X-ray source and

radiology workers is two meter 8

Using the collimators during medical radiography has a

great benefits and reduce the patient dose 9

Protective lead must periodically examined to avoid any

cracks in the lead 10

Thickness of the lead lined the X-ray room wall, which is

exposed to primary X-rays should be 2 mm based on the

principle of ALARA

11

The doors of X-ray room must be lined from one or two

sides with a lead layer thickness of 1 mm 12

125

The ideal X-ray room space should not be less than 36 m2,

the ceiling height is 3.6 m and the exterior windows

height is 2.2 m above the X-ray room floor

13

The primary radiation barrier must be height 2m from the

X-ray room floor 14

The X-ray machines maintenance and calibration must be

periodically carried out to prevent radiation leakage 15

The periodic maintenance for X-ray rooms walls, doors

and radiation protection tools should be performed to

ensure their efficiency

16

The experience of workers must be taken into

consideration when X-ray machines were imported and

involved them in the specification of the purchase

17

The error in the selection of appropriate kilo volts due to

technical error or malfunction of X-ray machine leads to

excessive radiation dose to the patient

18

Part four: Description of radio-diagnostic workers practices about radiation

protection issues:

Som-

etimes NO Yes Question No.

Have you ever received any training in radiation

protection? 1

Do you explain the radiological examination instructions

to the patient before the exam? 2

Do you use X-ray tube collimation during the

radiography in order to reduce patient body dose?

3

Do you stand behind the lead barrier during giving the

radiation dose? 4

If the doctor doesn't ask for imaging the Gonads, do you

use the gonadal shield to protect these organs? 5

Do you ask the patient escorts to evacuate the X-ray

room before giving the X-ray dose?

6

Do you make sure that the X-ray door is closed during

the radiological examination?

7

Do you keep the requierd distance between the X-ray

source and yourself during using a mobile X-ray

machine?

8

Do you take the necessary precautions to protect patient

escorts and other patients in the room during using a

mobile X-ray machine?

9

Do you wear the radiation protection devices to protect

yourself from ionizing radiation? 10

Do you protect the patient escort, who hold the child

during the radiological examination? 11

Have you been asked to check your radiology center

when there is suspicion of radiation leakage? 12

Are you interested in maintenance conducting for X-ray

machines when the defect related with radiation 13

126

protection?

Does the administration respond to workers' demands

regarding to check the X-ray rooms to make sure about

of their safety?

14

Do you think that your radiology center conformity with

the safety and radiation protection standards? 15

Part five: Evaluating the personal radiation exposure monitoring process:

1. Does the hospital have Radiation Protection Adviser (RPA) or departmental

Radiation Protection Supervisor (RPS)?

2. Does the hospital provide you with any personal radiation monitoring

device?

(If no, only answer question no. 7)

3. If yes, do you use it during your work in the radio-diagnostic rooms?

4. Did you receive a guidance about the proper handling with the personal radiation monitoring device?

5. Are the measurements results taken into consideration by the safety officers?

6. Do you receive another personal radiation monitoring device when the device

collect to measure of radiation dose?

7. If no, what is the reason for non-provision of the device?

carelessly of hospital

management

not request for it

127

Annex (6): Certificate of radiation survey meter (OD-01) calibration

128

Annex (7): The equivalent radiation dose rate measurements

Eq

uiv

alen

t

rad

iati

on

do

se H

W

mS

v/y

ear

Eq

uiv

alen

t

rad

iati

on

do

se H

W m

Sv

/wee

k

Wo

rklo

ad

in t

he

roo

m

mA

.min

/w

-eek

Rad

iati

on

do

se r

ate

mS

v/m

in R

adia

tio

n

do

se r

ate

mS

v/h

r L

oca

tio

ns

of

rad

iati

on

do

se r

ate

mea

sure

m

ents

Nam

e o

f

mac

hin

e

and

roo

m

nu

mb

er N

ame

of

ho

spit

al

0.04 Electrical zero

balancing value

Flu

oro

sco

py

roo

m n

o.1

Al

Sh

ifa

Med

ical

Co

mp

lex

2296.9 47.85144

840

0.28483 17.09 Directional

45.7 0.952056 0.00567 0.34

At 1 meter distance from the tube by

closing the collimators

10.7 0.223944 0.00133 0.08 At control panel

8.1 0.168 0.001 0.06 At corridor (door

closed)

9.4 0. 196056 0.00117 0.07 At Patient waiting

room

0.03 Electrical zero

balancing value

Flu

oro

sco

py

roo

m n

o. 2

2109.7 43.953

735

0.299 17.94 Directional

41.2 0.857451 0.00583 0.35

At 1 meter distance from the tube by

closing the collimators

8.2 0.171402 0.00117 0.07 At control panel

7.1 0.147 0.001 0.06 At corridor (door

closed)

9.4 0.195951 0.00133 0.08 At Patient waiting

room

0.03 Electrical zero

balancing value

Bas

ic X

-ray

roo

m n

o. 6

107.5 2.24

1750

0.32 19.20 Directional

2.5 0.0525 0.0075 0.45

At 1 meter distance from the tube by

closing the collimators

1.8 0.03731 0.00533 0.32 At control panel

1.7 0.036169 0.00517

0.31

At corridor (door closed)

1.2 0.025669 0.00367 0.22 At Patient waiting

room

1.3 0.02681 0.00383 0.23 Behind the chest

stand wall

0.04 Electrical zero

balancing value

Bas

ic X

-ray

roo

m n

o. 7

79.1 1.6485

1750

0.2355 14.13 Directional

1.7 0.036169 0.00517 0.31

At 1 meter distance from the tube by

closing the collimators

1.95 0.04081 0.00583 0.35 At control panel

1.1 0.02331 0.00333 0.20 At corridor (door

closed)

1.1 0.02331 0.00333 0.20 At Patient waiting

room

0.9 0.018669 0.00267 0.16 Behind the chest

stand wall

129

0.02 Electrical zero

balancing value

Bas

ic X

-ray

emer

gen

cy r

oo

m

98.8 2.058

2100

0.245 14.7 Directional

2.02 0.042 0.005 0.30

At 1 meter distance from the tube by

closing the collimators

3.8 0.0798 0.0095 0.57 At control panel

1.8 0.0378 0.0045 0.27 At corridor (closed

door)

2.02 0.042 0.005 0.30 At dark room

1.9 0.040572 0.00483 0.29 Behind the chest

stand wall

0.04 Electrical zero

balancing value

CT

sca

n

CT

sca

n r

oo

m

1338.1 27.8775

33075

0.236 14.16 Directional

752.97 15.687 0.1328 7.97

At 1 meter distance from the C.T scan

gantry

14.2 0.2953125 0.0025 0.15 At control panel

13.2 0.2755856 0.00233 0.14 At door of the control

panel (door closed)

12.3 0.2559769 0.00217 0.13 At corridor (closed

door)

13.2 0.2755856 0.00233 0.14 At patients waiting

room

0.04 Electrical zero

balancing value

Bas

ic X

-ray

ou

t cl

inic

roo

m n

o. 1

105.3 2.19408

2100

0.2612 15.67 Directional

4.2 0.0882 0.0105 0.63

At 1 meter distance from the tube by

closing the collimators

1.4 0.0294 0.0035 0.21 At control panel

1.9 0.039228 0.00467 0.28 At corridor (door

closed)

1.2 0.0252 0.003 0.18 At dark room

1.6 0.0336 0.004 0.24 Behind the chest

stand wall

0.04 Electrical zero

balancing value

Bas

ic X

-ray

ou

t cl

inic

roo

m n

o. 2

103.7 2.16048

2100

0.2572 15.43 Directional

2.4 0.0489997 0.00583

3 0.35

At 1 meter distance from the tube by

closing the collimators

2.2 0.0462 0.0055 0.33 At control panel

2.02 0.042 0.005 0.30 At corridor (door

closed)

1.8 0.0378 0.0045 0.27 At dark room

2.1 0.043428 0.00517 0.31 Behind the chest

stand wall

0.02 Electrical zero

balancing value

Po

rt-a

ble

X-r

ay

roo

m 1

Nas

ser

Med

ical

Co

mp

lex

30.7 0.6400125

262.5

0.17067 10.24 Directional

6.7 0.140602 0.0857 5.14

At 1 meter distance from the tube by

closing the

130

collimators

0.4 0.0087375 0.00233 0.14 At control panel

0.09 0.001875 0.0005 0.03 At corridor (door

closed)

0.06 0.0012375 0.00033 0.02 At dark room

0.09 0.001875 0.0005 0.03 Behind the chest

stand wall

0.02 Electrical zero

balancing value

Bas

ic X

-ray

roo

m n

o. 2

107.3 2.2344

2450

0.228 13.68 Directional

1.1 0.022834 0.00233 0.14

At 1 meter distance from the tube by

closing the collimators

1.4 0.0294 0.003 0.18 At control panel

0.9

0.0196 0.002 0.12

At corridor (door closed)

0.16 0.003234 0.00033 0.02 At dark room

0.2 0.0049 0.0005 0.03 Behind the chest

stand wall

0.03 Electrical zero

balancing value

Mam

mo

gra

phy

roo

m n

o. 3

29.1 0.606309

87.5

0.27717 16.63 Directional

0.5 0.0105656 0.00483 0.29

At 1 meter distance from the tube by

closing the collimators

0.2 0.0040031 0.00183 0.11 At control panel

0.05 0.0010938 0.0005

0.03

At corridor (door closed)

0.03 0.0007219 0.00033 0.02 At dark room

0.02 Electrical zero

balancing value

Flu

oro

sco

py

roo

m n

o. 4

899.1 18.732

420

0.223 13.38 Directional

16.1 0.336 0.004 0.24

At 1 meter distance from the tube by

closing the collimators

10.9 0.2268 0.0027 0.12 At control panel

5.4 0.11172 0.00133 0.08 At corridor (door

closed)

6.05 0.126 0.0015 0.09 At Patient waiting

room

0.02 Electrical zero

balancing value

CT

sca

n ro

om

no

. 5

606.1 12.62625

14700

0.2405 14.43 Directional

262.5 5.468925 0.10417

6.25

At 1 meter distance from the C.T scan

gantry

5.9 0.1224825 0.00233 0.14 At control panel

6.3 0.13125 0.0025 0.15 At door of the control

panel (No door)

1.7 0.0350175 0.00067 0.04 At corridor (door

closed)

0.8 0.0174825 0.00033 0.02 At patients waiting

room

131

0.03

Electrical zero balancing value

Bas

ic X

-ray

ou

t cl

inic

ro

om

128.7 2.68177

2275

0.2947 17.68 Directional

1.2 0.025753 0.00283 0.17

At 1 meter distance from the tube by

closing the collimators

0.4 0.007553 0.00083 0.05 At control panel

0.4 0.007553 0.00083 0.05 At corridor (door

closed)

0.2 0.00455 0.0005 0.03 At dark room

0.2 0.00455 0.0005 0.03 Behind the chest

stand wall

0.02 Electrical zero

balancing value

Bas

ic X

-ray

roo

m n

o. 2

Eu

rop

ean

Gaz

a h

osp

ital

46.6 0.9702

1050

0.231 13.86 Directional

0.3 0.0063 0.0015 0.09

At 1 meter distance

from the tube by

closing the

collimators

0.1 0.0021 0.0005 0.03 At control panel

0.1 0.0021 0.0005 0.03 At corridor (door

closed)

0.2 0.004914 0.00117 0.07 At dark room

0.1 0.0021 0.0005 0.03 Behind the chest

stand wall

.02 Electrical zero

balancing value

Bas

ic X

-ray

roo

m n

o. 4

150.4 3.134334

2450

0.31983 19.19 Directional

2.7 0.057134 0.00583 0.35

At 1 meter distance

from the tube by

closing the

collimators

2.2 0.045766 0.00467 0.28 At control panel

0.16 0.003234 0.00033 0.02 At corridor (door

closed)

0.2 0.0049 0.0005 0.03 Dark room

0.2 0.0049 0.0005 0.03 Behind the chest

stand wall

0.01 Electrical zero

balancing value

ES

WE

L

Flu

oro

sco

py

ro

om

1290.2 26.88

525

0.256 15.36 Directional

148.7 3.0975 0.0295 1.77

At 1 meter distance

from the tube by

closing the

collimators

3.4 0.07035 0.00067 0.04 At control panel

2.5 0.0525 0.0005 0.03 At corridor (door

closed)

2.5 0.0525 0.0005 0.03 At patient waiting

room

3.4 0.07035 0.00067 0.04 At door of the control

panel(door closed)

0.02 Electrical zero

balancing value

Bas

ic X

-

ray

roo

m n

o. 2

Ab

u Y

ou

sef

Al

Naj

jar

Mar

tyr

ho

spit

al

83.6 1.74181

1750

0.24883 14.93 Directional

0.6 0.011669 0.00167 0.1 At 1 meter distance

from the tube by

132

closing the

collimators

0.3 0.005831 0.00083 0.05 At control panel

0.6 0.011669 0.00167 0.1 At corridor

(door closed)

0.1 0.00231 0.00033 0.02 At dark room

0.2 0.0035 0.0005 0.03 Behind the chest

stand wall

0.02 Electrical zero

balancing value

Flu

oro

sco

py

roo

m n

o. 2

1338.1 27.8775

525

0.2655 15.93 Directional

17.6 0.3675 0.0035 0.21

At 1 meter distance

from the tube by

closing the

collimators

5.04 0.105 0.001 0.06 At control panel

6.7 0.139965 0.00133 0.08 At corridor (door

closed)

2.5 0.0525 0.0005 0.03 At dark room

.04 Electrical zero

balancing value

Bas

ic X

-ray

emer

gen

cy r

oo

m

52.1 1.08486

1050

0.2583 15.15 Directional

0.7 0.013986 0.00333 0.2

At 1 meter distance

from the tube by

closing the

collimators

2.02 0.042 0.01 0.6 At control panel

0.3 0.007056 0.00168 0.1 At corridor (door

closed)

0.2 0.003486 0.00083 0.05 At dark room

0.2 0.0042 0.001 0.06 Behind the chest

stand wall

0.04

Electrical zero balancing value

Bas

ic X

-ray

emer

gen

cy r

oo

m

Kam

al A

dw

an M

arty

r ho

spit

al

154.9 3.227742

3150

0.25617 15.37 Directional

1.5 0.0315 0.0025 0.15

At 1 meter distance from the tube by

closing the collimators

4.03 0.084042 0.00667 0.4 At control panel

0.8 0.016758 0.00133 0.08 At corridor (door

closed)

0.7 0.0147042 0.00117 0.07 At dark room

0.03 Electrical zero

balancing value

Bas

ic X

-ray

roo

m n

o. 2

162.9 3.393558

3150

0.26933 16.16 Directional

4.4 0.092358 0.00733 0.44

At 1 meter distance from the tube by

closing the collimators

2.3 0.048258 0.00383 0.23 At control panel

2.4 0.0504 0.004 0.24 At corridor (door

closed)

0.9 0.0189 0.0015 0.09 At dark room

0.04 Electrical zero

balancing value

Flu

oro

sc-

op

y

roo

m n

o. 3

1572.5 32.76

525

0.312 18.72 Directional

12.6 0.2625 0.0025 0.15 At 1 meter distance

from the tube by

133

closing the collimators

7.6 0.1575 0.0015 0.09 At control panel

6.7 0.13965 0.00133 0.08 At corridor (door

closed)

8.4 0.17535 0.00167 0.07 At dark room

0.04 Electrical zero

balancing value B

asic

X-r

ay

roo

m n

o. 3

55.6 1.157814

1050

0.27567 16.54 Directional

0.8 0.0168 0.004 0.24

At 1 meter distance from the tube by

closing the collimators

0.9 0.018186 0.00433 0.26 At control panel

0.5 0.0105 0.0025 0.15 At corridor (door

closed)

0.4 0.0091014 0.00217 0.13 At dark room

0.5 0.0105 0.0025 0.15 Behind the chest

stand wall

0.01 Electrical zero

balancing value

Bas

ic X

-ray

roo

m n

o. 1

Al

Aq

sa M

arty

rs h

osp

ital

106.5 2.219742

3150

0.17617 10.57 Directional

3.2 0.067158 0.00533 0.32

At 1 meter distance from the tube by

closing the collimators

2.01 0.041958 0.00333 0.2 At control panel

0.2 0.0041958 0.00033 0.02 At corridor (door

closed)

0.2 0.0041958 0.00033 0.02 At dark room

0.5 0.0104958 0.00083 0.05 At radio-diagnostic

workers room

0.01 Electrical zero

balancing value

Bas

ic X

-ray

roo

m n

o.2

58.8 1.2243

1050

0.2915 17.49 Directional

0.4 0.0084 0.002 0.12

At 1 meter distance from the tube by

closing the collimators

0.2 0.004914 0.00117 0.07 At control panel

0.5 0.009786 0.00233 0.14 At corridor (door

closed)

1.4 0.02814 0.0067 0.16 At dark room

0.1 0.0021 0.0005 0.03 Behind the chest

stand wall

0.01 Electrical zero

balancing value

Flu

oro

sco

py

roo

m n

o. 2

1367.5 28.48965

525

0.27133 16.28 Directional

18.5 0.385035 0.00367 0.19

At 1 meter distance from the tube by

closing the collimators

7.6 0.1575 0.0015 0.09 At control panel

10.1 0.21 0.002 0.12 At corridor (door

closed)

6.7 0.139965 0.00133 0.08 At dark room

134

0.03 Electrical zero

balancing value

Flu

oro

sco

py

roo

m n

o. 1

Ab

del

Azi

z R

ante

ssi

Mar

tyr

Ped

iatr

ic h

osp

ital

987.8 20.58

420

0.245 14.7 Directional

17.5 0.36372 0.00433 0.26

At 1 meter distance from the tube by

closing the collimators

4.7 0.0980028 0.00117 0.07 At control panel

4.03 0.084 0.001 0.06 At corridor (door

closed)

3.4 0.069972 0.00083 0.05 At dark room

0.04 Electrical zero

balancing value

CT

sca

n ro

om

no

. 2

983.8 20.49666

18375

0.31233 18.74 Directional

483.5 10.073438 0.1535 9.21

At 1 meter distance from the C.T scan

gantry

6.3 0.13125 0.002 0.12 At control panel

3.7 0.0767813 0.00117 0.07 At door of the control

panel (door closed)

4.2 0.0872813 0.00133 0.08 At patients waiting

room

0.04 Electrical zero

balancing value

Bas

ic X

-ray

roo

m n

o. 1

Al

Nas

er P

edia

tric

ho

spit

al

64.4 1.3412028

2100

0.15967 9.04 Directional

2.6 0.0546 0.0065 0.39

At 1 meter distance from the tube by

closing the collimators

1.9 0.0392028 0.00467 0.28 At control panel

1.01 0.021 0.0025 0.15 At corridor (door

closed)

0.3 0.0069972 0.00083 0.05 At dark room

0.5 0.0098028 0.00117 0.07 Behind the chest

stand wall

0.05 Electrical zero

balancing value

Bas

ic X

-ray

roo

m n

o. 1

Bei

t H

ano

un

ho

spit

al

67.8 1.41288

1400

0.2523 15.14 Directional

0.9 0.018648 0.00333 0.2

At 1 meter distance from the tube by

closing the collimators

1.3 0.028 0.005 0.3 At control panel

0.3 0.0056 0.001 0.06 At corridor (door

closed)

0.2 0.004648 0.00083 0.05 At dark room

0.3 0.0056 0.001 0.06 Behind the chest

stand wall

135

Annex (8): Radio-diagnostic machines and rooms specifications data sheet

No

. o

f ra

dio

log

ica

l

pro

ced

ure

s p

er d

ay

Th

ick

nes

s o

f le

ad

lin

ing

th

e

roo

m d

oo

rs

Dis

tan

ce b

etw

een

th

e X

-ra

y

tub

e a

nd

co

ntr

ol

pa

nel

Th

ick

nes

s a

nd

hei

gh

t o

f le

ad

lin

ing

o

f ro

om

wa

lls

Width of room

walls/cm

Dim

ensi

on

s o

f ra

dio

log

y

roo

m/c

m

Type of machine

working (constant or

portable)

Da

te o

f in

sta

lla

tio

n

Sta

tus

Mo

del

No

. M

an

ufa

ctu

rer

com

pa

ny

Na

me

of

ma

chin

e a

nd

ro

om

nu

mb

er

Na

me

of

ho

spit

al

Material of room

walls (electronic or manual)

Material of control

panel wall

(Film processing

digital or analogue)

------- 2 mm 150

cm

2 mm

200-210

cm

20 cm

550 X 330

cm

Constant

20

05

Mal

fun

ctio

n

-in

g

SH

F-5

35

Sed

ecal

Bas

ic X

-ray

roo

m n

o.1

Ab

u Y

ou

sef

Al

Naj

jar

Mar

tyr

ho

spit

al

Cement Electronic

Wood

Analog

5

fluorosc-

opy.

50 basic

X-rays

2 mm 200

cm

2 mm

200-210

cm

20 cm

490 X 380

cm

Constant

20

07

Fu

nct

ion

-

ing

UD

15

OB

-

30

Sh

imad

zu F

luo

rosc

o-

py

an

d

bas

ic X

-

ray

roo

m n

o. 2

Cement Electronic

wood Analog

30 2 mm 150

cm

2 mm

200-210

cm

20 cm

410 X 410

cm

Constant

20

05

Fu

nct

ion

-

ing

UD

15

0L

40

E

Sh

imad

zu

Bas

ic X

-

ray

Em

erg

en-

cy r

oom

Cement Electronic

Wood

Analog

------- 2 mm 300

cm

2 mm

200-210

cm

20 cm

700 X 500

Constant

20

00

Mal

fun

-

ctio

nin

g S

ires

ko

-pe

CX

Sie

men

s F

luo

rosc

o-

py

roo

m n

o. 1

Eu

rop

ean

Gaz

a

ho

spit

al

Cement Electronic

Cement

Analog

136

30 2 mm 330

cm

2 mm

200-210

cm

2 cm

570 X 420

Constant

20

02

Fu

nct

i-

onin

g M

ult

ixC

o

mp

-act

K

Sie

m-

ens

Bas

ic

X-r

ay

roo

m

no

. 2

Cement Electronic

Cement Analog

------- 2 mm 30

cm

2 mm

2 m

20 cm

220 X 330

Constant

20

04

Mal

fu

nc-

tio

nin

g

Mam

m

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141

Annex (9): The questionnaire analysis tables

Table (1): Socio-demographic and related work factors of the study participants

Item Frequency Percentage

1. Age

From 20-29 years 44 24.3

From 30-39 years 84 46.4

From 40-49 years 38 21.0

More than 50 years 15 8.3

Total 181 100

2. Sex

Male 137 76.1

Female 43 23.9

Total 180 100

3. Occupation

Radiologist 38 20.9

Medical radiographer 144 79.1

Total 182 100

4. Academic qualification

Diploma 16 9.2

Bachelor 144 82.8

Higher degree 14 8.0

Total 174 100

5. Practical experience

1-4 years 32 18.0

5-9 years 64 36.0

10-14 years 48 27.0

15-20 years 34 19.1

Total 178 100

6. Name of hospital

Abu Yousef Al Najjar hospital 12 6.6

European Gaza hospital 16 8.8

Nasser medical complex 29 15.9

Al Aqsa Martyrs hospital 20 11.0

Al Shifa Medical complex 57 31.3

Al Naser pediatric hospital 12 6.6

Abdel Aziz Rantessi Martyr 9 4.9

Kamal Adwan Martyr hospital 17 9.3

Beit Hanoun hospital 10 5.5

Total 182 100

7. Type of radio-diagnostic machine

Basic X-ray 151 83.0

CT scan 80 44.0

Fluoroscopy 107 58.8

Panorama 44 24.2

Mammography 27 14.8

Portable X-ray 76 41.8

8. Daily work hours in radio-diagnostic rooms

1-2 hours 21 11.9

2-3 hours 49 27.8

142

3-4 hours 60 34.1

4-5 hours 32 18.2

More than 5 hours 14 8.0

Total 176 100.0

Table (2): Responses of study participants about the availability of personal

radiation protection devices items

Radiation protection devices

Yes No Don't Know

No. % No. % No. %

Lead aprons 174 95.7 7 3.8 1 0.5

Gonadal shields 29 16 142 78.0 11 6.0

Lead curtains 10 5.5 135 74.2 37 20.3

Lead shields / barriers 73 40.2 92 50.5 17 9.3

Thyroid shields 138 75.9 41 22.5 3 1.6

Lead glass 76 41.8 98 53.8 8 4.4

Lead gloves 38 20.9 134 73.6 10 5.5

Breast shields 13 7.1 155 85.2 14 7.7

Radiation warning signs 41 22.5 132 72.5 9 4.9

Caution lights 48 26.4 122 67.0 12 6.6

Average 35.2% 58.1% 6.7%

Table (3): Responses of study participants to radiation protection awareness

items

Items Yes No

Don't

Know

No. % No. % No. %

1.The annual average dose over five

years should not exceed 20 mSv for

occupational exposure

125 68.7 21 11.5 36 19.8

2.Public should not be exposed to more

than an average of 1 mSv per year 107 58.8 20 11.0 55 30.2

3. Radiation dose limits for pregnant

woman who work in radiation field is 2

mSv during pregnancy period

67 36.8 44 24.2 71 39.0

4. Protection of patient and public from

unnecessary radiation during

radiological examinations are the

responsibility of radiology staff

173 95.1 7 3.8 2 1.1

5. Utilizing high kV during radiological

examinations leads to an increase the

permeability of the radiation beam and

reduce the absorbed dose in the patient

body

163 89.6 10 5.5 9 4.9

6. Short radiation exposure time during

radiological examinations, leads to less 178 97.8 3 1.6 1 0.5

143

patient radiation dose

7. Increasing the distance from the

radiation source to double, leads to

reduce the received dose to half

135 74.2 36 19.8 11 6.0

8. The recommended distance between

X-ray source and radiology workers is

two meter

61 33.5 99 54.4 22 12.1

9. Using the collimators during medical

radiography has a great benefits and

reduce the patient dose

170 93.4 9 4.9 3 1.6

10. Protective lead must periodically

examined to avoid any cracks in the

lead

139 76.4 33 18.1 10 5.5

11. Thickness of the lead lined the X-

ray room wall, which is exposed to

primary X-rays should be 2 mm based

on the principle of ALARA

117 64.3 21 11.5 44 24.2

12. The doors of X-ray room must be

lined from one or two sides with a lead

layer thickness of 1 mm

103 56.6 40 22.0 39 21.4

13. The ideal X-ray room space should

not be less than 36 m2, the ceiling

height is 3.6 m and the exterior

windows height is 2.2 m above the X-

ray room floor

90 49.5 24 13.2 68 37.4

14. The primary radiation barrier must

be height 2m from the X-ray room

floor

129 70.9 11 6.0 42 23.1

15. The X-ray machines maintenance

and calibration must be periodically

carried out to prevent radiation leakage

174 95.6 4 2.2 4 2.2

16. The periodic maintenance for X-

ray rooms walls, doors and radiation

protection tools should be performed to

ensure their efficiency

176 96.7 4 2.2 2 1.1

17. The experience of workers must be

taken into consideration when X-ray

machines were imported and involved

them in the specification of the

purchase

171 94.0 5 2.7 6 3.3

18. The error in the selection of

appropriate kilo volts due to technical

error or malfunction of X-ray machine

leads to excessive radiation dose to the

patient

172 94.5 6 3.3 4 2.2

Average 74.8% 12.1% 13.1%

144

Table (4): Responses of study participants to radiation protection practices

items

Items Yes No

Don't

Know

No. % No. % No. %

1. Have you ever received any training

in radiation protection? 63 34.6 119 65.4 0 0.0

2. Do you explain the radiological

examination instructions to the patient

before the exam?

95 52.2 48 26.4 39 21.4

3. Do you use X-ray tube collimation

during the radiography in order to

reduce patient body dose?

134 73.6 23 12.6 25 13.7

4. Do you stand behind the lead barrier

during giving the radiation dose? 171 94.0 5 2.7 6 3.3

5. If the doctor don't ask for imaging the

Gonads, do you use the gonadal shield

to protect these organs?

30 16.5 140 76.9 12 6.6

6. Do you ask the patient escorts to

evacuate the X-ray room before giving

the X-ray dose?

101 55.5 30 16.5 51 28.0

7. Do you make sure that the X-ray door

is closed during the radiological

examination?

136 74.7 18 9.9 28 15.4

8. Do you keep the requierd distance

between the X-ray source and yourself

during using a mobile X-ray machine?

139 76.4 18 9.9 25 13.7

9. Do you take the necessary precautions

to protect patient escorts and other

patients in the room during using a

mobile X-ray machine?

121 66.5 25 13.7 36 19.8

10. Do you wear the radiation protection

devices to protect yourself from ionizing

radiation?

123 67.6 18 9.9 41 22.5

11. Do you protect the patient escort,

who hold the child during the

radiological examination?

57 31.3 86 47.3 39 21.4

12. Have you been asked to check your

radiology center when there is suspicion

of radiation leakage?

67 36.8 107 58.8 8 4.4

13. Are you interested in maintenance

conducting for X-ray machines when the

defect related with radiation protection?

109 59.0 51 28.0 22 12.1

14. Does the administration respond to

workers' demands regarding to check the

X-ray rooms to make sure about of their

safety?

47 25.8 92 50.5 43 23.6

15. Do you think that your radiology

center conformity with the safety and

radiation protection standards?

66 36.3 101 55.5 15 8.2

Average 53.4 32.3 14.3

145

Table (5): Responses of study participants to evaluation the personal radiation

exposure monitoring process items

No. Items No. %

1. Does the hospital have Radiation Protection Adviser

(RPA)?

Yes 8 4.4

No 174 95.6

Total 182 100

2. Does the hospital provide you with any personal

radiation monitoring device?

Yes 111 60.4

No 71 39.6

Total 182 100

3. If yes, do you use it during your work in the radio-

diagnostic rooms?

Yes 61 55.0

Sometimes 35 31.5

No 15 13.5

Total 111 100.0

4. Did you receive a guidance about the proper handling

with the personal radiation monitoring device?

Yes 27 24.3

No 84 75.7

Total 111 100

5. Are the measurements results taken into consideration

by the safety officers?

Yes 39 35.1

No 72 64.9

Total 111 100

6.

Do you receive another personal radiation monitoring

device when the device collect to measure of radiation

dose?

Yes 0 0

No 111 100

Total 111 100

7. What is the reason for non-provision of the device?

No radiation safety officer to provide the service 63 64.9

Carelessly of hospital management 56 57.7

Lack of fund to purchase these devices 31 32.0

Radiology workers do not request for it 24 24.7