Identifying The Factors Influencing The Attitude Of Radiographers To Their Professional Body

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IDENTIFYING THE FACTORS INFLUENCING THE ATTITUDE OF RADIOGRAPHERS TO THEIR PROFESSIONAL BODY

CHAPTER 1

Background of THE STUDY

1.1   INTRODUCTION

The discovery of the properties of x-rays just over a century ago gave medicine one of its most powerful and indispensable diagnostic tools (Murray, 2004). It is actually estimated that about 30% to 50% of critical medical decisions are based on x-ray examinations (Tavakoli, Seilanian Toosi & Saadatjou 2003:3). Today, the use of x-rays in both public and private health services is wide-spread in South Africa. And since x- rays are used for diagnostic purposes frequently, it is fairly well known to many patients, in developed urban areas as well as in rural areas not close to modern and sophisticated health care facilities.

Some patients feel it is so important to be x-rayed to the extent that if the doctor does not refer them for x-rays they and their families feel that the doctor has neglected them in some way (Murray, 2004). Many patients, according to Picano (2004a:579), demand examinations because they feel reassured by the use of high tech equipment. The rural hospital in one of the health districts of Enugu North LG where the researcher is employed is no exception.

Although the number of performed x-rays is on the rise, the majority of these x-ray examinations do not yield results that will alter or influence the course of clinical management. For instance, a study done in the United Kingdom (UK) on the importance of patient pressure and perceived medical need for investigations showed that physicians believed that about half of the investigation were only slightly necessary or were not needed at all (Little, Dorward, Stephens, Senior & Moore 2004:445). In the same vein, Levin and Rao (2004a:169), argue that much of this rise in demand is unnecessary and wasteful. Thus, the number of radiological studies performed is in excess of those actually required for diagnostic purposes (Cascade, Webster & Kazerooni 1998:561). These researchers estimate the volume of unwarranted radiological tests in the United States of America to be in the range of 10%-50%. Picano (2004a:579), on the other hand, writes that up to a third of radiological examinations are totally or partially inappropriate.

The unnecessary use of medical x-rays and the associated radiation risk remain a major concern to many health workers, patients and authorities in some countries (Mubeen, Abbas & Nisar 2008: 118). This, however, is not the case at the rural hospital where the researcher works. Patients here believe that x-rays are essential as a diagnostic tool in many conditions where the doctors’ clinical judgment indicates they are not essential. This mindset concurs with the results of a qualitative study on the importance of radiological imaging which showed that 72% of the 93 patients investigated considered radiological imaging as ‘‘very important’’ (Balagué & Cedraschi 2006:509). The findings of these researchers and many other studies raise the question of the reasons for the importance patients confer on radiological examinations.

Literature indicates that even with a reduction of up to 50% of x-rays, care and treatment of patients would not be influenced negatively (Murray, 2004). Bouzarjomehri (2003:121) holds the same view: namely, that exposure to medical x-rays can be reduced substantially without compromising quality. Many of these x-ray examinations that are demanded by patients are not in anyway associated with improved physical functioning or reduced pain. Therefore, elimination of these unnecessary x-ray examinations could, apart from leading to significant reduction in the unnecessary radiation exposure to the patient, lessen the undue pressure that is exerted on limited health care resources and budgetary constraints. This may result in a meaningful economic impact. Furthermore, the reduction would accord faster access to radiographic services to those patients who really need them.

1.2  BACKGROUND OF THE PROBLEM

1.2.1   Historical overview of medical x-rays

 Radiography started in 1895 after the discovery of x-rays and since then it has become an integral part of any health care system. Since the discovery, x-rays have been utilised for both diagnostic and therapeutic purposes and its use for medical purposes has continued to grow (Ratnapalan, Bentur and Koren 2008:1293). Currently, radiological imaging is the second most rapidly growing sector of the health care industry (Lee, Saokar, Dreyer, Weilburg, Thrall & Hahn 2007:858). The use of x-rays as a diagnostic tool and their contribution towards patient management is enormous. According to Tavakoli et al (2003:3), the benefits of ionising radiation to the patient are considerable in terms of comfort, diagnostic and therapeutic effectiveness. However, x-ray examinations can be expensive and x-rays are potentially hazardous.

Unlike other aspect of preventative health care like patient drug compliance, very few studies have been conducted on factors influencing the demand for radiology or x-rays as a predominant diagnostic tool. It seems as if some of the patients believe being x- rayed will cure the sickness or prevent it. In the perception of this researcher, patients’ demand for x-ray examination is high at this enugu north rural hospital compared with the demand at other hospitals where the researcher worked before.

Patients’ knowledge about x-rays may be an important factor in influencing their behaviour in connection with x-rays. Poor knowledge of x-rays by patients at this enugu north rural hospital, for instance, may account in part for the high numbers of patients demanding x-ray examinations. Furthermore, poor knowledge may also lead to misconception and myths about medical x-rays.

1.2.2   X-ray utilisation

 Ideally a request for an x-ray examination is determined by clinical factors. Therefore performance of an x-ray examination, regardless of the results, should be beneficial and should significantly influence the course of patient care management. However, in the experience of the researcher, most patients visiting the Out Patient Department (OPD) of the rural enugu north hospital where the researcher is employed insists on having an x-ray done irrespective of their clinical conditions. From the patient’s perspective, if the doctor does not refer him/her for the x-ray examination, the patient and his/her relatives feel that the doctor has in some way neglected them. To an extent, this concurs with the results of a study practice which showed that patients were likely to give a low rating for care in cases where they perceived that their legitimate requests were denied or ignored (Kravitz, Bell, Azari, Krupat, Kelly-Reif & Thom 2002:47). Even though the x-ray examination in itself does not relieve pain, a lot of patients prefer to have it done because they believe it is essential. This mind set is in line with the views of Werner (2008:28) who indicates that both health providers and patients in general seem to have faith in imaging as a useful tool. What the patients know and believe about x-rays, however, appears to be a problem, because they are not aware of the specific indications.

The result of what is described above is the substantial overuse of x-ray examinations resulting in unnecessary radiation exposure of patients, unnecessary demand for professional time and the monetary cost which is enormous in relation to the limited health care resources. Studying the validity of radiological requests, Blake (1995) reported that at least 20% of radiological examinations carried out in the UK’s National Health Service (NHS) were clinically unhelpful. This, he added, translates to an annual average of seven million unnecessary x-ray examinations for the whole country costing about £60million (R780million). In this vein, Bairstow, Mendelson, Dhillon and Valton (2006:51) are of the view that unwarranted services are the most significant threat to the effective allocation of health care resources. Patients’ lack of adequate knowledge about the cost, limitation and associated risks of diagnostic x-rays may be potential barriers to effective reduction of unwarranted x-rays.

Hence in order to better understand and help patients change this behaviour, which in this case is the demand for x-ray examinations, health care workers need to be aware of factors that influence patients to behave in the way they do. Therefore, an effective health education promotion strategy to stem this trend will necessitate sound and fact- based knowledge of factors that influence patients’ demand for x-ray examinations.

1.3  POSSIBLE FACTORS THAT COULD INFLUENCE PATIENT BEHAVIOUR

In order to curb patients’ demand for x-ray examinations it is important to know and understand factors that influence them.

1.3.1   Perception

Perception, according to Wallace, Robertson, Millar and Frisch (1999:1144), could be either positive or negative on a theme; which is x-ray examination in this regard. Perception is affected both by internal and external factors. Internal influences includes past learning, motivation and expectation.

The way patients perceive the benefits and risks of medical x-rays is often subjective. Patients’ views of benefits and risks are frequently such that they differ from medical assessment. Therefore, one is likely to assume that the perception of a patient will be influenced by many factors.

1.3.2   Influence of health workers on patient behaviour

Issues related to health care workers is another set of modifying factors that have been identified as having influence on patients’ preference for medical x-ray. The manner in which health staffs advise a patient the first time he/she demands to have an x-ray could have an impact, even in cases where x-rays are not requested by the doctor. For instance, a study conducted by Espeland and Baerheim (2003) identifies issues other than clinical criteria that would affect general practitioners’ decisions about ordering plain radiography for back pain. Some of the issues identified by these researchers are related not only to patients’ wishes but also to pressure from other health care providers. This, though, is despite the fact that the use of medical x-ray imaging should be rightfully determined by clinical factors.

1.3.3   Public health media campaigns

 Of late public health has been moving towards changing health-related behaviour by focusing on individual behavioural risk factors such as drug and alcohol abuse, smoking and encouraging women to undertake mammography screening (Corso, Hammitt, Graham, Dicker & Goldie, 2002:93; Chin, Monroe & Fisicella, 2000:317). While health- related media campaigns have been used to improve individuals’ knowledge and behaviour towards a number of health issues such as tuberculosis, malaria and HIV/AIDS, very little has been done about informing the public about the risks associated with medical x-rays.

For instance, a study done in Finland on the evaluation of written patient educational materials in the field of diagnostic imaging emphasised the need for patients to be well informed when coming for a radiographic examination (Ryhänen, Johansson, Virtanen, Salo, Salantera & Leino-Kilpi 2009:e2). Awareness campaigns, pamphlets  and education should be used to inform both patients and health workers about the benefits, costs and risks associated with medical x-ray imaging. This might reduce patients’ demand for x-ray examination and thereby enhance effective utilisation of medical x- rays.

1.4  PROBLEM STATEMENT

  In the present era of increasing cost, attention has been given to the use of public health resources including medical x-ray imaging. Yet with regard to the utilisation of medical x-rays little success has been recorded. This failure, according to Wilson, Dukes, Greenfield and Hilman (2001:257), may be that not enough is known about the determinants of the use of radiological testing. In particular little is known about factors influencing patient preferences for x-ray examination. If factors which influence patients’ demand for x-ray examination were to be identified it might be possible to change this patient behaviour which in some ways is detrimental to the very health they are trying to improve. Thus, successful implementation of strategies that will reduce unnecessary use of medical x-rays by patients will need to be informed by research (Martin, Bates, Sussman, Ros, Hanson & Khorasani 2006:8).

The problem is that this researcher could not find a specific study that has been done to describe and explore factors influencing patients’ demand for x-ray examinations, specifically in South Africa. Furthermore, the little literature on the factors influencing patient demand for x-ray examination brought to the fore the fact that medical x-ray services and factors that prohibit or enhance its utilisation by patients remain complex. Yet, the researcher has over years of practice in several hospitals in this region noticed an upward demand for diagnostic x-rays by patients. This demand has been characterised by possible unwarranted radiation exposure to the patients and wastage of scarce health care resources. There seems to be a rise in the cost of imaging resources and unwarranted demand for professional time. Why, then, this high expectation? What are the factors influencing patients’ high demand for x-rays at a hospital in rural enugu north? It is against this background that this study was proposed in an attempt to identify and describe factors influencing patients’ demand for x-ray examination.

1.5  AIM AND OBJECTIVES OF THE STUDY

The aim of this study was to describe social demographic factors that influence patients’ demand for x-ray examinations in the rural area of enugu north.

Objectives of this study are to:

  • identify the social demographic characteristics of patients who prefer x-ray examination in rural enugu north
  • determine the patients’ level of knowledge of x-rays.
  • determine and or identify factors other than sociodemographic that may influence patients’ demand for x-ray examinations in rural enugu north.

1.6  SIGNIFICANCE

Although many patients seem to be fond of x-ray examination, serious concerns about health risks have been raised. Previously there has been a mistaken assumption that

exposure from x-ray examination was negligible. But evidence is now overwhelming that there is no threshold dose (Gofman, 2001). This means that every exposure to the x- ray by the patient counts and the consequences accumulate. Therefore, even though general radiography delivers low doses well below 10mGy, it is believed that stochastic effects occur even at these low doses. Hence the International Committee on Radiation Protection (ICRP) considers it scientifically reasonable to assume that the incidence of induced cancer or hereditary effect rises in proportion to increased absorbed dose (Mathews & Brennan 2008:350). Some of the radiation exposure risks include cancer, leukaemia, infertility, skin burns, cataract and genetic effects. In fact the possibility for cell mutations already exists but x-ray exposure can trigger these mutations to begin to develop. A study conducted in the United Kingdom and 14 other countries showed that Japan has the highest annual exposure to diagnostic x-ray and the highest (3.2%) estimated cancer risk attributable to it (de González & Darby, 2004:350).

Because of the technical nature of the topic, radiation risk is typically misperceived by the public in general and the patient in particular. Lack of awareness of the risk associated with x-ray radiation becomes pertinent when one considers the number of patients who receive unnecessary radiation exposure (Shiralkar, Rennie, Snow, Galland, Lewis & Gower-Thomas 2003:372).

Knowing patients’ knowledge about x-rays has an important significance for stemming the trend and consequently not only reducing wastage of resources but also protecting patients from unwarranted radiation. Thus, the development and implementation of feasible strategies to reduce unnecessary patient demand may lie in the understanding of influencing factors (Little, Cantrell, Roberts, Chapman, Langridge & Pickering 1998:264). These results can help to formulate a plausible strategy for the reduction of unwarranted x-ray examinations.

1.7  DEFINITION OF KEY CONCEPTS

The word ‘concept’ according to Ahonen (2008:289), means a mental impression of a certain object or phenomenon.

Diagnostic radiation: Primarily, but not exclusively, x-rays and it also includes fluoroscopy and CT scans (Gofman, 1999). For the purpose of this study x-ray examinations included only conventional radiography.

Patient: Oxford Advanced Learner’s Dictionary (2005:1068) defines patient as a person who is receiving medical treatment, especially in a hospital. For the purpose of this study, a patient is defined as any individual who comes to the hospital seeking health services as an in-patient or out-patient.

Demand: Oxford Advanced Leaner’s Dictionary (2005:388) defines demand as a very firm request for something that somebody needs. For the purpose of this study demand is can be defined as patient request to have an x-ray examination regardless of the outcome of the clinical investigation.

X-ray examinations in the context of this study means the process of undergoing a general radiographic test by the patient.

1.8  OVERVIEW OF RESEARCH DESIGN AND METHODOLOGY

In chapter 3 the research approach and methodology is described in detail. The following is a summary of that outline.

1.8.1   Research design

Research design is defined as a blueprint for a study (Burns & Grove 2005:211). A non- experimental, quantitative research approach was used in this study. A survey was done, which, according to Polit and Beck (2008:323), is a strategy designed to obtain information about different aspects of people

1.8.2   Study population

Burns and Grove (2005:342) describe population as the entire set of individuals having some common characteristics. In this study the population included all patients seeking health care at the rural enugu north hospital where the researcher is employed.

1.8.3   Sample size

A non probability sampling approach: namely, convenience sampling, was used to select a sample of 110 patients.

1.8.4   Data collection

The research data was collected by means of a structured questionnaire over a period of three weeks.

1.8.5   Approach to data analysis

Using Epi 6 info, data analysis included descriptive and inferential statistics. The choice of statistics was based on the fact that most of the variables that were measured were categorical.

1.8.6   Reliability

Some researchers define reliability as dependability of the measurement instrument thus the extent to which the instrument gives the results when repeated (Terre Blanche et al 2006:152). The questionnaire was pilot-tested on patients before the actual study to ensure reliability of data collection instruments.

1.8.7   Validity

 Elasy and Gaddy (1998:757) describe validity as the extent to which an instrument measures what it purports to measure. To enhance content validity the questionnaire was pre-tested on a number of patients.

1.8.8   Ethics

An ethics application for permission to conduct a study in the hospital was submitted to the Provincial Health Research and Knowledge Management. Consent from respondents was obtained by means of oral consent. Permission was also sought from UNISA’s ethics committee.

1.9  SCOPE AND LIMITATION

This study focused only on patients seeking health care services at a enugu north rural hospital. Therefore, results may not be generalised to the entire enugu north province let alone to the entire population of South Africa.

This research was limited to studying the factors that influence patient’s demand for diagnostic x-ray examinations particularly those seeking health care during day time. This, then, means that those patients who came after hours and during weekends were excluded. Furthermore, convenience sampling was used in the selection of respondents and as this method does not allow for a representative sample to be selected the difference between the sample and the study population was not ascertained. The effect of this bias was, therefore, not determined. Another limitation of this study is that it was cross-sectional representing one point in time. This means that the study was unable to represent possible changes of individual factors over time.

1.10  CONCLUSION

 The discussion in this chapter provides the introductory information on the study. The reader was oriented on the background to the study, the problem statement, aim and objectives of the study, as well as the significance of the study. A review of the literature follows in the next chapter.

IDENTIFYING THE FACTORS INFLUENCING THE ATTITUDE OF RADIOGRAPHERS TO THEIR PROFESSIONAL BODY

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