Assessment of Jordanian’s Knowledge of the Risks of Radiation Exposure

Abstract

Purpose

The growing use of ionizing radiation in medical imaging requires balancing diagnostic benefits with radiation risks. This study assesses awareness and knowledge of radiation doses and risks among Jordanians.

Methods

This cross-sectional study surveyed 582 Jordanian social media users online between December and February 2023, using 24 multiple-choice questions on demographics, radiological health risks, and precautionary awareness.

Results

The cohort consisted of 321 (55%) males and 261 (45%) females, with most patients (54%) being from the 18–30 age group. Findings revealed a 42% incidence of direct radiation exposure within the past six months, predominantly advised by physicians (82%). Notably, 94% of participants recognized the risk of radiation exposure to pregnant women’s pelvic and abdominal regions. Awareness of the carcinogenic potential of radiation was high (92%), yet only 18% reported wearing protective gear during exposure. There was a significant difference between medical and non-medical respondents in the awareness of wearing protective gear (25% vs. 11%, p-value < 0.001), risk of cancer, infertility, cataracts, and the effect of spiral CT scans to 100–800 X-rays (83% vs. 69%, p-value < 0.001). In addition, 37% of medical respondents thought warning signs are enough for comprehensive explanation compared to 27% in non-medical respondents (p-value = 0.012).

Conclusion

The study reveals satisfactory awareness of medical radiation hazards among Jordanians, with disparities between medical and non-medical respondents. However, low protective gear usage and knowledge gaps indicate the need for improved education in radiology and public health campaigns on radiation safety.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13139-025-00919-z.

Introduction

Radiation is a component of man’s physical environment and is broadly classified into ionizing and non-ionizing radiation [1]. Ionizing radiation used in medical imaging for diagnostic and interventional purposes has risen dramatically in recent years [1]. Most patients who visit hospitals are requested to undertake a radiologic examination [2], after estimating the potential risk of radiation and the potential benefits of testing [3]. Several studies have demonstrated that exposure to medical radiation hazards is harmful [4, 5], and it may occur after a single high-dose exposure or after multiple low-dose exposures [6]. The documented evidence of poor knowledge of radiation safety among various cadres of health workers at risk of occupational exposure shows the enormity of the problem at hand [1]. Radiographic investigations in medicine cause radiation exposure to both the patient and the radiographer, and care is to be taken to protect both. According to the position distance rule, the radiographer’s position should be at least six feet away from the source at an angle of 90° to 135° to the central X-ray beam [7]. According to the World Health Organization (WHO), excessive radiation exposure may damage living tissues and organs, depending on the amount of radiation received (i.e., the dose). The extent of the potential damage depends on several factors, including:

• The type of radiation

• The sensitivity of the affected tissues and organs

• The manner and length of time exposed

• The radioactive isotopes involved

• The characteristics of the exposed person such as age, gender, and underlying condition [8].

The radiation dose used in most computed tomography (CT) examinations is creeping upwards and is significantly higher than it was a decade ago [9]. CT scanning accounts for more than 10% of the procedures for diagnostic radiology and nearly two-thirds of the collective radiation dose [9]. For example, the dose from a CT of the chest is 100 to 1000 times greater than a conventional chest X-ray [9].

Several studies have demonstrated that exposure to medical radiation increases the risk of bone marrow suppression, cataract, infertility, birth deformities, and several types of cancer, especially thyroid carcinoma [10–12]. Based on the Life-Span Study, the Radiation Effects Research Foundation reports a relative risk of 1.6 for solid cancer after 1 Sv of radiation exposure [6]. The threshold dose varies across radiation-related diseases and age groups. For example, levels between 100 and 200 mGy was shown to be associated with teratogenic effects and cancer, whereas 500 mGy is associated with cataracts [10]. In contrast, a mean dose of 76.0 mGy was seen in patients with brain tumors suggesting there is no standardized dose limit of radiation exposure [13]. Additionally, prenatal radiation exposure poses the highest risk to a fetus during the first trimester (organogenesis), potentially contributing to prenatal death, malformation, or central nervous system impairment [6]. A study published in 2020 suggests that there is a reasonable level of awareness but a relative lack of knowledge about radiation hazards and protection among anesthesia personnel and surgical subspecialists. Therefore, continuing medical education (CME) on radiation hazards and protection must be encouraged [10]. Furthermore, study that was conducted on general and specialist physicians in Iranian hospitals found that most medical doctors did not have enough awareness about the amount of radiation received by patients undertaking radiologic investigations [2].

In Jordan and the middle east, there is a noticeable lack of awareness and non-compliance to radiation safety and non- which can lead to harmful events for both healthcare providers and patients if safety measures are not met [14, 15]. Therefore, it is crucial to assess and evaluate the awareness levels of radiation exposure and safety in both the medical and non-medical residents of Jordan, to contribute to a better understanding of radiation exposure risks, leading to more proactive behavior in reducing unnecessary exposure, thus improving overall public health in Jordan. In this cross-sectional study, we aim to examine the awareness levels of radiation exposure and safety in the Jordanian population.

Materials and Methods

Subjects and Study Design

This cross-sectional study was conducted among the Jordanian population via social media platforms using Google Forms from December 1 st to February 28 th, 2023. The purpose of the study was explained to all participants, and consent was obtained from all respondents. Participant recruitment was through social media platforms, where the questionnaire’s link was shared across various groups and networks of platforms. There was no specific target for the number of individuals, and we did not determine the response rate, as the total number of individuals reached through social media cannot be accurately tracked.

Questionnaire

The questionnaire consisted of 24 mandatory multiple-choice questions in Arabic language. The first five questions collected demographic information (gender, medical background, age group, level of education, city), while the remaining questions assessed the level of knowledge the subject had about the health risks associated with incidental and habitual radiological exposure and gauged the subject’s awareness of precautionary measures.

The questionnaire included items assessing both factual knowledge of medical radiation risks and general awareness of safety practices and information exposure. Knowledge was evaluated using eight true/false items with defined correct answers. Awareness was assessed through questions about prior counseling, protective behaviors, and exposure to educational content. Full questionnaires in Arabic and English are provided in the supplementary material.

Ethical Considerations

All respondents’ data was non-identifiable. The Institutional Review Board (IRB) at our institution approved the study (number:32/152/2022). Respondents’ consent was acquired at the beginning of the survey.

Statistical Analysis

Continuous data will be summarized as mean (standard deviation) and analyzed using the Student’s t-test for normally distributed variables, or as median (range) with the Wilcoxon rank-sum (Mann-Whitney U) test for non-normally distributed variables. Categorical data will be reported as frequencies and percentages and analyzed using the Chi-square test or Fisher’s exact test for counts less than 5. All analyses will be performed using R statistical software. A two-tailed p-value of 0.05 or less was considered statistically significant. We also calculated a “correct answer score” by tallying the correct responses and further used that score for later analysis across demographic categories. IBM SPSS Statistics, version 26 (IBM Corp., Armonk, NY, USA), was used for all statistical analyses.

Results

Socio-demographic Characteristics of the Study Participants

Five hundred eighty-two people from different age groups participated in this research. Most of the participants were between the ages of 18–30 (54.3%), the rest were distributed as follows: 18.2% between 30 and 40 years, 13.9% between 40 and 50 years, 12.5% over 50 years, and 1% of participants were less than 18 years old. Of these, 321 (55.2%) were male and 261 (44.8%) were female.

Most of the participants were educated. They were 133 (22.9%), 392 (67.4%), and 50 (8.6%) of higher education, bachelor’s degree, and secondary level respectively. Seven (1.2%) only were under the secondary level. 289 (49.7%) of these Participants were from the medical field.

Participants were distributed from different regions of the kingdom, 332 (57%) of them were from the northern region, 231 (39.7%) from the central region, and 19 (3.3%) from the southern region. Further detailed information is shown in Table 1.

Table 1.

Sociodemographic characteristics of included sample

Characteristic	N = 5821
Sex
Female	261 (44.8%)
Male	321 (55.2%)
Occupation
Medical	289 (49.7%)
Non-medical	293 (50.3%)
Age group
< 18	6 (1.0%)
18–30	316 (54.3%)
30–40	106 (18.2%)
40–50	81 (13.9%)
> 50	73 (12.5%)
Education
Higher education	133 (22.9%)
Bachelor’s	392 (67.4%)
High school	50 (8.6%)
Middle/Elementary	7 (1.2%)
Residency region
Northern	332 (57%)
Central	231 (39.7%)
Southern	19 (3.3%)
Radiation exposure in workplace	123 (21.1%)
X-ray Indication
Doctor’s order	478 (82.1%)
Never had X-ray	32 (5.5%)
Imaging requested for additional reassurance	72 (12.4%)
Direct radiation exposure within previous 6 months
> 5 times	56 (9.6%)
1–5 times	244 (41.9%)
Never	282 (48.5%)
Were you advised about the risks of radiation by radio-technician?	236 (40.5%)
Were you advised about the precautions of radiation by radio-technician?	340 (58.4%)
Protective gear upon radiation exposure
Always	104 (17.9%)
Never	319 (54.8%)
Sometimes	159 (27.3%)

¹ n (%)

Radiation Exposure

Most of the participants were not continuously exposed to radiation in their workplace and they formed 459 (78.9%) while 123 (21.1%) were exposed continuously, it was 89 (72.4%) among them were medical workers.

Of all participants who were exposed to radiation 478 (82.1%) were exposed by order from their doctors while 72 (12.4%) had imaging requested for additional reassurance, others were not exposed at all (n = 32, 5.5%). Most of those who answered this question were between the ages of 18–30.

At the time of data collection, participants were asked about radiation exposure in the last 6 months 56 (9.6%) of them were exposed more than 5 times, 244 (41.9%) were exposed 1–5 times while 282 (48.5%) of them were not exposed at all.

Precautions

The participants were asked if the radiographers told them before exposure to radiation imaging about the most important risks of radiation and the results were 346 (59%) did not received any information about the risks, while 236 (41%) have received information about the risks of radiation exposure. Also, they were asked about the precautionary measures and the results were (n = 242, 42%) who didn’t receive and (n = 340, 58%) who received this information.

Most of individuals 319 (54.8%) never wore a radiation-protection vest, whereas 159 (27.3%) wore it occasionally and 104 (17.9%) always wore it. Further analyzed by the worker field, it was observed that 72 only were from the medical field who wear the vest always, other were distributed as Table 2.

Table 2.

Comparison in the awareness of radiation risks between medical and non-medical respondents

Characteristic	Medical, N = 289	Non-medical, N = 293	p-value
Sex			0.039
Female	142 (49.1%)	119 (40.6%)
Male	147 (50.9%)	174 (59.4%)
Age group			0.003
< 18	0 (0.0%)	6 (2.0%)
> 50	27 (9.3%)	46 (15.7%)
18–30	171 (59.2%)	145 (49.5%)
30–40	57 (19.7%)	49 (16.7%)
40–50	34 (11.8%)	47 (16.0%)
Radiation exposure in workplace	89 (30.8%)	34 (11.6%)	< 0.001
X-ray indication			0.001
Doctor’s order	229 (79.2%)	249 (85.0%)
Never had X-ray	26 (9.0%)	6 (2.0%)
Imaging requested for additional reassurance	34 (11.8%)	38 (13.0%)
Direct radiation exposure within previous 6 months			< 0.001
> 5 times	43 (14.9%)	13 (4.4%)
1–5 times	98 (33.9%)	146 (49.8%)
Never	148 (51.2%)	134 (45.7%)
Were you advised about the risks of radiation by radio-technician?	124 (42.9%)	112 (38.2%)	0.250
Were you advised about the precautions of radiation by radio-technician?	176 (60.9%)	164 (56.0%)	0.228
Protective gear upon exposure			< 0.001
Always	72 (24.9%)	32 (10.9%)
Never	122 (42.2%)	197 (67.2%)
Sometimes	95 (32.9%)	64 (21.8%)
Pregnant women are prohibited from exposure to radiographic imaging	269 (93.1%)	279 (95.2%)	0.271
Pregnant women are exposed to radiation safely	30 (10.4%)	27 (9.2%)	0636
Carcinogenic effect of radiation to body organs	276 (95.5%)	259 (88.4%)	0.002
Eye clouding risk due to frequent radiation	245 (84.8%)	229 (78.2%)	0.040
Joint deformities risk due to repeated radiation exposure	179 (61.9%)	163 (55.6%)	0.122
Infertility risk due to high doses of radiation exposure	232 (80.3%)	213 (72.7%)	0.031
Spiral CT equivalence to (100–800) X-ray images	240 (83.0%)	202 (68.9%)	< 0.001
Have you ever read the warning signs?	230 (79.6%)	234 (79.9%)	1.000
Warning signs are enough to provide comprehensive explanation	107 (37.0%)	80 (27.3%)	0.012
Subjective measure for the levels of knowledge about radiation risks			< 0.001
Very bad	6 (2.1%)	26 (8.9%)
Bad	26 (9.0%)	63 (21.5%)
Fair	121 (41.9%)	149 (50.9%)
Good	90 (31.1%)	44 (15.0%)
Very good	46 (15.9%)	11 (3.8%)

Knowledge of Radiation Hazards

Through eight questions that were scored to assess general population knowledge of the risks of radiation exposure, only 65 (9.6%) answered all 8 questions correctly whereas 526 (90.4%) had 1 to 6 mistakes (Table 2). The overall knowledge status according to the percentages mentioned above was analyzed with respect to age and it was found that the awareness of radiation risks was more in the 18–30 age group, (Fig. 1). It was observed that most of the participants who answered all the questions correctly were among the holders of a bachelor’s degree and then a postgraduate degree, 31 of them were from the medical field. Correct answers were equally distributed in northern and central regions, while no correct answers were recorded in southern regions.

Fig. 1.

The distribution of the participants who answered the eight questions correctly according to their age

Radiation Awareness

Questions regarding warning signs in the radiology department, 464 (79.7%) of the participants read it while 118 (20.3%) did not read it, and of all participants 395 (6.9%) individuals believe it is not enough and does not give an appropriate explanation, whereas 187 (32.1%) participants believe it is sufficient.

The vast majority did not attend awareness lectures about the risks of radiation, while some were educated about the subject through lectures, YouTube, social networking sites, and Google.

Comparison between Medical and non-medical Occupations

There was a significant difference in age and sex between medical and non-medical respondents, in which the majority of non-medical respondents were males (59.4% vs. 50.9%, p-value = 0.039), and the majority of medical respondents were in the age group of 18–30 years (59.2% vs. 49.5%, p-value = 0.003) as shown in Table 2. Regarding radiation exposure, 89 (30.8%) of medical respondents were exposed to radiation in the workplace compared to 34 (11.6%) in the non-medical respondent group (p-value < 0.001). Within the previous 6 months, 43 (14.9%) of medical respondents were exposed to direct radiation compared to 13 (4.4%) in the non-medical respondent group (p-value < 0.001). Protective gear was more commonly used in medical respondents compared to non-medical respondent (24.9% vs. 10.9%, p-value < 0.001). Regarding the effect of radiation on body organs, 276 (95.5%) of medical respondents were aware of the carcinogenic effects of radiation compared to 259 (88.4%) in non-medical respondents (p-value = 0.002), while 232 (80.3%) of medical respondents were aware of the risk of infertility compared to 213 (72.7%) of non-medical respondents (p-value < 0.001). Of the medical respondents, 240 (83%) were aware of the equivalence of spiral CT to 100–800 X-rays compared to 202 (68.9%) of non-medical respondents (p-value < 0.001). Additionally, 107 (37%) of medical respondents thought warning signs were enough to provide comprehensive explanation compared to 80 (27.3%) of non-medical respondents (p-value = 0.012). The overall knowledge of radiation risks was fair in 121 (41.9%) of medical respondents, compared to 149 (50.9%) of non-medical respondents (p-value < 0.001).

Discussion

Medical imaging plays a crucial role in modern healthcare, enabling physicians to obtain detailed insights into the human body using different modulates such as X-rays, computed tomography (CT) scans, and nuclear medicine, aiding in detecting and treating diseases. However, the use of ionizing radiation poses certain risks to patients that need to be carefully considered. While the radiation hazard associated with each single medical imaging study is minimal [9], the continuous increase in the uses of medical imaging raises the chances that a certain individual will undergo multiple imaging examinations during their life which in turn leads to more radiation exposure and subsequently higher likelihood of the risks. For example, several studies analyzed the relationship between radiation exposure from CT scans and the subsequent risk of developing malignancy, a cohort study showed that the use of multiple CT scans on children could potentially increase the risk of leukemia and brain cancer in these patients [10]. The level of awareness about the radiation hazards associated with medical images is crucial in reducing unnecessary examinations and thus reducing the overall risk. From this point, our study aims to evaluate the general basic knowledge and awareness about ionizing radiation among the Jordanian population.

Out of the 582 participants who were included in the study, 55.3% were under the age of 30, which is representative of the youth population of Jordan [13], in addition, 90.3% of the participants mostly held a university degree and about 50% are working in medical fields. Of the eight questions we use in the questionnaire to assess the basic general knowledge about radiation hazards, the two questions about the use of Ionizing radiation exposure during pregnancy were answered correctly by the vast majority (90.2% ad 94.1%) of the participants, indicating a good level of awareness about the risk of radiation during pregnancy. Five other questions about the general effect of radiation on the human body were also answered correctly by most of the participants. The last question revealed that a total of 70% of respondents were aware that chest CT exposes them to higher levels of radiation in comparison to chest radiography, which is a slightly higher percentage compared to a study conducted in Italy where only around 55% of respondents were knowledgeable about this fact [14].

Consistent with prior studies [15, 16] that link the patients’ educational level to their understanding of potential adverse effects from the uses of ionizing radiation, our study also revealed that a higher level of education is associated with better awareness about the risk as most of the respondents who answered all or most of questions in the questionnaire had higher education beyond high school level (Fig. 2). Among respondents who underwent medical imaging that uses radiation, about 60% of them indicated that they did not receive any information about radiation hazards or the protective measures from their radiographer prior to imaging, in addition, 67.9% findthat the warning signs and signboard in the radiology departments do not provide enough information and explanation about the radiation.

Fig. 2.

The distribution of the participants who answered the eight questions correctly according to their level of education

Our study has several limitations. First, our study was conducted using social media platforms, which may not provide a truly representative sample of the Jordanian population, as people without internet access or who do not use social media were excluded, potentially causing sampling bias, and an underrepresentation of the older adult population in our study’s sample, who are more likely to get medical imaging that uses ionizing radiation and more likely to use different radiological modalities like CT scans and X-rays [17]. Also, about 50% of the sample are working in the healthcare sector, this could cause bias in the results as those are more likely to have more information about radiation compared to non-healthcare workers. The geographic representation was imbalanced, with most participants from northern Jordan, limiting generalizability. Additionally, we did not provide longitudinal data with analysis of changes in knowledge or behavior over time. Cultural and linguistic factors also limit the applicability of the findings to non-Arabic speaking populations.

Conclusion

In conclusion, the results of our study indicate that a satisfactory basic level of knowledge about medical radiation hazards among the Jordanian population. However, more effort should be made to achieve a higher level of awareness starting from the radiology department with the need for more informative signs and educational booklets. Further research should be made to assess in more depth and comprehensively evaluate the Jordanian population’s knowledge about radiation in general and radiation used in medical fields.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Authors’ contributions

Haneen M. Hazaymeh: Conceptualization, data collection, and manuscript drafting.

Naser Obeidat: Supervision, data analysis, and critical revision of the manuscript.

Rana A. Ghawanmeh: Data collection and interpretation, and manuscript editing.

Mohammed H. Anagreh: Statistical analysis and manuscript review.

Khaled S. Abu alkheir: Literature review and final manuscript approval.

Funding

None received.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Declaration of generative AI in scientific writing

No AI tools were used in drafting the manuscript or analyzing data.

Ethics approval and consent to participate

All respondents’ data was non-identifiable.

The Institutional Review Board (IRB) at King Abdullah University Hospital (KAUH) and Jordan University of Science and Technology (JUST) approved the study (number: 2022/152/32).

Respondents’ consent was acquired at the beginning of the survey.

Consent for publication

All authors agree to the publication of the manuscript.

Competing interests

None declared.