© I. Harbaj et al., Published by EDP Sciences 2025

1 Introduction

Medical imaging has advanced significantly in recent decades, and it is now a crucial tool for diagnosing and treating a wide range of pathologies. Technological advances, particularly in X-rays and computed tomography (CT), have significantly increased diagnostic accuracy, enhancing care quality. However, this development has resulted in a considerable rise in patient exposure to ionizing radiation. From 2009 to 2018, 4.2 billion radiographic exams were conducted annually globally, including diagnostic, interventional, and nuclear medicine radiography. Notably, CT scans, which account for only 9.6% of all radiological examinations, contribute 61.6% of the total collective dose due to their higher exposure level. CT exams have increased by 82%, reaching an annual volume of over 400 million, demonstrating the rising relevance of this modality in medical imaging (UNSCEAR, 2022).

To address these challenges, medical practitioners must understand radiation protection principles and the radiation doses corresponding to the different types of imaging. The principle of justification is fundamental, requiring a convincing demonstration that any radiation exposure results in a significant diagnostic or therapeutic benefit that outweighs the potential risks (ICRP, 2007). This notion is particularly pertinent in the context of CT scans, which add considerably to total radiation exposure. Strict adherence to justification criteria is critical not just for reducing radiation exposure but also for optimizing the use of healthcare resources.

This development raises serious concerns about the potential health effects of increased radiation exposure, particularly radiation-induced cancers (Nahangi and Chaparian, 2015; Karimizarchi and Chaparian, 2017). Although most studies on the overuse of imaging tests focus on expensive, high-dose radiation procedures like CT scanning, it is critical not to ignore the possible negative consequences of low-dose examinations (Bonnici, 2021). Around the world, rising concern focuses on inadequate compliance with justification requirements for radiological exams (Lehnert and Bree, 2010; Vilar-Palop et al., 2018; Martins et al., 2020), often linked to prescribing physicians’ lack of knowledge about radiation protection. Several studies consistently highlight a lack of awareness regarding radiation doses and related hazards, leading to a common overestimation of the dangers associated with these procedures (Kada, 2010; Rehani, 2017; Bwanga, 2019; Bonnici, 2021).

The Moroccan context reflects the worldwide trend. Research in Morocco shows that many physicians remain uninformed about the hazards of radiation exposure, particularly the radiation dosages associated with CT scanning. For example, numerous practitioners underestimate the potential harm of low-dose X-rays (Semghouli et al., 2017; Tahiri et al., 2022; Amaoui et al., 2023).

Furthermore, it has proved that general practitioners, serving as the primary prescribers of medical imaging exams, prescribe less suitable examinations than specialists. For example, Spanish research found that general practitioners request 40.4% of inappropriate referrals compared to 18.9% for hospital specialists (Vilar-Palop et al., 2018). These findings highlight the importance of appropriate education for practitioners to accurately assess the necessity for diagnostic testing, understand the risks involved, and make adequate decisions.

In this context, this study aims to evaluate Moroccan general practitioners’ knowledge, attitudes, and practices regarding the justification of radiological exams and to identify the factors that influence these practices. The findings might have significant implications for Moroccan medical education and clinical practice, potentially contributing to better radiation protection measures and more appropriate use of medical imaging.

2 Materials and methods

Between January and March 2024, 367 Moroccan general practitioners working in various health institutions nationwide participated in this descriptive study. The study examined their knowledge of the justification for radiological tests, their attitudes toward this justification, and their practices, particularly concerning computed tomography (CT).

A structured electronic questionnaire, developed based on data from the scientific literature, was created using the Google Forms platform and then distributed to general practitioners via multiple social media networks. The questionnaire consisted of 44 items, including multiple-choice and Likert scales. It examined participants’ personal and professional characteristics, as well as their knowledge and attitudes toward justifying radiological examinations and their practices.

The first part discusses the participants’ general characteristics, such as gender, age, professional experience, radiation protection training, level of satisfaction with the training, the need for more training, and scanner prescription routines.

The second section included 12 multiple-choice questions designed to assess general practitioners’ knowledge of the justification for radiological examinations. The topics covered comprised identifying irradiating examinations, determining the least invasive alternative to CT scanning, knowing the presence of radiation-induced cancer risk from the dose of ionizing radiation associated with computed tomography (CT) scans, recognizing the most sensitive tissue to ionizing radiation, identifying the most vulnerable age group, knowing the dose limit for pregnant women, the mean dose administered in a typical abdominopelvic CT scan, awareness of the comparative effective dose between a chest CT scan and a chest X-ray, understanding the meaning of the justification principle in radiation protection, identifying the essential criteria for justifying a radiological examination, knowing the need to document the justification for an examination and finally understanding the conditions warranting a reevaluation of the rationale for a radiological examination.

The third section comprises 12 statements designed to evaluate general practitioners’ attitudes toward the justification for radiological examinations. These statements evaluate various aspects, including physicians’ responsibility in justifying radiological procedures, their focus on systematically assessing the benefit-risk balance for each examination, their adherence to best practice guidelines, and their commitment to continuously evaluating the justification for examinations. Additionally, the section explores their views on incorporating continuing education to justify radiological exams, the importance of collaborating with radiologists, their approach of advising patients about the hazards resulting from CT scans before prescribing them, and their awareness of the need to reduce unnecessary medical examinations. The section also evaluates their perspectives on how enhanced patient communication might decrease the number of unnecessary scan requests, their confidence in justifying radiological procedures, the importance of conducting pregnancy tests before radiological exams in women of childbearing age, and their perspectives on over-prescribing scans.

The replies to these assertions get scored on a Likert scale with five points, ranging from “strongly disagree" (1 point) to “strongly agree" (5 points). Possible scores vary from 12 to 60 points, with higher scores suggesting a more positive attitude about the justification for radiological tests and a greater predisposition to adopt appropriate practices.

The final part consisted of 12 questions about general practitioners’ practices in justifying radiological exams. Participants were required to specify how frequently they used the following practices: assessment of clinical indications and consideration of non-ionizing alternatives, taking into account the age of the patient when prescribing a radiological examination, systematic verification of recent imaging history of the patient, consultation of good practice guidelines, assessment of the benefits and possible hazards associated with the use of X-rays, discussion of the need for the examination with a radiologist, clarification of the specific clinical question on the prescription, providing comprehensive information to the patient about the potential risks of radiation and the benefit-to-risk ratio before ordering a scan, requesting beta-HCG measurements in women of childbearing age before prescribing an abdominopelvic scan, refraining from requiring a repeat radiological examination even if the quality of the images or the initial interpretation is imperfect, systematic refusal of radiological examinations requested by patients, and responding to patients’ concerns about the hazards of X-rays. Respondents rated the frequency of these practices on a Likert scale with five points, from "Never" (1 point) to “Always” (5 points).

After developing the questionnaire, a pilot study was conducted with 20 participants from the target group to test the tool’s validity and reliability. Cronbach’s alpha values for attitude scores were 0.75, while for practice scores, they were 0.79. Participants received written notification that their participation was voluntary and anonymous, and they provided informed consent by completing the questionnaire.

The data were analyzed statistically using SPSS version 26 software. Participants’ demographic profiles, knowledge, attitudes, and practices regarding radiological examination rationale were detailed using descriptive statistics such as frequencies, percentages, averages, and standard deviations. Independent-sample t-tests and one-way analyses of variance (ANOVA) were applied to compare differences in participants’ knowledge, attitudes, and practices, with Tukey post-hoc testing utilized when necessary. Pearson’s correlation coefficient was employed to examine the relationship between knowledge, attitudes, and practices related to radiological examination justification. Finally, multiple regression was applied to study the factors influencing practices concerning the justification of radiological examinations. A p-value of <0.05 was considered statistically significant.

To ensure the highest quality of scientific reporting in our study, we used ChatGPT (GPT-4) exclusively for linguistic and grammatical revisions, while the scientific content was entirely developed by the authors.

3 Results

3.1 Participant socio-demographic data

A total of 367 general practitioners participated in our study. Table 1 displays the participants’ demographic and professional details. Males made up 54.0% of the sample (n = 198). The most represented age group was 30–39 (38.1%). A significant proportion (39.8%) had less than five years of experience in their line of work. For 51.0% of the doctors, public hospitals were the primary practice setting. 89.1% of participants had received basic radiation protection training. However, 86.9% deemed this training inadequate. Notably, none of the participants had undergone additional training in this area. Furthermore, 97.8% of the surveyed physicians indicated a need for further training, and all reported prescribing CT scans as part of their clinical practice.

3.2 Participants’ knowledge, attitudes and practices regarding the justification of radiological examinations

Participants’ average knowledge score on the justification of radiological exams was 6.41 ± 1.36 out of 12 points. The average attitude score towards radiological examination rationale was 3.79 ± 0.42 out of 5 points, while the average practice score was 3.38 ± 0.42 out of 5 points (see Tab. 2).

3.3 Variations in knowledge, attitudes, and practices in justifying radiological examinations based on participants’ socio-demographic characteristics

Table 3 shows the survey results for knowledge, attitudes, and practices related to the justification of radiological tests depending on general practitioner characteristics. Gender analysis indicated significant differences in attitudes (t = 2.39, p = 0.017) and practices (t = 2.91, p = 0.004), with women performing better. However, the analysis did not reveal a statistically significant difference in knowledge (F = 1.12, p = 0.263). Older doctors and those with over ten years of experience scored significantly higher in all three areas (p < 0.001). In terms of their workplace, doctors in public hospitals or private practices scored better in knowledge (F = 6.911, p = 0.001), whereas doctors in private practices scored higher in attitudes (F = 7.61, p = 0.001) and practices (F = 4.64, p = 0.10). Doctors who did not receive radiation protection training scored considerably higher in all three areas (p < 0.001 for knowledge; p < 0.01 for attitudes and practices).

3.4 Correlation between knowledge, attitudes and practices related to the justification of radiological examinations

The correlations between knowledge of the justification of radiological examinations, attitudes towards this rationale, and associated practices were analyzed. As shown in Table 4, knowledge of radiological examination justifications exhibited a statistically significant positive correlation with attitudes toward this subject (r = 0.566, p < 0.001). Moreover, this knowledge is also significantly correlated with justification practices (r = 0.547, p < 0.001). Furthermore, attitudes towards justification reveal a significant association with practices (r = 0.517, p < 0.001).

3.5 Factors influencing practices for justifying radiological examinations

A multiple regression analysis was employed to determine the factors that impact general practitioners’ practices regarding the justification of radiological exams. The regression model incorporated statistically significant characteristics from the univariate analysis, such as gender, age group, professional experience, workplace, and radiation protection training. Furthermore, the model included independent variables that correlated significantly with justification practices, such as knowledge about the rationale of radiological examinations and attitudes toward their justification. We created dummy variables by converting categorical data, including gender, age group, total work experience, workplace location, and radiation protection training. We examined the dependent variables’ multicollinearity and autocorrelation. The Durbin-Watson score of 1.926 suggests that the dependent variable has no autocorrelation. The correlations among the independent variables ranged from −0.18 to 0.55, with none exceeding 0.80, indicating that the explanatory factors were independent. Tolerance varied from 0.12 to 0.95, above 0.1, while the variance inflation factor (VIF) was between 1.05 and 8.10, below 10, indicating the absence of multicollinearity. Regression analysis was consequently deemed appropriate for the study’s data.

The regression model was significant (F = 20.42, p < 0.001) and had a 42.8% explanatory power for radiological examination justification practices. Factors influencing general practitioners’ practices included knowledge of radiological examination justification (β = 0.28, p < 0.001), attitudes towards justification (β = 0.24, p < 0.001), gender (β = 0.24, p < 0.001), and age. The 40-49 (β = 0.33, p = 0.004) and over-50 (β = 0.36, p = 0.001) age groups significantly influenced these practices. In contrast, work experience, workplace, and radiation protection training did not have a considerable influence (p > 0.05) (Tab. 5).

4 Discussion

The current study evaluated general practitioners’ knowledge, attitudes, and practices concerning the justification of radiological examinations, investigating the links between these characteristics and identifying the factors that influence these practices. The goal was to provide baseline data to guide the development of future educational programs focused on improving radiological examination justification practices among general practitioners.

The results indicate a moderate level of comprehension regarding the rationale of radiological exams, with a mean score of 6.41 ± 1.36 out of 12 points. This result is consistent with previous studies that indicated insufficient knowledge and underestimated the radiation doses and hazards associated with conventional diagnostic imaging procedures (Kada, 2010; Willoughby et al., 2013; Moifo et al., 2014; Semghouli et al., 2017; Bwanga, 2019; Tahiri et al., 2022; Amaoui et al., 2023). Similarly, a Norwegian study also showed that medical students had similar shortcomings, with an average score of 3.91 out of 11 points, underscoring the urgent need to improve radiation protection training in medical curricula (Kada, 2017).

The mean attitude score for justifying radiological testing was 3.79 ± 0.42 out of 5, indicating a high level. This result is consistent with a comparable study, which demonstrated that 74.6% of prescribing physicians had a favorable attitude toward the rationale of radiological tests (Bwanga, 2019).

The practice of justifying radiological exams received a moderate rating (3.38 ± 0.42 out of 5). This conclusion is similar to earlier studies that have revealed deficiencies in physicians’ practices. For example, only 12% of CT scan prescribers inform their patients about the hazards caused by radiation exposure (Amaoui et al., 2023), that general medical interns do not systematically discuss radiological risks with their patients (Willoughby et al., 2013) and that only 10% of doctors use CT examination guidelines (Semghouli et al., 2017). However, another study found that more than half of prescribers (61.3%) accurately follow procedures for justifying radiological exams (Bwanga, 2019).

The findings also revealed that females outperformed males in attitudes and practices, but there was no significant difference in knowledge. Women’s meticulous approach to clinical decision-making and more compassionate communication with patients may have contributed to this outcome. Furthermore, older doctors and those with ten or more years of experience performed better in all three domains, highlighting the value of professional experience. Additionally, doctors working in private practice exhibited better knowledge, attitudes, and practices.

Regarding radiation protection training, 89.1% of participants reported having received formal instruction—a finding that stands in stark contrast to previous studies where only 28% and 35% of participants had received training in radiology and radiation protection, respectively (Willoughby et al., 2013; Bwanga, 2019). A recent study in Morocco highlighted this disparity, revealing that only 20% of clinicians had undergone radiation protection training (Amaoui et al., 2023). Interestingly, our study revealed an unexpected pattern: practitioners without formal training achieved higher scores across all three domains (knowledge, attitudes, and practices) than those with initial radiation protection training. This finding contradicts the results of similar studies (Kada, 2010; Yuan et al., 2024; El Fahssi et al., 2024), which demonstrated that formal training typically enhances knowledge and promotes practices aligned with radiation protection standards.

Our analysis suggests that older and more experienced practitioners have developed effective ways to compensate for their lack of initial training. They employ various learning strategies, including self-directed study, peer-to-peer knowledge exchange, and learning through extensive hands-on experience in clinical situations where radiation protection is crucial.

Furthermore, the ineffective nature of radiation protection training during medical studies in Morocco may explain this result. The training sessions, which occur in the early semesters (Amaoui et al., 2023), focus too much on theoretical concepts and fail to provide practical applications that align with field requirements. 86.9% of participants supported this finding, considering their training insufficient. Another limiting factor is the lack of continuing education among all study participants. Ongoing training would have allowed practitioners to update their knowledge of technological advances and new radiation protection guidelines. As a result, untrained practitioners have developed solid radiation protection skills through practical experience and self-learning, matching or surpassing the impact of formal training, which often proves too theoretical or poorly suited to field needs.

Moreover, our study revealed significant positive correlations between general practitioners’ knowledge, attitudes, and practices regarding the justification of radiological examinations. Physicians with a better understanding of justification principles generally adopt more favorable attitudes and appropriate practices. This result underscores the importance of enhancing knowledge and improving attitudes to foster practices that comply with radiation protection standards. A coherent educational strategy, combining robust theoretical training with contextualized practical training, is essential to optimize the quality and safety of radiological care. However, this observation contrasts with another study, which found no significant association between knowledge, attitudes, and practices related to the justification of radiological examinations (Bwanga, 2019).

Finally, the multiple regression analysis identified several factors influencing justification practices. Knowledge of participants, along with their gender, age, and attitudes, emerged as significant predictors. The model explained 42.8% of the total variance in observed practices. In contrast, professional experience and workplace location had no significant effect. Despite untrained practitioners achieving higher scores, the analysis did not identify radiation protection training as a determinant predictor of justification practices.

These findings highlight the need to revise foundational radiation protection training programs and implement mandatory targeted continuous education to regularly update physicians’ knowledge in line with current clinical requirements. Future studies should use qualitative methodologies, such as interviews or focus groups, to better understand practitioners’ sources of knowledge and their perceptions of the usefulness of existing training programs. These efforts will help address the gaps identified in this study and align training outcomes with tangible enhancements in clinical practices.

5 Conclusion

The current study evaluated Moroccan general practitioners’ knowledge, attitudes, and practices concerning the justification of radiological exams, revealing moderate knowledge and practices despite positive attitudes. The results show a significant correlation between knowledge, attitudes, and practices. Further research showed that doctors’ age, gender, knowledge, and attitudes positively influenced their practices, with older doctors and women achieving better results. Interestingly, radiation protection training programs appeared less effective than anticipated, as those without such training achieved better results. Consequently, it is crucial to reevaluate and strengthen these programs by focusing on practical cases and real-life scenarios while developing continuous training and local support tools. Additionally, awareness campaigns and ongoing monitoring of prescribing practices are essential to improve the justification of radiological examinations and support physicians in their daily work.

Funding

This research did not receive any specific funding.

Conflicts of interest

The authors declare that they have no conflict interest.

Data availability statement

The research data associated with this article are including within the article.

Author contribution statement

I. Harbaj: methodology, data collection, data analysis, writing. A. Kharchaf: questionnaire design, data analysis, writing. E. Chakir: writing-reviewing. S. Harbaj: data collection, data analysis.

Ethics approval

Ethical approval was not required.

Informed consent

This article does not contain any studies involving patients and the participation of the nurses was voluntary.

References

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