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UNIVERSITI TEKNOLOGI MARA ASSESSMENT OF KNOWLEDGE AND PRACTICE TOWARD RADIATION PROTECTION AMONG RADIOGRAPHERS IN NUCLEAR MEDICINE NUR KHUZAIMAH BINTI KASMAT BACHELOR (HONS.) OF MEDICAL IMAGING MARCH 2023

i DECLARATION I declare the work in this dissertation was carried out in accordance with the regulations of University Teknologi Mara. It is original and the results of my own work, unless otherwise indicated or acknowledge as referenced work. This thesis has not been submitted to any other academic institution or non-academic institution for any degree or qualification. I, hereby, acknowledge that I have been supplied with the Academic Rules and Regulations for Postgraduate, University Teknologi Mara, Regulating the conduct of my study and research. Name of Student : Nur Khuzaimah binti Kasmat Student No. : 2018666942 Program : Bachelor (Hons) in Medical Imaging Faculty : Health Sciences Dissertation Title : Assessment Of Knowledge And Practice Toward Radiation Protection Among Radiographers In Nuclear Medicine Signature of Student : khuzaimah Date : January 2023

ii ACKNOWLEDGEMENT Firstly, I wish to thank God for giving me the opportunity to embark on my degree and for completing this long and challenging journey successfully. My gratitude and thanks go to my supervisor Mr. Mohd Hafizi Mahmud. Firstly, Alhamdulillah I would like to express my gratitude to Allah s.w.t who gave me the opportunity to finish my research project in a good health and was able to complete it within the time given. I faced a few problems when doing this study but with the help of Allah, I was able to cope with them and get the strength to finish it by the end. I would like to express a million thanks to the radiographers who participated in this research for sharing their knowledge related to experiences and values. I am also thanking my lecturers, for sharing beneficial knowledge, great ideas, guidance, and priceless experiences in this study field. In addition, sincere thanks to my family and friends for always supporting me through thick and thin to complete this study. Lastly, special thanks to those who have got involved in helping me during the time finishing this research. I hope that this research would benefit us and other people. My last dedication, thank you again to all and your devotion will always be in my mind.

iii TABLE OF CONTENT DECLARATION........................................................................................................................i ACKNOWLEDGEMENT.........................................................................................................ii TABLE OF CONTENT........................................................................................................... iii LIST OF TABLES....................................................................................................................vi The level of Knowledge and Practice distribution....................................................................vi The association of knowledge and practice with demographic data.........................................vi LIST OF FIGURES ..................................................................................................................vi LIST OF ABBREVIATION....................................................................................................vii ABSTRACT........................................................................................................................... viii CHAPTER 1: INTRODUCTION..............................................................................................1 1.1. Background of Study .................................................................................................1 1.2 Problem Statement.....................................................................................................2 1.3 Rationale of Study......................................................................................................4 1.4 Objective ....................................................................................................................4 1.4.1 General Objectives.................................................................................................4 1.4.2 Specific Objectives ................................................................................................4 1.5 Research Hypothesis..................................................................................................5 CHAPTER 2: LITERATURE REVIEW...............................................................................6 2.1 Radiation Protection and Safety in Nuclear Medicine...............................................6 2.2 Knowledge of Radiation Protection and Safety among Health Personnel in Nuclear Medicine ................................................................................................................................7 2.3 Practice of Radiation Protection and Safety among Health Personnel in Nuclear Medicine ................................................................................................................................7

iv 2.4 Association of demographic factors with knowledge and practice of Radiation Protection and Safety among Health Personnel in Nuclear Medicine ...................................8 CHAPTER 3: RESEARCH METHODOLOGY ................................................................10 3.1 Ethical Consideration...............................................................................................10 3.2 Study Design............................................................................................................11 3.3 Questionnaire Designed and Method of Data Collection ........................................11 3.4 Research Flow Chart................................................................................................14 3.5 Study Setting............................................................................................................15 3.6 Sample Selection......................................................................................................15 3.7 Inclusion Criteria .....................................................................................................15 3.8 Pilot Study................................................................................................................16 3.9 Statistical Analysis...................................................................................................16 CHAPTER 4: RESULT.........................................................................................................17 4.1 Introduction..............................................................................................................17 4.2 Analysis of Pilot Study ............................................................................................17 4.3 Descriptive Analysis................................................................................................19 4.4 The level of Knowledge of Radiographers Toward Radiation Protection...............23 4.5 The Inferential Analysis...........................................................................................25 CHAPTER 5: DISCUSSION ................................................................................................27 5.1 Introduction..............................................................................................................27 5.2 Knowledge of Personnel Towards Radiation Protection Safety in the Nuclear Medicine Department...........................................................................................................27 5.4 The Practice of Personnel Toward Radiation Protection Safety in. Nuclear Medicine Department...........................................................................................................30 CHAPTER 6: CONCLUSION..............................................................................................35 6.1 Introduction..............................................................................................................35 6.2 Conclusion ...............................................................................................................35

v REFERENCES ........................................................................................................................38 APPENDICES .........................................................................................................................43 Appendix I : Questionnaire..................................................................................................43 Appendix 2: Pilot Study Cronbachs Alpha Analyses For Knowledge Section ...................47 Appendix 3: Pilot Study Cronbach’s Alpha Analyses For Practice Section .......................48 Appendix 4: Ethical Approval Letter...................................................................................49 Appendix 5: Gender Result Analysis...................................................................................50 Appendix 6: Age Group Analysis Result.............................................................................51 Appendix 7: Education Level Analysis Result ....................................................................52 Appendix 8: Analysis Of Years Of Services .......................................................................53 Appendix 9: Analysis of The Level Of Knowledge And Practice.......................................54 Appendix 10: Analysis Of The Association Between Knowledge And Gender .................55 Appendix 11: Analysis Of The Association Between Knowledge And Age Group ...........56 Appendix 12: Analysis Of The Association Between Knowledge And Certification.........57 Appendix 13: Analysis Of The Association Between Knowledge And Years Of Services 58 Appendix 14: Analysis Of The Association Between Gender And Practice .......................59 Appendix 15: Analysis Of The Association Between Practice And Age ............................60 Appendix 16: Analysis Of The Association Between Practice And Certification ..............61 Appendix 17: Analysis Of Association Between Practice And Years Of Services.............62 Appendix 18: Gantt Chart....................................................................................................63 Appendix 19: Ouriginal Similarity Result ...........................................................................64

vi LIST OF TABLES Table 4.4.1: The level of Knowledge and Practice distribution Table 4.5.1: The association of knowledge and practice with demographic data. LIST OF FIGURES Figure 3.1.1 Ethical Approval Letter Figure 3.3.1: The survey tools have been distributed through media of the WhatsApp® platform. Figure 3.3.2: The survey tools have been distributed through media of the Telegram platform. Figure 3.3.3: The survey tool was manufactured from Google Form® design. Figure 3.6. 1: Raosoft Sample Size Calculator Figure 4.2. 1: Cronbach’s Alpha Result for questions in Practice Section. Figure 4.3. 1: Gender Distribution Figure 4.3 .2: Age Distribution Figure 4.3. 3: Education Level Distribution Figure 4.3. 4: Years of Service Distribution Figure 4.4.1 : Distribution of The Level of Knowledge and Practice

vii LIST OF ABBREVIATION ALARA: As low as reasonably achievable ICRP: International Commission on Radiological Protection KAP: Knowledge, Attitude and Practice PET: Positron Emission Tomography SPSS: Statistical Package for Social Science SPECT: Single Photon Emission Computed Tomography TLD Thermoluminescent dosimeters UNSCEAR United Nations Scientific Committee on the Effects of Atomic Radiation UITM Universiti Teknologi MARA WHO World Health Organization

viii ABSTRACT Objective: To assess the radiation protection knowledge and practice of radiographers in the nuclear medicine department in Malaysia. Methods: A cross-sectional study was carried out among radiographers who worked in four selected hospitals. The study was carried out from July to September 2022. An adopted questionnaire comprising three sections was given out to 17 participants to answer. Data were analysed descriptively and statistically using the Statistical Package for Social Science (SPSS) version 26.0. Results: In this study which runs in the nuclear medicine section, the survey found that 81% of radiographers have a strong practice and roughly 63% have sufficient knowledge of radiation protective safety. It was determined that knowledge and practice of radiation protection were generally committed to efficiently. Radiographer experience and the number of years they have worked in the nuclear medicine department are significantly correlated (p=.007). Senior nuclear medicine radiographers were found to have broad experience with radiation safety. Conclusion: Although there was particularly high practise of radiation protection safety and adherence to radiation protection knowledge, this is insufficient. More information needs to be added to ensure that knowledge is applied to improve correct safety precautions, assure effective work, and eventually minimize the harmful effects of ionising radiation

1 CHAPTER 1: INTRODUCTION 1.1.Background of Study In the Nuclear Medicine department, unsealed radioactive chemicals are injected into the body during nuclear medicine operations to produce images that indicate an organ's structure or function (International Atomic Energy Agency, 2022). The radioactive substance might be given intravenously, orally, or even through the air. Typically, radionuclides are coupled with targeted chemicals to create radiopharmaceuticals, which are disseminated throughout the body based on their physical or chemical properties (Komal et al., 2020). In order to create diagnostic images, radiation emitted from the body will be analysed by a gamma camera known as Single Photon Emission Computed Tomography (SPECT) for gamma rays or Positron Emission Tomography (PET) for positron-emitted radiopharmaceuticals (Saxena & Paul, 2022). So, the image produced from the radiopharmaceutical uptake varies its function. The kit used will define the type of organ to be imaged and its functions (Payolla et al., 2019). Diagnostic nuclear medicine operations have increased of 22% from 32.7 million in 2008 which is 40 million based on the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) 2008 report (UNSCEAR, 2022). 37 million nuclear medicine procedures are performed each year (World Health Organization (WHO), 2023). Ionizing radiation exposure could result in cancer, genetically induced mutations, aberrant development, and degenerative disorders (National Cancer Institute, 2019). Radiation protection knowledge and practice among radiographers in nuclear medicine is a critical aspect of patient safety and quality of care. Radiographers are responsible for performing imaging. In the department of nuclear medicine, ionizing radiation is essential for the diagnosis and treatment of various medical conditions. Thus, it is obligatory to ensure its safe use while minimizing its associated risk. There are three crucial aspects that need to be taken into account when radiation exposure occurs. The first is the justification principle, which states that the medical benefits of radiation exposure must outweigh the risks. The second is the maximisation of protection, which states that justifiable radiation exposure should be maintained as low as reasonably achievable (ALARA). The third one is the principle of dose limiting, which states that the total amount of radiation that each person receives should be kept below the International

2 Commission on Radiological Protection (ICRP) -recommended thresholds. This means that a specific dose must be established and should be lowered to the lowest level that is reasonably practicable (The International Commission on Radiological Protection, 2007). The health effects of ionising radiation generally fall into two categories. On the one hand, there are deterministic effects, whose severity rises with the amounts of radiation absorbed and which are directly related to it. A threshold (of 100 mGy or more) below which a deterministic effect does not take place is typical. On tissue damage, deterministic effects are developed. Ionizing radiation-induced lens opacities and erythema of the skin are recognized as deterministic consequences. The stochastic effects of ionising radiation must be taken into account, on the other hand. Stochastic effects are chance occurrences; the likelihood of the effect increases with the dose received, but the impact of the effect is unrelated to the dose. It is assumed that stochastic effects have no threshold. Hereditary diseases and cancer risk are primarily stochastic factors. Good laws and regulations can stop unwanted injuries and complications. So, in order to achieve this goal, a technologist needs to be well-educated and skilled. An extremely skilled and knowledgeable technologist is a key member of the healthcare team who can afford appropriate imaging facilities and evaluates radiographs for methodological quality. The beginning of a technologist's ability development is an ideal occupational programme for technologists, which produces talented technologists for both therapeutic and diagnostic working circumstances. To meet the needs of the healthcare community, it is essential to raise imaging standards in light of recent changes in the area. One of the most exposed categories of workers is nuclear medicine technologists, who contribute significantly more than any other group to the total collective doses. This study was directed to explore the staff’s awareness in terms of knowledge and practice based on their knowledge and radiation-safety practice. It is for the perceptions and actions that could have an impact on the health services offered. 1.2 Problem Statement As the procedure in nuclear medicine uses radiopharmaceutical routinely, there are three ways to reduce radiation dose based on the principle of time, shielding and distance (Kim, 2018). However, in the nuclear medicine department’s daily routine, shielding is not applicable to use as radiation protection. So, it is important to care about radiation protection based on the

3 principle of time, shielding and distance as it must be applied in running nuclear medicine procedures in daily routine. based on Atomic Energy Licensing ACT 1984 and ACT 1984, any procedure that might lead to increased radiation exposure should be carefully planned in accordance with the basic principles, prioritizing protection by ensuring exposure to the lowest radiation dose even while taking into social and economic considerations. (Atomic Energy Licensing ACT 1984 & ACT 1984, 2006). It indirectly lowers the dose of the radiation employees by decreasing the duration close to the radioactive source, increasing the distance from the source, and using the proper shields. The radiation's effects on personnel should not be overlooked as they may have both immediate and long-term implications for the health of the staff involved, even if they do not directly receive radiation. Radiation exposure levels can pose a health concern that could have an impact on the health of those who are directly exposed as well as their descendants. Radiation-induced biological impacts are divided into deterministic such as cataracts and stochastic effects such as cancer and genetic damage. Radiation safety has gained more importance in nuclear medicine since the Fukushima Daiichi Nuclear Power Plant disaster in 2011 (Cho et al., 2017). In conjunction with safety in radiation protection, this study aimed to determine the level of knowledge and practice in radiation protection and safety among allied health personnel in the Department of Nuclear Medicine. At the same time, it will come out to determine the association between demographic factors and knowledge and their practice in radiation protection and safety among nuclear medicine personnel. It is to ensure staff safety at the optimum level. By the end of the study, collected data can be used to focus on the causes of any lacking knowledge or practice in radiation protection safety to overcome the related problem. It is to maintain and make sure the practice of radiation protection is applied all-time in working with ionizing radiation. Previously, there are very limited studies on radiation protection and safety run in the department of nuclear medicine. There is a study that assesses the knowledge, attitude, and practice of Malaysian nurses in nuclear medicine. It targets only the groups of nurses who use ionizing radiation to serve in health facilities instead of radiographers (Mohd Rahimi et al., 2021). Otherwise, most of study in Malaysia in radiation protection safety focus only on radiology department, without involving technologists working in the nuclear medicine department. So, this study will fulfill the gap of the previous study. It is to guarantee the safe use of medical radiation.

4 1.3 Rationale of Study Radiation protection in nuclear medicine is to ensure that the patient receives the anticipated medical benefit and that the procedure is maximized while minimizing the radiation risk to the patient, the medical profession and the general population. In conjunction with three principles of radiation protection, this study may increase awareness and gain more knowledge among radiographers in nuclear medicine department. So, the rationale of this study may be able to define the level of knowledge of radiation protection in the nuclear medicine department among technologists and how they practice safety in radiation protection in working with ionizing radiation in the department of nuclear medicine. Moreover, it may come out with any possible reason that affects knowledge and practice in the safety of radiation protection in nuclear medicine. Thus may find the gap of poor practice in radiation protection safety. Besides that, there is limited study in Malaysia that focus on radiation protection in the nuclear medicine department. Most of the studies found focus on the radiology department only. To fulfill the gap between them, this study hopes to apply a good attitude toward radiation protection safety among radiographers working in the nuclear medicine department. 1.4 Objective 1.4.1 General Objectives The study aims to investigate the knowledge and practices among radiographers in Nuclear Medicine Department. 1.4.2 Specific Objectives a) To determine the level of knowledge in radiation protection and safety among radiographers in nuclear medicine. b) To determine the level of practice in radiation protection and safety among radiographers in nuclear medicine.

5 c) To evaluate the association of demographic parameters with knowledge and practice in radiation protection and safety among radiographers in nuclear medicine. 1.5 Research Hypothesis a) There is good knowledge of radiation protection safety among radiographers in nuclear medicine. b) There is good practice in radiation protection safety among radiographers in nuclear medicine. c) There is a statistical association between demographic parameters with knowledge and practice in radiation protection safety among radiographers in nuclear medicine.

6 CHAPTER 2: LITERATURE REVIEW 2.1 Radiation Protection Safety in Nuclear Medicine Radiation protection seeks to prevent the negative consequences of ionising radiation by reducing unnecessary radiation exposure (Frane & Bitterman, 2021). It is because any radiation exposure, even the lowest poses a potential risk to humans. Reducing radiation exposure for patients and medical workers is a result of formal radiation protection training (The International Commission on Radiological Protection, 2007). Based on The International Commission on Radiological Protection (ICRP), the effective dose for occupational workers must not exceed 20mSv in a year, meanwhile 1mSv in a year for the public. To determine preventive measures and assess radiation exposure, the government and organizations, estimate radiation worker doses is crucial. The previous study in Costa Rica shows the highest annual effective doses were recorded among nuclear medicine workers compared to other medical radiation areas with 1.55mSv per year which is higher than UNSCEAR 2008 reported world value 0.55mSv per year with almost double (Mora & Acuña, 2011). Even if it is below the international dose limit which is 20mSv per year for occupational workers, regarding the optimization principle which is “As Low As Reasonably Achievable” (ALARA), it means even if the dose is small, it can be avoided as radiation does not have a direct benefit. As well, The need for radiation protection for nuclear medicine personnel is also unavoidable. So this study will analyse how is the practice of radiographers in nuclear medicine in Malaysia based on the concept of ALARA in their daily routine as occupational workers by the application of time, shielding and distance. Besides that, another study in Ghana revealed that only a small amount of workers wearing thermoluminescent dosimeters (TLD) strictly compared to those who only sometimes (Goula et al., 2021). Another study conducted in Edirne, Turkey also showed over 123 respondents from the Cardiology, Radiology, Nuclear Medicine and Oncology Department, 10% of them not using dosimeters regularly (Zekioğlu & Parlar, 2021). It is alarming and surprising since the usage of TLD is important to ensure the personal safety of occupational workers in radiation working areas. It is reinforced even more by the study done in Nuclear Medicine Department, Hospital Kuala Lumpur which concluded dosimeters will enhance occupational safety program by minimizing radiation risk among radiation workers (Kufian et al., 2018).

7 2.2 Knowledge of Radiation Protection and Safety among Health Personnel in Nuclear Medicine A pilot study titled “Assessment Of Radiation Safety Awareness Among Nuclear Medicine Nurses’ was done at the National Cancer Institute Putrajaya showing the knowledge and awareness of radiation safety among them is still at a moderate level even after attending a training program to increase awareness in radiation safety (Yunus et al., 2014). Moreover, they also recommended conducting a study which able to determine the level of knowledge about radiation and radiation safety awareness among all medical staff in Malaysia. Another study was done at the University of Sains Islam Malaysia, which assessed the knowledge of radiation protection knowledge among nurses who work in the medical radiation area. According to the study, Malaysian nurses are well-versed in radiation usage and protection but are unaware of the radiation physics (Mohd Rahimi et al., 2021). Radiographers were taught about radiation protection in their formal education before working in the radiation field, meanwhile not for nurses. previous studies in Saudi Arabia, in which only 27% of radiographers acknowledge the annual dose limit (Alotaibi & Alkhalifah, 2019). So to encourage good radiation protection knowledge and practice, it is important to make sure radiographers play an important role in promoting the good practice of radiation practice and knowledge to ensure the safe use of medical radiation. So, this study will assess the level of knowledge and practice among radiographers in nuclear medicine in Malaysia to enhance their practice and knowledge in radiation protection safety. 2.3 Practice of Radiation Protection and Safety among Health Personnel in Nuclear Medicine Nuclear medicine departments were mandated by regulation and good working practice to check syringe activity prior to patient administration. In Tehran University of Medical Sciences research on radiation-exposed medical personnel in 16 hospitals, respondents' overall level of radiation protection knowledge and radiation protection practice was found to be unsatisfactory (Paolicchi et al., 2016). Meanwhile, despite having a thorough understanding of their significance, various radiation protection measures like thyroid shields and eye goggles are not

8 used as recommended, for the same reason (availability) (Alotaibi et al., 2015). In a different study of physicians' knowledge, attitudes, and radiation safety practices at Suez Canal University Hospital, Abdellah et al. (2015) concluded that physicians' practices were insufficient and that only half of the physicians were using lead gloves (Abdellah et al., 2015). In another study to answer if the lead aprons are really helpful in nuclear medicine from the spectroscopy perspective, higher educational level, years of experience, being a physician, and attending training courses were all strongly associated with the adequate practice of radiation protection among exposed personnel (He et al., 2017). Other studies revealed, workers who have working experience more, have good practice in the radiation protection (Alavi et al., 2017; Seifi et al., 2019). Besides that, the study stated that from the standpoint of radiation protection, these secondary rays should also be taken into account. When the photon energy is around 140 keV, using lead aprons can help people reduce the absorbed dose in half. From the perspective of their experimental result, the apron is less effective for 131I and positron radioactive nuclides (He et al., 2017). 2.4 Association of demographic factors with knowledge and practice of Radiation Protection and Safety among Health Personnel in Nuclear Medicine There are several studies that relate demographic factors to radiation protection knowledge and practice. One study concluded there was no discernible correlation between educational level and awareness of radiation protection, which may be the result of ongoing training sessions (Shabani et al., 2018). Meanwhile, it also has been demonstrated in the past that employees with a background in basic sciences had higher levels of radiation protection awareness (Shah et al., 2007). Others may say, young radiographers (those with under three years of experience) scored much higher than senior radiographers in terms of expertise. The youthfulness of the younger staff may be to account for this (Paolicchi et al., 2016). It has been concluded in the study conducted in Indonesia that Radiographers' and healthcare professionals' compliance with RPs is impacted by three significant factors: (1) Education; (2) the workplace; (3) years of experience; and (3) inspection (Sarman, 2016). most studies had proven the strongly correlated between knowledge level and certification level with the higher certification they have, the better their knowledge was (Alavi et al., 2017; Bolbol et al., 2021; Fiagbedzi et al.,

9 2022; Maharjan et al., 2020; Mohd Rahimi et al., 2021). They also strengthen that the level of knowledge increase with work experience. However, another study also revealed the effect of gender and level of knowledge with female staff having better knowledge (Seifi et al., 2019). Studies among nurses working in nuclear medicine found that nurses aged 28-37 years old have better knowledge compared to the younger staff nurses (Mohd Rahimi et al., 2021) In a nutshell, there are very limited studies in Malaysia that focus on Nuclear Medicine Department. Most of the data were collected throughout the worldwide study in the nuclear medicine field. Meanwhile, some studies focus on study in radiology part. Perhaps this study would be a reference in the nuclear medicine field in Malaysia.

10 CHAPTER 3: RESEARCH METHODOLOGY 3.1 Ethical Consideration This research asked for approval by the supervisor in charge and the study protocol was requested for approval by the Research Ethics Committee of Faculty Health Sciences, UiTM Puncak Alam. Figure 3.1.1 below shows the Ethics Approval from the Research Ethics Committee of Faculty Health Sciences, UiTM Puncak Alam (Ethics Approval Number : FERC/FSK/MR/2022/0153). Figure 3.1. 1

11 3.2 Study Design A cross-sectional survey will be used for this study design to determine both knowledge and practice of radiation protection among radiographers in the Nuclear Medicine Department at Hospital Sultanah Aminah, Johor Bahru, Hospital Kuala Lumpur, Hospital Pulau Pinang and National Cancer Institute, Putrajaya and correlate with demographic data of radiographers. The questionnaire was developed from previous related studies published by Fiagbedzi et al., (2022). 3.3 Questionnaire Designed and Method of Data Collection The questionnaire was developed from previous related studies published (Fiagbedzi et al., 2022). The questionnaire was designed to include direct and 3-point Likert scale questions that require a single selection of answers. The questionnaire was divided into three sections which consist of evaluating demographic data in the first section. Meanwhile, the second section evaluates knowledge of radiation protection, and the third section evaluates the practice of personnel in radiation protection. Overall questions consist of 20 questions. The questionnaire was distributed to the sample which was radiographers working in four different hospitals. The sample received the questionnaire through Google Forms that was distributed through WhatsApp and Telegram medium. A respondent that fulfils the inclusion and exclusion criteria was selected. The purpose of the study was stated and the consent form was filled up before proceeding to the questionnaire section. The sample has read and answered all questions. Respondent was given a period of two weeks to complete and resubmit the questionnaire. The answered questionnaire was resubmitted by completing the questionnaire.

12 Figure 3.3.1: The survey tools have been distributed through media of the WhatsApp® platform. Figure 3.3.2: The survey tools have been distributed through media of the Telegram platform.

13 Figure 3.3.3: The survey tool was manufactured from Google Form® design.

14 3.4 Research Flow Chart Report Interpret Data Perform data analysis by using Statistical Package of Social Science (SPSS) version 26 Distribute questionnaire through google form to sample Run pilot study and check questionnaire's reliability Develops Questionnaire Identify the sampling Population and choose data collection mode Specify the population of interest Define research question

15 3.5 Study Setting The study was carried out at Nuclear Medicine Department in four selected government hospitals in Peninsular Malaysia. There were Hospital Sultanah Aminah Johor Bahru, Hospital Pulau Pinang, Hospital Kuala Lumpur and National Cancer Institute Putrajaya. The study was done in 12 months. The tools needed for this study were only an online questionnaire generated through Google Forms. It had been distributed to all samples by WhatsApp and Telegram applications. Samples are given 2 weeks’ time for them to resubmit the answered question form again. The purpose of the study and consent form was included at the beginning of the survey. Thus, participants need to read then fill up the consent form before participating in the study. The answered questionnaire was collected in Google Drive after the participant completed and submitted their answer. 3.6 Sample Selection There were 17 radiographers from Nuclear Medicine Department in four hospitals. All of these were selected as samples in this study. Sample size also calculates using The Raosoft sample size calculator based on a 95% confidence level. Image 3.6.1 below was the calculation done on Raosoft software. Image 3.6. 2 3.7 Inclusion Criteria Inclusion criteria in this study are radiographers working in Nuclear Medicine Department without any minimum service duration.

16 3.8 Pilot Study In the early development of this study, a pilot study was run among personnel working in the nuclear medicine department. 10% samples were selected from 74 populations that involves radiographers, medical lab technologists, medical assistants and staff nurses working in the nuclear medicine department in four hospitals. The four hospitals were Hospital Sultanah Aminah Johor Bahru, National Cancer Institute, Hospital Kuala Lumpur and Hospital Pulau Pinang. Questionnaires were distributed by Google Forms through WhatsApp and Telegram medium. The pilot study was run for 1 week to allow the respondent to complete their questionnaire session. After 1-week data were collected and run Cronbach’s Alpha to check the reliability of the questionnaire. The Cronbach's Alpha value of the questionnaire was found to be a negative value which means the questionnaire wasn’t reliable. Another pilot study was done again which only focus on radiographers from nuclear medicine departments only, its only 17 radiographers in four hospitals. Then, Cronbach’s Alpha was run again. The value of Cronbach's alpha meets the criteria for questionnaire reliability and the alpha value of 0.8> 0.7 was considered acceptable. 3.9 Statistical Analysis Statistical analysis was performed using Statistical Package for Social Science(SPSS) version 26.0 for Windows (SPSS Inc., USA). A p-value <0.05 was considered statistically significant. The demographic data, knowledge and practice of radiation protection safety among radiographers in Nuclear Medicine were expressed as frequencies and percentages. Due to the low sample size, Fisher’s exact test was used to analyze the association between demographic data with practice and knowledge. Initially, Cronbach’s Alpha was done first before distributing the questionnaire to samples. It was used to check the reliability of the questionnaire.

17 CHAPTER 4: RESULT 4.1 Introduction This chapter will cover the data analysis, which includes the descriptive analysis for presenting the demographic data and inferential analysis to answer the research questions of the study. This study aimed to investigate the knowledge and practices of radiation protection safety among radiographers in nuclear medicine departments. There were two specific objectives carried out in this study; (1) to determine the level of knowledge and practice in radiation protection and safety among nuclear medicine radiographers and (2) to determine the association between radiographers' demographic factors and knowledge and practice in radiation protection and safety. A reliability test for the questionnaire has been done before the distribution of the questionnaire. The correlation between the variables was tested using Fisher’s Exact Test to determine the relationship. The results are presented below. 4.2 Analysis of Pilot Study The pilot study was run again among radiographers in nuclear medicine and the alpha value was 0.828 for the knowledge section meanwhile for the practice section, the alpha value was 0.986. The alpha value of 0.8> 0.7 was considered acceptable, meanwhile 0.9> 0.8 good questionnaire. The result of Cronbach’s Alpha shows in Figures 4.2.1 and 4.2.2 below.

18 Figure 4.2. 2: Cronbach’s Alpha Result for questions in Knowledge Section.

19 Figure 4.2. 3: Cronbach’s Alpha Result for questions in Practice Section. 4.3 Descriptive Analysis Participants for this study were selected among radiographers working in the nuclear medicine departments of four hospitals which involved Hospital Sultanah Aminah, Johor Bahru, Hospital Kuala Lumpur, National Cancer Institute and Hospital Pulau Pinang. Demographic data were analysed in the context of age, gender, level of qualification and years of working in The Nuclear Medicine Department. There were eight questionnaires to evaluate the radiographer’s knowledge meanwhile eight questions were used to evaluate radiographers' practice in radiation protection in nuclear medicine. The relationship between demographic data and survey questions has been analysed throughout this study. A reliability test for the questionnaire has been done before the distribution of the questionnaire.

20 4.3.1 Demographic Data of Radiographers Questionnaires in Google Forms were distributed among radiographers working in the nuclear medicine department to be filled. The questionnaire was sent through WhatsApp and Telegram applications to 17 respondents. Meanwhile, only 16 respondents answered and completed the questionnaire meanwhile 1 respondent did not respond to the questionnaire. Based on Figure 4.3.1, there were 6 (37.5%) male respondents and 10 (62.5%) respondents were female radiographers. Besides that, from the total respondents, there were 4 (25%) radiographers aged 30 years and younger. Meanwhile greater number of 12 (75%) respondents were aged 31 and older. It can be seen in Figure 4.3.2 below. Figure 4.3. 5: Gender Distribution 37.50% 62.50% Gender Male Female

21 Figure 4.3 .6: Age Distribution Figure 4.3.3 below, indicates the level of qualification of all respondents. Out of 16 respondents, only one respondent with a percentage of 6% (1) was a degree holder. The rest, 94% (15) were Diploma holders. The last question in the demographic questionnaire was the years of service for each respondent. It is described in Figure 4.3.4 which recorded that 12 (75%) of the respondents have been employed in the nuclear medicine department for more than 6 years. Meanwhile, 25% (4) respondents were employed in nuclear medicine for less than 5 years in nuclear medicine.

22 Figure 4.3. 7: Education Level Distribution Figure 4.3. 8: Years of Service Distribution

23 4.4 The level of Knowledge of Radiographers Toward Radiation Protection The level of knowledge and practice of radiographers toward radiation protection was determined by the mean score. Based on the total scores for knowledge 8 items with the 2 types of 3-point Likert scale; (1) Disagree, Neither Agree nor Disagree, and Agree, (2) Yes, No, and Unsure. Meanwhile, in section practice, there were 8 items to be answered with the choice of, rarely, sometimes, and often. The level of knowledge and practice was categorized into Good and Poor based on total correct answer score responses.

24 Table 4.4.1: The level of Knowledge and Practice distribution Knowledge Practice Level n (%) n (%) Good 10 (62.5) 13 (81) Poor 6 (37.5) 3 (19) Total 16 (100) 16 (100) Figure 4.4.1 : Distribution of The Level of Knowledge and Practice Table 4.4.1 and Figure 4.4.1 above showed the level of knowledge and practice of radiation protection safety among radiographers in the nuclear medicine department. The majority of them, which are 10 (62.5%) radiographers have good knowledge related to radiation protection safety, meanwhile, 6 (37.5%) have a poor level of knowledge. in radiation protection safety. Besides that, regarding the level of practice, the majority of radiographers applied good practice in radiation protection safety with 13 (81%) having a good practice, the rest 3 (19%) having poor practice level in radiation protection safety. 38% 63% 19% 81% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Poor Good Knowledge and Practice Distribution Practice Knowledge

25 4.5 The Inferential Analysis The analysis was done to answer the research questions stated at the beginning of Chapter 1. It was analysed with the Chi-Square analysis to determine the association between the demographic data with the level of knowledge and practice. 4.5.1 The Correlation Analysis Fisher’s Exact Test was used in this analysis. This Fisher’s Exact Test analysis was used to evaluate the association between the demographic data with the level of knowledge and practice in radiation protection safety. Due to the small size of the sample, Fisher’s Exact Test was used in order to get a valid significant value. When there are two nominal variables and wish to evaluate if the proportions of one variable differ based on the value of the other variable, use Fisher's exact test of independence. Use it when there is a small sample size (Mc Donald, 2015). Due to the small sample size, Fisher Exact Test was used instead of the Chi-square result. Fisher's exact test can be utilised when expected counts are greater than or equal to 5 in more than 20% of cells, as the approximation method application is inadequate (Beca et al., 2021). So, the category was reduced into two categories to allow Fisher’s exact test Table 4.5.1 above shown summarised the Fisher exact test of independence to evaluate the relationship between knowledge and practice with demographic data. The demographic data included gender, age, certificate and years of service. As the test was carried out with a 0.05 significance level. A p-value less than 0.05 is typically considered to be statistically significant, in which case the null hypothesis should be rejected. A p-value greater than 0.05 means that deviation from the null hypothesis is not statistically significant, and the null hypothesis is not rejected.

26 Table 4.5.1: The association of knowledge and practice with demographic data. Variables p-value/ Sig. Knowledge Practice Gender (N=16) .118 .518 Age (N=16) .604 .136 Certificate (N=16) 1.000 1.000 Years of Service (N=16) .118 .007 As shown in the table above, the p-value of .118 showed there was no association between the knowledge of radiographers and gender. Meanwhile, it same goes for the practice. There was no significant correlation between gender and the practice of radiographers toward radiation protection safety (p=.136). Besides that, it showed there was no significant correlation (p=.604) between age and knowledge. It is also the same with no significance, between the practice of radiographers in radiation protection safety with age (p=.136). Other than that, it seems there was no significant correlation between the level of certification of radiographers achieved with both knowledge and practice (p=1.000,1.000). Different from the others, it shows there were an association between years of radiographers being employed in the nuclear medicine department in the scope of practice (p=.007). However, there is no association in the scope of knowledge of radiographers in radiation protection safety in nuclear medicine toward years of service (p=.0118) Generally, from this analysis, it can be concluded that there was no association between demographic factors and the knowledge of radiographers toward radiation protection safety. However, there is a significant association between years of service of radiographers in the practice of radiation protection safety in the nuclear medicine department.

27 CHAPTER 5: DISCUSSION 5.1 Introduction To the best of our knowledge, this study is the first to examine the level of knowledge and practices among radiographers in the nuclear medicine department in the field of radiation protection safety in Malaysia. Previously, most studies about radiation protection safety were run in the radiology department rather than the nuclear medicine department. Holistically, this study aimed to determine the knowledge and practice of radiographers toward radiation protection in the nuclear medicine department. This study was conducted in four hospitals which include the nuclear medicine department at Hospital Sultanah Aminah Johor Bahru, Hospital Kuala Lumpur, National Cancer Institute and Hospital Pulau Pinang. Moreover, this chapter also addresses the substantial differences in radiographers' demographic factors either reflecting the knowledge and practice or not in the clause of radiation protection safety in the nuclear medicine department. Radiation protection in nuclear medicine is to ensure that the patient receives the anticipated medical outcome and that the process is maximized while minimizing the radiation risk to the patient, the medical field, and the public. 17 sets of questionnaires were distributed to the respondent. Meanwhile, only 16 respondents respond to the questionnaires. The finding of collected data will be discussed in this chapter. 5.2 Knowledge of Personnel Towards Radiation Protection Safety in the Nuclear Medicine Department Collected data had shown most radiographers have good knowledge of radiation protection safety in the nuclear medicine department. Based on Appendix 9, out of 16 samples, 10 (62.5%) of them have good knowledge of radiation protection safety, meanwhile, the rest have poor knowledge. Based on Fisher's exact test of independence, it has been analysed that there is no association between knowledge and demographic factors. A previous study revealed poor knowledge among personnel in radiation protection may lead to the absence of suitable university courses at the undergraduate and postgraduate levels followed by poor training (Hassan Mohamed Soliman et al., 2019). Globally, there has been a recognised lack of understanding of radiation protection knowledge among healthcare workers. Lack of radiation education poses a serious risk to the health of both personnel and patients (Frane & Bitterman, 2022). Other studies that evaluate radiographers' knowledge of radiation protection conducted

28 in Egypt show, gender had a significant predictor with the knowledge of radiographers' fields (Hassan Mohamed Soliman et al., 2019). Lack of appropriate undergraduate and graduate-level university courses as well as inadequate staff training may be to blame for the low level of knowledge in their study. Another study run in the nuclear medicine department at National Cancer Institute shows a moderate level of knowledge even after attending training programs among nurses working in the nuclear medicine department (Yunus et al., 2014). Studies in Saudi Arabia reveal that the annual dose limits for occupational exposure were only acknowledged by 27% of radiographers, and only 25% recognized the recommended limit for the pregnancy (Alotaibi et al., 2015). Meanwhile, in this study, only 7 (44%) of radiographers answered the correct answer regarding the annual dose limit for radiation workers. Based on Appendix 10, good knowledge in this present study was recorded mostly among female radiographers meanwhile only 2 males had good knowledge of radiation protection safety. A significance value of 0.118 between knowledge and gender shows that there is no correlation between the knowledge and gender of radiographers. Furthermore, a study to assess the knowledge, practice and attitude (KAP) of nuclear medicine staff toward radiation protection in Iran revealed that gender affects the level of radiation protection knowledge of staff with female staff having a better knowledge of radiation protection compared to male staff (Seifi et al., 2019). There was also no statistically significant difference between males and females in radiation protection knowledge, according to the study of the sex and knowledge association (p = 0.130) (Shabani et al., 2018). A related study conducted in Malaysia cannot relate the association between knowledge and gender since all participants are only females, (Mohd Rahimi et al., 2021). The outcome of this study may vary if the number of sample increase since the current study was done with a large gap between female and male respondents. Other than that, there is also no association between the knowledge of radiographers in radiation protection safety and the age of radiographers from this study. This study with a pvalue of .604 shows there is no correlation between both variables. Meanwhile, a previous study had shown a correlation between age and personnel in the radiation knowledge (Mohd Rahimi et al., 2021). It shows nurses aged between 28-37 years old have better knowledge of radiation compared to 18-27 years old age nurses. Based on Appendix 11, the highest group with good knowledge was recorded among radiographers aged 31 and older with (8) 50% of all radiographers. A study by Hassan Mohamed Soliman et al., (2019) shows there is an

29 association between knowledge and gender. The same study titled Assessment of radiation protection knowledge and practice among radiographers in the central region of Ghana stated regarding knowledge of radiation protection, the age group 25–35 years old had better knowledge (Fiagbedzi et al., 2022). Based on the present study, shows that the outcome of this study is contrary to this study. It may be due to an imbalanced number of radiographers in the distribution of ages. The small sample size may be the cause of this issue. In different factors, Fisher's exact test shows in Appendix 12, there is no association between the knowledge of radiographers and the level of education of respondents in this study. Appendix 12 shows almost all respondents with 93.8% of respondents being Diploma holders. Meanwhile, only 1 respondent 6.3% was a degree holder. Mohd Rahimi et al., (2021), in their previous study, did not state the correlation between certification and the knowledge of nurses. However, they revealed nurses who had not received radiation protection training, and nurses who got medical radiation education had substantially greater levels of this understanding with p+0.01 (Mohd Rahimi et al., 2021). However, a study conducted by Alavi et al., ( 2017) said respondents scored higher on knowledge tests the more educated they were. They concluded it’s more likely that having a higher education in the medical sciences and working around radiation will be linked to having greater knowledge. According to Alavi et al., (2017) study, levels of education were the most important predictors of knowledge based on the findings of the linear regression analysis. From this study, it can be seen most of the respondent was diploma holder compared to only one respondent being a degree holder. Most previous studies had revealed knowledge and level of certification was statistical significance. For example, a study conducted in Nepal revealed that graduates with a diploma had an average degree of radiation protection knowledge of 7.76 (55.42%) suggesting that the diploma holders were ignorant about radiation safety compared to medical physicists who have the highest knowledge level (Maharjan et al., 2020). To strengthen the significant association, another study also stated the correlation between knowledge in radiation protection and the level of certification (Bolbol et al., 2021; Fiagbedzi et al., 2022). However, in this study, it can be seen the result in the imbalance education level of radiographers may affect the result of the relationship between knowledge and education level supported by a small number of respondents. Most of the radiographers were diploma holders which contrary to the other certification group respondents.

30 In the context of the years of service of radiographers, the analysis from this study had shown there is no significant association between the years of service and the knowledge of radiographers (p=0.118) (Appendix 13). The highest frequency was recorded among radiographers with years of service more than 6 years who have good knowledge with 31.3% of respondents. In almost similar comparison to this study, nurses who have worked longer in nuclear medicine have better knowledge of radiation compared to nurses who working not over 4 years (Mohd Rahimi et al., 2021). Contrary to this study, the assessment of radiation protection knowledge among radiographers in Italy revealed knowledge and years of service were related (Paolicchi et al., 2016). It concluded radiographers who work less than 3 years had better knowledge compared to older radiographers. They conclude it as the factors of radiographers’ educational system changed. However, contrary to another study by Maharjan et al., (2020), there was no statistically significant between years of service and level of knowledge in radiation protection safety. However, students had knowledge better in radiation protection safety compared to non-student (Maharjan et al., 2020). It also in agreement with other study (Bolbol et al., 2021). The finding from this study regarding the correlation between service years and knowledge of radiographers cannot use to describe the total population since this study was run in certain hospitals only which involved only a small amount of sample size. A study on radiation safety knowledge showed that radiation workers had a critical need to improve their radiation protection knowledge (Paolicchi et al., 2016). Findings from numerous research have shown the importance of ongoing professional development for medical radiation workers in order to increase their understanding of radiation protection concerns and capacity for managing radiation exposure. Specific regular training courses should be implemented at regular intervals either at the institutional or national levels. Furthermore, it needs to involve every person who works in nuclear medicine especially. Good knowledge may affect good practice in radiation protection safety. 5.4 The Practice of Personnel Toward Radiation Protection Safety in. Nuclear Medicine Department The gathered information demonstrates nearly all radiographers have good practice in radiation protection safety in the nuclear medicine department (Appendix 9). It shows that about 81% of radiographers had good practice in radiation protection safety. Only a small number had poor practices of radiation protection safety with 19% of all respondents. A strong correlation

31 between some demographic parameters was recorded in the analysis outcome. A previous study by Hassan Mohamed Soliman et al., ( 2019) demonstrates a general lack of adequate radiation safety precautions across all radiographers. This is similar to a study conducted by Ricketts et al. (2013), which found that 92% of patients were not told about the radiation risks associated with the tests they were scheduled to have, and 50% of doctors reported that 0% to 25% of their patients had inquired about radiation risk, while the remaining doctors said that no patients had done so (Ricketts et al., 2013). The main objective of radiation protection is to give precise guidelines for using optimize radiation safely for the public, employees, and patients without experiencing any negative effects from optimize radiation.(López et al., 2018). Analysis results from this study had shown the correlation between the level of practice and gender of radiographers. This research uncovered that the significant value of both variables was not significant with a p-value of .518 (Appendix 14). A previous study by Shabani et al., (2018) revealed the relationship between radiation protection practice and sex was not statistically different (p = 0.330). Generally, the correlation between gender and level of practice in radiation protection safety among radiographers is likely to be minimal or nonexistent. Research on the topic is limited, and studies that have been conducted have shown no correlation between gender and the level of practice in radiation protection safety among radiographers. Another part of demographic factors which is age group also shows no association between the age of radiographers with the practice of radiographers toward radiation protection safety (p=.136). Appendix 15 shows there is no association between these two variables. It shows that the highest number (68.8%) of good practices was recorded among radiographers aged 31 years old and older. Meanwhile, the youngest age group which is 30 years old recorded only 2 (12.5%) radiographers in both good and poor categories of practice. This study outcome is in line with a study conducted by Fiagbedzi et al., (2022), who revealed that in the age range of 35 to 45, a high level of commitment to radiation protection practice can be seen. However, based on the frequency of age, this study was imbalanced with the majority of radiographers being aged 30 years old and more which is incomparable with the other age group. Other than that, another demographic factor that was evaluated in this study was the level of education of radiographers toward the practice of radiation protection safety (Appendix 16). Only 1 (6.3%) respondent was a degree holder meanwhile the rest were diploma holders.

32 It shows that 12 (75%) of radiographers with diploma holders have good practice in radiation protection analysis shows there was no association between these two variables (p=1.00). In another study by Fiagbedzi et al., (2022), they showed the correlation between the level of education and the level of radiographers’ practice toward radiation protection. It shows that radiographers with bachelor’s degrees have good practice in radiation protection than master’s holders (Fiagbedzi et al., 2022). A higher education degree fosters feelings of self-assurance, personal growth, self-realization, and professional achievement. By combining these characteristics, the staff generates greater professional satisfaction, which is crucial for delivering high-quality medical care (Seifi et al., 2019). Generally, the level of practice in radiation protection safety and the level of certification among radiographers are positively correlated. It is contrary to the finding of this study. It can be related to small samples which can result in overfitting, it may inhibit the model from extrapolating to new information. The model will be excellent at predicting the training data, but it won't be able to do it anyway (IBM, 2023). Holistically, from the analysis, this study showed an imbalanced number of respondents in the clause of their certification due to the low sample size in this study. Move to other demographic factors that may contribute to the level of practice of radiographers in radiation protection safety which is years of service. Appendix 17 shows an association between years of service and the practice of radiographers in radiation protection safety. Radiographers who had been employed in the nuclear medicine department for over 6 years have good practice in radiation protection safety in the nuclear medicine department with 12 (75%) of them. Meanwhile, the poor practices were only recorded by radiographers who were employed in the nuclear medicine department for less than 5 years. Alavi et al., ( 2017) revealed radiation protective behavior was substantially predicted by gender and radiation exposure history. Moreover, Shabani et al., (2018) in their study revealed those who had completed at least 15 years of service scored considerably better on the radiation protection practice than those who had not (p 0.001). The radiation protection practice score was significantly higher in the group with years of experience of more than 15 years than in the group with years of experience less than 15 years (p 0.001). As radiographers gain more experience and spend more time working in nuclear medicine, they will likely gain a deeper understanding of radiation protection safety and develop better practices for protecting themselves, their patients, and others from harmful radiation exposure. With the passage of time, radiographers will be exposed to different situations, equipment, protocols, and procedures and will have the opportunity to learn from their mistakes and successes. However,

33 it is also important to note that ongoing education and training in radiation protection safety is crucial to maintain and updating knowledge and practices because radiation protection safety regulations and guidelines are constantly evolving. However, this study cannot identify the total population since there is a very small sample size with there being mostly senior radiographers among respondents. In nutshell, the level of practice in radiation protection safety varies in different demographic factors. Anyhow, it is compulsory for those who work in the radiation area or work with radiation to practice good behavior. The three key terms “justification,” “optimization,” and “dose limit” are a concise description of the fundamentals of radiation protection against the risk of optimize radiation. Any medical radiation exposure must be justified, and optimize radiation-using exams must be optimized, to reduce the hazards associated with exposure. The examination must be beneficial and justified from a medical standpoint. When imaging is optimized, it must be done at doses that are ALARA (as low as reasonably possible), commensurate with the diagnostic task. All of these can be applied with good knowledge and good practice among personnel. Generally, the outcome from this discussion had shown most of the analysis comes with imbalanced value in each category. The sample size was too small. In these four hospitals, there was a limited number of radiographers who worked in the nuclear medicine department. The distribution percentages of radiographers were different in the four hospitals. Even though the sample size was almost 100% of the population in these four hospitals, the number of respondents was only 17. Furthermore, a small number of radiographers did not contribute to this study giving a large impact on the percentage of respondents. In Malaysia, nuclear medicine technologists may consist of medical assistants and medical lab technologists and radiographers themselves. The distribution of these multiple professions varies in each nuclear medicine department. Medical assistants and medical lab technologists in the nuclear medicine department were doing the same job scope as radiographers. However, there is no data found about this distribution. Only a survey in each hospital was done for information on nuclear medicine technologists’ distribution. An improvement can be made for future studies to involve nuclear medicine technologists in multiple professions and enlarge the sample size. From this study, it can be seen the limitation of the small sample size. A small sample size led to a greater average bias

34 (Beca et al., 2021). A sample size that is either too small or too large may make it difficult to generalise the results and highlight statistical differences that are not clinically significant (Altman, 1991). A study's power is reduced and the margin of error is increased when the sample size is too small, which might make the study irrelevant (Chris Deziel, 2018). A toosmall sample size raises the chance that a Type II error would distort the results, lowering the study's power. A Type II error happens when the study's findings support the original hypothesis while an alternate one is more likely to be correct. The margin of error has an inversely proportional relationship with sample size. As a result, decreasing the sample size reduces the study's confidence level. The margin of error also rises as the sample size is reduced. However, this study is still important even though the sample size is small because the scale of the influence investigated will eventually determine whether this is a significant concern in the knowledge and practice of radiation protection among radiographers in the nuclear medicine department. Due to the low sample size, another study can be made with an increase in the sample size to cover other hospitals and technologists who work in the nuclear medicine department (Ministry of Health Malaysia, 2022).

35 CHAPTER 6: CONCLUSION 6.1 Introduction The advice and safety measures that should be followed are covered in this part in order to enhance future studies and gather more reliable and accurate data. This final portion will also cover the limitations that the researcher faced while conducting the study. 6.2 Conclusion Essentially, this study presented the level of knowledge and practice towards radiation protection in the nuclear medicine department among radiographers in four hospitals that provide nuclear medicine services; (1) Hospital Sultanah Aminah, Johor Bahru, (2) Hospital Kuala Lumpur, (3) National Cancer Institute, Putrajaya and (4) Hospital Pulau Pinang. The objective of this study has been satisfactory in determining the level of knowledge and practice of radiographers in radiation protection safety in the nuclear medicine department. More than that, this study also addresses evaluating the level of knowledge and practice based on demographic data. The level of knowledge and practice has been determined using descriptive statistics of a total of 16 radiographers in four hospitals. Additionally, a good knowledge level, as well as assessment practice had been made. Therefore, the first and second objectives had been achieved. The third objective which was to correlate the level of knowledge and demographic data was achieved by analyzing the Fishers’ exact test. The method had been used due to the small sample size in the study. Generally, this study appoints several gaps which this study filled numerous gaps in the existing literature concerning radiographers' knowledge and practice in radiation protection in the nuclear medicine department as there is a lack of study-appointed radiographers in the nuclear medicine department in the context of radiation protection safety. Several actions can be taken into consideration in the future study. Even though this study’s result may not represent the population, it can be considered a kick-start in the nuclear medicine field, especially in radiation protection safety.

36 6.1 Limitation and Recommendation By increasing the study's sample size and population numbers, accurate data can be gathered. The results are therefore categorised as even more reliable because there are more respondents than in the current poll. Then, rather than only focusing on one particular location, a sizable sample of respondents from a variety of additional institutions should be obtained for the following study. As this study only focused on radiographers working in nuclear medicine and only involved four hospitals instead of six hospitals under the Ministry of Health Hospitals and other university hospitals. Another recommendation for the future is to utilize a questionnaire technique. The survey can then be distributed to the respondents via personal email rather than remaining connected via the WhatsApp® program. This is owing to the study's fault, which is that there is a strong tendency to overlook messages sent via WhatsApp® group. This can happen because the respondents' WhatsApp® program had too many other messages arriving, causing them to miss the Google Form® link address. A further proposal for future research is to broaden the study's scope rather than increase the number of respondents. For instance, the future study may expand its scope to include a broader circle of medical care professionals, such as doctors, physicians, medical lab technologists, medical assistants, staff nurses, medical attendants, and rather than concentrating just on the knowledge and practices of radiographers. Apart from that, the time allocation was insufficient for the researcher to conduct a more thorough investigation. This semester, the researcher has four months to complete the assigned research. Most of the research's accomplishments were limited by the limited number of studies' time and space. The researcher had to pay for the research himself, therefore this was the other restriction brought on by financial constraints. Because of this, the researcher chose a practical sample strategy. Last but not least, current research shows the diversity of the factors influencing knowledge and practice of radiographers in radiation protection in nuclear medicine departments. In order to increase the need for appropriate and consistent healthcare, it is

37 crucial to engage healthcare providers, fill gaps in knowledge, and enhance interpersonal involvement in radiation protection safety. In the remaining amount of this study, the performance of the employed methods will be carefully investigated, along with recommendations for future action to solve the problems identified.

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