A cross-sectional study to assess the knowledge, attitude and risk- behaviour towards Road Safety among Undergraduate Medical Students, Kanchipuram, Chennai

Road traf(cid:977)ic accidents/injuries in recent times have become a major global epi-demic and the most important cause of death among younger population of age group 15-29 years. Countries that have undergone extensive and rapid development face an increase in the number of road accidents. This is due to the motorisation associated with urbanisation and development. A cross-sectional study was conducted among the Undergraduate Medical students of a private medical college in Chennai. Two hundred and three participants were studied by convenient sampling method. Participants were from 1 st year to 4 th year, and the duration of the study was for three months. A pre-tested, semi-structured and self-administered questionnaire was given, and the desired information was elicited. Data was then analysed with the help of statistical package for the social sciences software (SPSS). Chi-square test was done to test the signi(cid:977)icance (p <0.05). Among 203 study participants, 121 (59.6%) of them had a driving license. The mean age of participants was found to be 19.99, and the standard deviation equals + 1.3 years. Signi(cid:977)icantly more number of participants having driving license stopped the vehicle for pedestrians to cross the road and stopped their vehicle at a zebra crossing. The highest positive response was seen in giving way to an ambulance in those with and without a license. The number of participants wearing helmet and seat-belt was less, and the knowledge about the speed limit on national highways was also low. Signi(cid:977)icant increase in the number of female participants wearing a seat-belt, helmet, following traf(cid:977)ic rules, avoiding drunken driving and following speed limit was observed when compared to male participants. A multi-disciplinary approach towards creating more awareness and enforcing stringent laws is the urgent need of the hour to prevent mortality and morbid-ity due to Road Traf(cid:977)ic Incident.

to the motorisation associated with urbanisation and development. A crosssectional study was conducted among the Undergraduate Medical students of a private medical college in Chennai. Two hundred and three participants were studied by convenient sampling method. Participants were from 1 st year to 4 th year, and the duration of the study was for three months. A pretested, semi-structured and self-administered questionnaire was given, and the desired information was elicited. Data was then analysed with the help of statistical package for the social sciences software (SPSS). Chi-square test was done to test the signi icance (p <0.05). Among 203 study participants, 121 (59.6%) of them had a driving license. The mean age of participants was found to be 19.99, and the standard deviation equals + 1.3 years. Signi icantly more number of participants having driving license stopped the vehicle for pedestrians to cross the road and stopped their vehicle at a zebra crossing. The highest positive response was seen in giving way to an ambulance in those with and without a license. The number of participants wearing helmet and seatbelt was less, and the knowledge about the speed limit on national highways was also low. Signi icant increase in the number of female participants wearing a seat-belt, helmet, following traf ic rules, avoiding drunken driving and following speed limit was observed when compared to male participants. A multi-disciplinary approach towards creating more awareness and enforcing stringent laws is the urgent need of the hour to prevent mortality and morbidity due to Road Traf ic Incident.

INTRODUCTION
In the current world, transport has become an integral part of every human life. Every one of us is a road user in one way or the other. Every year road traf ic accidents result in loss of lakhs of lives and serious injuries. A road traf ic injury is an injury that occurs due to crashes involving vehicles partially or wholly on the public road. (nhp.gov). Developing countries like India are facing an additional problem of non-communicable diseases, including RTA on top of already existing communicable diseases (Jogdand et al., 2013). It is no longer considered accidental, relatively, a price we pay for misusing our progression in technology (www.dw.de/india). Like any other disease, even accident has agents, hosts and environmental factors. These work together to produce injury or damage (Park and Park, 2019).
Among the leading causes of the global disease burden, it is projected that road traf ic accidents will move up to the third position by the year 2020 (Mahawar et al., 2013). In India, motor vehicle sales are growing at a faster rate than the population and economic growth (Mahawar et al., 2013). Road traf ic mortality rate (per 100,000 population) in 2016 globally is 18.8 and in India is 8. Every year in India, about 80,000 people are killed in road crashes. This is about 13% of total RTA fatality all over the world (Dulipala and Gujjarlapudi, 2016).Pedestrians, cyclists, motorcyclists account for half of all road traf ic deaths. Adults aged between 15 to 44 years account for 59% of deaths (Reang and Tripura, 2014). It has been found that RTA has become the second leading cause of mortality among 20-24 years of age (Dulipala and Gujjarlapudi, 2016). The leading cause of death due to injury is road traf ic injury, followed by suicide, falls, and interpersonal violence (Hogarth, 1978). Males are more likely to be involved in road traf ic accidents compared to females (WHO, 2015). Among young drivers, males under the age of 25 years are three times more likely to be involved in a car accident as young females (WHO, 2015). Drunken driving has found to be one of the major causes of RTAs in highways among commercial vehicle drivers. Failure to use seat belts, helmets and child restraints in have also found to be a signi icant contributing factor to RTAs and deaths. ( nhp.gov). In low-and middle-income countries, it is found that 93% of worlds fatalities occur on the roads, though these countries have only 60% of worlds vehicles. (WHO 2020).
Unlike the past, people using personal transportation has been increasing drastically, concomitantly the rise of traf ic on the roads and risk exposure. Based on the WHO report, approximately 1.35 million people die annually as a result of this. With annually 130,000 deaths occurring, India has overtaken China and now has the highest RTA rate worldwide (dw.de/India). Driving at great speed increases the possibilities of road crashes occurring, and therefore the severity of the implications. Based on the WHO report, for each 1% increase in speed, fatal crash risk increases by 4% as speed increases the chance of death for the pedestrians to be hit by motorised vehicles increases signi icantly. While driving at 65 kilometres per hour, the chance of a pedestrian being hit by a vehicle is 4.5 times more than hit by a vehicle travelling at 50 kilometres per hour (WHO 2020). According to the report of National Highway Authority of India, road accidents and death on the expressway of our very own state, Tamilnadu is 25.17% and 26.8% respectively (morth.nic). As stated by, National Health Portal of India, comprehensive road safety laws are present only 28 countries which include measures on significant risk factors like speeding, drunken driving, and failing to use seat-belts, helmets and child restraints . (nhp.gov). Road safety is one among the issues that have never been stressed enough, thereby endangering people's lives on the road.
The injuries and deaths have caused an immeasurable impact on the families affected. This can be the primary explanation for concern, and both the society as well as the government should work together to scale back this preventable cause of death. A simple measure such as following road safety rules and regulations and having basic awareness on road safety can reduce RTA's signi icantly. Within the last decade in India, 1.3 million people died due to preventable road crashes, and another 5.3 million are disabled for all times. (save life foundation). Prevention of RTAs and death becomes mandatory and vital to boosting the life span and also the quality of life of individuals. Hence this study was done to assess and evaluate the knowledge, attitude and risk behaviour on road safety among undergraduate medical students using motorised vehicles.

MATERIALS AND METHODS
The study was designed to be a cross-sectional study, and the study was conducted at a Tertiary Care Medical College and Hospital, Kanchipuram Tamilnadu. The participants chosen for the study were the undergraduate medical students studying at this college, and the study was done for three months with data collection followed by analysis and discussion. The participants were selected by convenient sampling method. Those who consented for the study, which included students from 1 st year to 4 th year of Saveetha Medical College and Hospital were included in the study. The participant not available at the time of the study, and who didn't give responses to speci ic questions in the questionnaire were excluded. According to the report given by the Ministry of Road Transport and National Highways of India, Transport Research Wing, Tamilnadu has contributed 14.1 per cent of total road accidents in the country. Taking this as prevalence (14.1%) of road traf ic incident and assuming 95% con idence limit with a 5% allowable error, with the formula (4pq)/L 2 , the sample size is, N=193. To account for the non-response rate (about10%), a total of 203 subjects with inclusion criteria were chosen for the study.
Before proceeding with the study, pilot testing was done, and the necessary changes were made in the questionnaire. The students were visited in their classrooms and explained about the purpose of the study and pre-tested, pre-validated, semistructured questionnaires comprising the demographic details like, age, sex, year of study and along with questions which were needed to assess their knowledge, attitude and risk behaviour towards road safety was distributed and collected from a dropbox kept outside the classroom or wards after 15 mins to maintain the anonymity of the information shared by them. The data collected was entered in Microsoft Of ice Excel sheet (MS Excel). Informed written consent was obtained before collecting the data. The participants were explained the option to withdraw at any time without any penalty or loss of bene it. Before beginning with the study, approval was obtained from the ethical committee of the Institution. After completion of data collection, the frequencies of all variables were checked for completeness at regular intervals. Data was then analysed with the help of statistical package for the social sciences software (SPSS) for windows version 21. The descriptive statistics were shown in appropriate tables and igures. Association between categorical variables was determined using the Chisquare test. P-value was calculated at a 95% con idence interval with signi icant levels at p < 0.05.

RESULTS AND DISCUSSION
The current study was undertaken to evaluate the knowledge, attitude and risk behaviour towards road safety. Table 1 showed that among 203 study participants 121 (59.6%) of them had a driving license. The majority of the 144 (70.93%) were less than 20 years of age, and 59 (29.06%) were above 20. The mean age was found to be 19.99 +1.3years (Mean + SD). There were more female respondents 123 (60.6%) when compared to male respondents, 80 (39.4%). More than half the participants115 (56.65%) belonged to the 3rd year of under graduation.
On analysis, Table 2 of this study shows the general knowledge about the legal age for a license was high at 97% that is, no of males who knew the correct answer was 77(37.93%) and females knowing the correct answer was 122(60.09%) and 65 (32.01%) of males and 87 (42.85%) together,74% of all participants had correct knowledge about the side of overtaking. The knowledge about permissible alcohol level, the maximum penalty for driving without a license and speed limit on national highways of all participants was low at 49.25%, 48.76%, 25.12%. These are essential parameters, and yet the knowledge was lacking and therefore not a good sign. This lack of knowledge could be one of the reasons for increasing RTA. The knowledge of the speed limit on highways was very low in our study. Similar to our study Jogdand K et al. have also published that more than 40% of the students did not have correct knowledge of road safety rules and the overall knowledge was marginally higher in females, but it was not signi icant (Jogdand et al., 2013). In another study, 86% knew the correct side of overtaking, whereas our study showed only 74% knew the correct side (Mukhopadhyay, 2017). This could be because, in Mukhopadhyay's study, the majority (76%) of the participants were above 20 years. In a study by Manjula, only 47.8% knew the legal limit of alcohol for driving that was similar to our study, which was 49.25% (Manjula, 2017). In our study compared the knowledge between the sex, regarding legal age for license, permissible alcohol level, side of overtaking, maximum penalty for driving without a license, and average speed limit on National highways, gender differences were not statistically signi icant in our study.
Among the 203 participants, 121 (59.6%) of them had a driving license. We analysed the association between driving license among study participants and their attitude towards road safety. As shown in Table 3 signi icantly more no of participants having driving license 113 (93.38%) stopped the vehicle for pedestrians to cross the road even if there was no sign of police watching than those not having license65 (79.26%). In a similar trend, a more signi icant number of licence holders 105(86.77%) stopped their vehicle at a zebra crossing when compared to those who did not have license 61 (74.39%), and it was statistically signi icant. Significantly lesser no of license holders 18 (14.88%) felt that they were distracted by loud music when compared to those without license 25 (30.49%). In general, the majority of the participants (84.5%) with or without a license had the right attitude towards road safety. This positive attitude was seen in their response towards questions on whether road signs and symbols reduce road traf ic accidents, the need to follow traf ic rules at night, being in a calm and relaxed state of mind while driving, wearing a seat belt and giving way to an ambulance when hearing the siren. Similar to our study Manjula too observed that in their study, 88.9% had a right attitude about RTA (Manjula, 2017). The highest positive response    (Emmily et al., 2016).
In our study when we analysed the risk behaviour towards road safety among the 121 license holders, more male respondents agreed to drive the vehicle rashly, being intoxicated while driving a vehicle and using a mobile phone while driving when compared to female respondents. In Table 4 for the igures were 38 (57.57%), 9 (13.64%) and 18 (27.27%) in males and 12 (21.82%), 2 (3.64%), 6 (10.90%) in females respectively which was statistically significant. When compared to our study, Reang T in their study showed that lesser number of students crossed speed limit (27.5%), did drunken driving (3.3%) and used mobile phones (8.3%) (Reang and Tripura, 2014). In our study, more no of female participants, 30 (45.54%) wore a helmet while riding a two-wheeler compared to males 20 (30.37%). Ratna et al. in their study observed that overall, 74% wore a helmet (Ratna et al., 2017). The number of participants wearing a helmet in our study was far less, and this can be attributed to the relaxed law on helmet usage in our city and state. In our study, there was more percentage of male participants 47 (71.21) who exceeded the speed limit, drove a vehicle without the knowledge of parents, met with RTA, involved in racing and skipping trafic signal when compared to female participants. There was statistical signi icance between the genders in response to all the questions in table 4.  It was disheartening to know that both the sexes were still involved in driving rashly, not wearing a helmet, exceeding the speed limit and skipping traf ic signal in large numbers. Jogdand K et al. too, in their study observed that 39.73% of students were booked for not wearing the helmet and 32.59% were frequently using mobile phones, and 24.45% were over speeding (Jogdand et al., 2013). Mukhopadhyay, in his study, published, that 26.4% had moderate RTA, whereas, in our study, the RTA was 41.32% (Mukhopadhyay, 2017). This increase of RTA in our study can be attributed to increasing in vehicles over the past three years, and the participants of our study are from metropolitan city, whereas Mukhopadhyay did his study in a semiurban setting. Similar to our study, he also noted more female participants followed speed limit, did not use mobile phones, wore helmet and seat belts compared to male participants. Green et al. and Evans et al. have shown the bene icial lifesaving role of using seat belts in their study (Green et al., 1994;Evans, 1996). Unfortunately, still, a large section of drivers and passengers do not use seat belts. In our study of 203 participants, the general use of seat belts was 170 (83.75%) out which 107 (86.99%) were female, and 63 (78.75%) were male as seen in Table 5.

Figure 1: Awareness of road signs in all 203 study participants
Similarly, in a study by Emmily et al., 80% of the participants wore a seat belt. In our study, there was a signi icant gender difference in stopping the vehicle at zebra crossing with 100 (81.3%) female participants stopping compared to 14 (17.5%). However, more female participants, 93 (75.61%) agreed that they were distracted if they listen to loud music while driving compared to male participants 50 (62.5%), which was also statistically signi icant. There was a better positive response among female participants who agreed that following traf ic rules and regulations reduce the incidence of accidents, road signs and symbols reduce accidents and the need to follow traf ic rules.
Our study Figure 1 shows that a maximum number of incorrect responses was in identifying hairpin bend sign (90%) followed by a little bridge sign (73.9%). A few participants had responded answers like "turn over, turning ahead, maintain right and take a turn" instead of right hairpin bend. Likewise, for narrow bridge the participants had responded "intersection, double way, two-way, roads diverging" etc. Uncommon use of this sign could be the reason for unfamiliarity, and incorrect answers (Mukhopadhyay, 2017). Incorrect response that was seen in interpreting signs for no entry (52.70%) and school zone (56.50%) was also high. Only 41 % and 36% of participants correctly interpreted the school zone and no entry, both of which are very crucial in road safety.

CONCLUSIONS
This study brings out the de iciency in the knowledge, attitude and risk behaviour towards road safety among the undergraduate medical students. This is to be viewed seriously, and measures for increasing awareness on road safety must be taken on a large scale. This study is done in an urban population, and we can extrapolate a still low road safety awareness in rural areas. Training must start early as we see more and more youngsters handling vehicles. Stringent enforcement of rules to wear helmets, seat belt, to follow traf ic rules and lights, avoid drunken driving and speeding must be enforced.
Every driver has to learn of being cautious on the road as it's a trait they have to master before they step behind the wheels of the vehicle. "Man, behind the wheels play an important role on the road". Therefore, emphasis should be made for appropriate training of drivers through a strict driving license system. This should be considered as an effective strategy to increase the road safety attitude and bring down the incidents of RTAs.