Image Gently, Step Lightly: Increasing Radiation Dose Awareness in Pediatric Interventions through an International Social Marketing Campaign

Children and Radiation Safety 

IN March 2009, the National Council on Radiation Protection and Measurement released a critical report (1) indicating that radiation dose exposure to the United States population had increased dramatically since the early 1980s. This report disclosed that US citizens had experienced a sevenfold increase in radiation dose, with computed tomography (CT) scans and nuclear medicine being the two largest contributors to medical radiation. Fluoroscopy used during interventional procedures is the third largest contributor of medical radiation to the public in the United States, accounting for 14% of the medical radiation dose (1). Although children undergo medical imaging and intervention in smaller numbers than adults, they are more sensitive to radiation effects and have a longer lifespan during which to manifest possible changes as a result of radiation exposure. In addition, some children who undergo interventional procedures may have chronic illnesses and receive a higher lifetime cumulative dose as a result of repeat procedures and exposure (2, 3, 4, 5, 6).

There is controversy among medical physicists and medical experts as to whether lower doses of medical radiation cause cancer (7, 8, 9). However, extrapolation from atomic bomb data, using the linear no-threshold model, suggests that even low doses have led to a small but increased incidence of cancer within that study population (10). It therefore behooves the medical community to act responsibly and conservatively by promoting radiation protection for children and health care workers during fluoroscopy. The purpose of this communication is to inform the interventional radiology community of simple strategies that may be readily implemented locally to decrease radiation dose during interventional radiology procedures. The Image Gently Step Lightly campaign is a grassroots effort of the Alliance for Radiation Safety in Pediatric Imaging and is supported by its partner, the Society of Interventional Radiology (SIR). By using the educational tools provided on the Web site (www.imagegently.com), interventional radiologists can minimize radiation dose to themselves, their medical colleagues in the interventional radiology suite, and most importantly, their pediatric patients.

Image Gently 

In 2006, spurred by the tremendous growth in CT scanning and increasing medical and public concern about radiation dose in children, a small group of health care professionals started the Alliance for Radiation Safety in Pediatric Imaging. The founding members of the Alliance were the Society for Pediatric Radiology (SPR), the American Association of Physicists in Medicine, the American College of Radiology, and the American Society of Radiologic Technologists. In 2008, the Alliance, working entirely through volunteer efforts, launched the national education/awareness campaign known as Image Gently (www.imagegently.com) (11). The goals of the campaign are to educate providers, referring physicians, technologists, medical imaging physicists, manufacturers, and the public on the need to reduce radiation dose from medical imaging, and to influence actual change in practice locally at the point of care (12, 13, 14). Today the Alliance consists of 41 international medical societies, including SIR and the SPR. To date, the Image Gently Web site has been visited 99,234 times, the pediatric CT protocols have been downloaded 9,439 times, and 2,058 medical professionals have taken the pledge to “Image Gently.”

Pediatric Interventional Radiology and the Step Lightly Campaign 

The field of pediatric interventional radiology has developed a more focused identity in the past 5 years. This change has been in response to its having reached a critical mass of practitioners, who nonetheless face severe workforce shortages, and an increasing need for scientific research and collaboration in the field (15, 16, 17, 18). To help address these needs, the Society for Pediatric Interventional Radiology (www.spirweb.org) was formed in 2007, with administrative support from the SPR. In addition, there are robust pediatric interventional radiology subcommittees within SIR (www.SIRweb.org) and the SPR (www.pedrad.org). Given the increasing need in pediatric interventional radiology, the Alliance steering committee in 2008 invited a multidisciplinary writing group consisting of pediatric interventional radiologists, medical imaging physicists, and a radiologic technologist to draft educational materials for placement on the Image Gently Web site and to develop a social marketing campaign (also called a public health campaign) in pediatric interventional radiology, modeled after the campaign in CT. The scientific background for a social marketing campaign and the educational tools to be provided in this campaign will be described in the remainder of this article.

Social Marketing 

Social marketing is defined by Andreasen as “the application of commercial marketing technologies to the analysis, planning, execution, and evaluation of programs designed to influence the voluntary behavior of a target audience in order to improve their personal welfare and that of the society of which they are a part” (19).

In its early development, social marketing was used simply as a public education tool, such as for promoting condom use in family planning (20). More recent evolution in the field has led to the realization that the true goal is not just to educate, but to actually influence behavioral change for the better. The requirements for an individual to change his/her behavior include: intention to change behavior, tools or skills needed to do so, and lack of external constraints preventing the change. In turn, the individual has to weigh the costs and benefits of the proposed behavior change, is influenced by perceived norms in his/her community, and has to feel empowered to make the change, given individual circumstances (21).

Given these theoretical underpinnings, a successful social marketing campaign should (i) reach the relevant target, (ii) convince people that the new behavior is beneficial to them, (iii) make it easy for them to perform the behavior, (iv) change the perceived norms of the community to make it “okay” or even desirable to make the change, and (v) help people feel empowered to carry out the behavior.

Pediatric Intervention: Step Lightly 

The main goal of the Step Lightly campaign is to educate the health care team and the public on the desirability of reducing radiation dose as much as possible in pediatric interventional radiology while continuing to benefit as a society from the innovative and at times life-saving techniques of the specialty. Ancillary goals include providing education on the effects of medical radiation in children, encouraging a team effort in improving radiation safety in pediatric interventional radiology, and providing easily accessible and usable information for health professionals and patients. Therefore, relevant information on radiation safety for pediatric interventional practice has been gathered and posted on the Image Gently Web site, along with key references and helpful links. There are separate sections for the various audiences: patients, radiologists, technologists, pediatricians, physicists, and the media, with more user-specific information on each page. Last, a variety of downloadable tools for patients and practitioners are available on the site, which detailed in the subsequent sections.

Building on the infrastructure created with the CT phase of Image Gently, this message is being disseminated to health care professionals through the voluntary donation by participating Alliance organizations of their individual electronic and print media for this purpose. At the launch of this campaign, printed advertisements were placed in selected scientific journals, including this one, along with a sticker bearing the Image Gently butterfly logo (Fig 1). The sticker should be placed on the fluoroscopy pedal or monitor as a reminder for those performing interventional radiologic procedures to use minimal radiation dose when performing the procedure. The photograph in the advertisement was taken by one of the members of the CT writing group of his daughter at ballet practice. This lovely image is meant to remind practitioners to “step lightly” on the fluoroscopic pedal during pediatric interventions, and to “leave a small footprint,” so to speak, on this sensitive population. The accompanying text carries a short message:

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Figure 1. Image Gently logo, reproduced on a sticker insert in this issue. The sticker is meant to be placed at the point of use in your angiography suite as a reminder to “child-size” the technique when performing pediatric interventional radiology procedures.

Treat kids with care:

Tools for Interventional Providers 

The materials on the Image Gently Web site are designed to be readily accessible and to make it easy for providers to practice best care. For example, the parent brochure is not only useful for patients, but also provides an organized approach for providers to use to discuss pediatric interventional radiologic radiation safety with families. These tools are also meant to be used by the whole interventional radiology team, based on the findings that a team approach with a mutually reinforced and articulated vision can reduce error (23, 24). To aid team education, the Web site contains a downloadable slide presentation on principles and practical tips for radiation safety in pediatric interventional radiology. This presentation contains information about the unique features of pediatric intervention regarding radiation protection, practical safety tips, visual demonstrations of safe practices, and information regarding dosimetry and quality improvement. Providers may use this slide show at their institutions to review radiation safety in pediatric interventional radiology with their teams and to teach trainees. In addition, with the knowledge that surgical safety checklists have been shown to reduce surgical complications, a downloadable checklist is provided that may be used by the interventional radiology team to review pediatric radiation safety steps before each case, the Step Lightly Procedure Checklist (Fig 2) (25). There is also a more comprehensive protocol outline of specific steps to be taken throughout the entire process to improve safety, entitled “Steps for Radiation Safety.” Finally, the Web site contains links to other useful sites and reference articles for more in-depth reading.

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Figure 2. Downloadable checklist to review with the team before each pediatric interventional radiologic procedure. The checklist is a reminder of steps that can be taken to reduce dose to patients and staff to the greatest degree possible in each case.

Summary 

The Image Gently, Step Lightly campaign is a volunteer effort of the Alliance for Radiation Safety in Pediatric Imaging that aims to collectively improve radiation safety in pediatric interventional radiology practice. Accessible information and tools are provided for health professionals and the public to work as a team in achieving this goal. To learn more, please visit (www.imagegently.com).