Faculty of Medicine

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A Comparison of learning strategies, orientations and conceptions of learning of first-year medical students in a traditional and an innovative curriculum
(2007) Marambe, Kosala Nimalani; Athuraliya, T Nimmi; Vermunt, Jan D; Boshuizen, Henny Petronella
Introduction: Students adapt their learning strategies, orientations and conceptions to differences in the learning environment. The new curriculum of the Faculty of Medicine, University of Peradeniya, Sri Lanka, which commenced in 2005, puts greater emphasis on student-centred learning. The aim of this study was to compare the learning strategies, orientations and conceptions measured by means of a validated Sri Lankan version of the Inventory of Learning Styles (ILS) at the end of the first academic year for a traditional curriculum student group and a new curriculum student group. Materials and Methods: The Adyayana Rata Prakasha Malawa (ARPM) 130-item Sinhala version of the ILS was administered to students of the traditional curriculum and the new curriculum at the end of their first academic year respectively. Mean scale scores of the 2 groups were compared using independent sample t-test. Results: Students of the new curriculum reported the use of critical processing, concrete processing and memorising and rehearsing strategies significantly more than those in the traditional curriculum group. With respect to learning orientations, personal interest scores were significantly higher for the new curriculum students while reporting of ambiguity was significantly lower among them. Conclusion: The results favour the assumption that changes made to the organisation of subject content and instructional and assessment methods have a positive impact on students’ use of learning strategies and motivation
A Histopathological study of cutananeous leishmaniasis in Sri Lanka
(2010) Herath, C. H. P.; Ratnatunga, N. V. I.; Waduge, R.; Ratnayake, P.; Ratnatunga, C. N.; Ramadasa, S.
Abstract Introduction Cutaneous leishmaniasis is endemic in Sri Lanka. The immunopathogenesis of these lesions in Sri Lankans has not been documented. Objectives To classify skin lesions into histological groups, to assess parasitic load, density of each inflammatory cell type and necrosis and to characterise the lymphocytic reaction in cutaneous leishmaniasis in comparison to leprosy. Methods Skin biopsies from 31 patients with demons- trable amastigotes in smears or tissue sections were studied. The lesions were classified by two independent observers into four distinct histological groups based on different cell types in the inflammatory infiltrate and formation of granulomata. Parasitic load and the presence of necrosis were recorded. Immunohis- tochemical staining for CD45RO and CD20 for counting T and B cells respectively was done. Results Histological groups of cutaneous leishmaniasis ranging from group I-IV were similar to that of the spectrum in leprosy ranging from lepromatous to tuberculoid leprosy. The histological groups from I-IV showed a significant inverse relationship with the mean parasitic index. Necrosis was not a prominent feature. The mean percentage of T cells in the histological spectrum from group I-IV in leishmaniasis was similar to the spectrum from lepromatous to tuberculoid leprosy. Mean per- centage of T cells were 20.1% in group I, 20.5% in group II, 33.8% in group III and 47.8% in group IV. Lepromatous, borderline tuberculoid and tuberculoid leprosy had 21.3%, 33.4% and 48.0% T cells respectively. Conclusion Cutaneous leishmaniasis is a spectral disease similar to leprosy. The mean percentage T cells from group I-IV were similar to those in the spectrum of leprosy and mean percentage B cells varied in a narrow range
Adrenaline toxicity following accidental administration of the 1:1000 solution during dental procedures; four case reports
(2012) Fernando, Dinesh M. G.; Dayaratne, K. M. P. L.
Four patients aged between 35 and 50 years attended the out patients department of a dental hospital for tooth extraction. Following administration of, what was thought to be the local anesthetic, Lignocaine, to the gum and sub mucosa, they all collapsed. What had, in fact, been injected was 1:1000 adrenaline. We would like to report the symptoms, signs and investigation findings that followed. Significantly elevated Troponin T, CPK (total), CPK (MB) and ECG changes were seen. Electromyography and Nerve Conduction Studies showed a myopathic pattern and reduction in motor and sensory conduction respectively. These patients were followed up for a period of five years. Long term effects such as tremor, muscle weakness, easy fatigability and shortness of breath on exertion, which is not reported in the literature, were reported by all patients.
Attitudes of Sri Lankan medical students toward learning communication skills
(2012) Marambe, Kosala N.; Edussuriya, D. H.; Dayaratne, K. M. P. L.
ABSTRACT Introduction: The General Medical Council of the UK, advocates that by the end of their undergraduate course, medical students should be proficient in communicating with patients. However, the attitude of some medical students toward formal training in communication skills seems lukewarm. Although several studies on assessing attitudes of medical students on learning communication skills have been carried out in Europe and America, Asian studies are very few and literature in the Sri Lankan context is lacking. To explore the attitudes of first to fourth year medical students of the Faculty of Medicine, University of Peradeniya (FOMUP), Sri Lanka on learning communication skills and to identify possible factors that may influence student attitudes. Methods: A total of 675 students from year 1 to 4 of the FOMUP were asked to complete a modified version of the Communication Skills Attitude Scale. Items of its positive attitude scale (PAS) were analyzed together while negative items were considered individually. Results: Response rates ranged from 70% to 98% for the various year groups. There were no significant differences between the PAS for males and females and for those exposed to formal training and those who were not. The junior students scored significantly higher on the PAS than seniors. Most students of all the groups disagreed with the item “I don’t see why I should learn communication skills”. Approximately one-quarter of the students of each group endorsed the statement “Nobody is going to fail their medical degree for having poor communication skills”. Out of the students who have undergone formal communication training, almost one-third agreed that they find it difficult to take communication skills learning seriously. Discussion: Although medical students seem to have realized the importance of communication skills training for the practice of medicine, a significant minority have reservations on attending such sessions. Sri Lanka faculty will need to make a concerted effort to change this attitude through improving teaching and assessment strategies
Awareness and attitudes towards HIV/AIDS among residents of Kandy
(Taylor and Francis, 2015) Navaratna, Samidi; Kanda, Koji; Dharmaratne, Samath D.; Tennakoon, Sampath; Jayasinghe, Ananda; Jayasekera, Niroshan; Nagano, Katsutoshi; Obayashi, Yoshihide; Arai, Asuna; Tamashiro, Hiko
Currently, interventions for HIV/AIDS control in Sri Lanka are only carried out among the most-at-risk populations. This study was conducted to identify the level of awareness and stigma-related attitudes among the general population of Sri Lanka. A cross-sectional study was carried out among 869 residents of 18-64 years of age in Kandy, Sri Lanka. A self-administered questionnaire was utilised to obtain information about stigma, discrimination and HIV/AIDS-related knowledge. Chi-square test and multivariate analysis were applied to find possible associations between HIV-related variables and socio-demographic indicators. Response rate was 82.0%. Overall, 93.5% of the participants have heard of HIV/AIDS but the knowledge on HIV/AIDS was low with an average score of 51.7%, no statistically significant difference between genders (p = 0.352). Only 58.1% were aware that a condom was an effective tool for its prevention. There were many misconceptions related to epidemiology of HIV/AIDS. The participants showed more positive attitudes towards HIV/AIDS and people living with HIV/AIDS (PLHIV) for all questionnaire items except for those listed under shame and blame. Positive attitudes towards PLHIV were observed to be greater among those with a better HIV/AIDS-related knowledge score. There was no significant association between the attitudes towards PLHIV and socio-demographic characteristics such as ethnicity and religion. There is a greater need of making attempts towards educating the public regarding HIV/AIDS to eliminate misconceptions prevalent in the society. Stigma-related attitudes are mainly due to shame and blame associated with the disease. As the attitudes towards PLHIV were more positive among those with a better HIV/AIDS-related knowledge score, targeted HIV/AIDS-related health education interventions maybe recommended in this regard.
Chemical and Biological Warfare
(2010) Fernando, D. M. G.; De Alwis, L. B. L.
Comparison of cardiovascilar risk factors between Sri Lankans living in Kandy and Oslo
(2010) Tennakoon, Sampath U. B.; Kumar, Bernadett, N.; Nugegoda, Danasela, B.; Meyer, Haakon E.
Background: South Asians living in western countries are known to have unfavourable cardiovascular risk profiles. Studies indicate migrants are worse off when compared to those living in country of origin. The purpose of this study was to compare selected cardiovascular risk factors between migrant Sri Lankans living in Oslo, Norway and Urban dwellers from Kandy, Sri Lanka. Methods: Data on non fasting serum lipids, blood pressure, anthropometrics and socio demographics of Sri Lankan Tamils from two almost similar population based cross sectional studies in Oslo, Norway between 2000 and 2002 (1145 participants) and Kandy, Sri Lanka in 2005 (233 participants) were compared. Combined data were analyzed using linear regression analyses. Results: Men and women in Oslo had higher HDL cholesterol. Men and women from Kandy had higher Total/HDL cholesterol ratios. Mean waist circumference and body mass index was higher in Oslo. Smoking among men was low (19.2% Oslo, 13.1% Kandy, P = 0.16). None of the women smoked. Mean systolic and diastolic blood pressure was significantly higher in Kandy than in Oslo. Conclusions: Our comparison showed unexpected differences in risk factors between Sri Lankan migrants living in Oslo and those living in Kandy Sri Lanka. Sri Lankans in Oslo had favorable lipid profiles and blood pressure levels despite being more obese.
Death due to adult repiratory distress syndrome following assault with 'Rubber Acid': could it have been averted
(2012) Fernando, Dinesh M. G.; Kaluarachchi, C. I.
Abstract Adult respiratory distress syndrome and chemical pneumonitis are well documented effects of exposure to chemical fumes. Many organic and non-organic agents cause chemical pneumonitis. The course of the disease depends on the nature of the chemical agent, intensity and duration of the exposure and the interval between exposure and start of treatment. Also the site of damage tends to vary with the gas involved; gases with higher water solubility being effectively scavenged by the upper respiratory mucosa, while insoluble toxic gases have their effects on the lower respiratory mucosa
Descriptive psychopathology of obsessions and compulsions of a clinic population of patients with obsessive compulsive disorder
(University of Peradeniya, 2011-11-24) Perera, S. R; Dalugama, D. A. C .L; Higgoda, R. A; Dias, G. S. S. R
Obsessive-compulsive disorder (OCD) affects approximately 2-3% of the adult population and is considered a debilitating and costly disorder, with associated impairments sp,anning the social, occupational, and familial domains. OCD is characterised by obsessional symptoms and compulsive behaviour. The obsessional symptoms include thoughts, images, ruminations and impulses. Compulsive behaviour ranges from overt acts to covert ritual or a mental manipulation. Objectives of the present study were to describe the frequency of the type of obsessions and the compulsions in a clinic population. The study also attempts to describe the contents of the obsessions and compulsions of the study population. All patients with OCD who were registered as out patients from 1997 to 2003 were included in the study. Patients were traced back from the clinic register where the final diagnosis of OCD was made by the consultant psychiatrist at their first visit. The relevant clinic notes were traced back and data on epidemiology as well as details of the particular obsessions and compulsions were recorded from the clinic notes.The study population consisted of 23 males and 17 females, and their average age was 27.7 years. The main type of obsession in this study was obsessive thoughts (70%) followed by ruminations (25%). The main theme of the obsession was to do with cleanliness (45%). Therefore, as observed in the study, washing behaviour is a commonly practiced (25%) ritual.
Differences in predicted cardiovascular risk in Sinhalese and Tamils in Sri Lanka compared with Sri Lankans in Norway
(2013) Tennakoon, Samapth U. B.; Kumar, Bernadette N.; Selmer, Randi; Mikram, Mihamed J. M.; Meyer, Haakon E.
Using data from 3 cross‐sectional studies, the authors compared the estimated risk of cardiovascular diseases between migrant Sri Lankans in Oslo, Norway, and Tamils and Sinhalese in Kandy, Sri Lanka. The authors found that Sri Lankans in Oslo had significantly lower Framingham coronary heart disease (CHD) risk. Among men, the prevalence with estimated 10‐ year risk of a CHD event ≥10% was 20.6% in Oslo, 31.1% in Kandy Tamils, and 44.2% in Kandy Sinhalese. The corresponding figures in women were 10.4% in Oslo, 19.2% in Tamils, and 14.9% in Sinhalese. Risk of fatal cardiovascular disease estimated by the SCORE model showed a similar pattern. The Oslo group had a higher body mass index (BMI), but the differences were observed in all BMI categories. In conclusion, despite a lower BMI, Tamils and Sinhalese in Sri Lanka had higher estimated cardiovascular risk compared with Sri Lankans in Norway, mainly because of poorer lipid profiles.
Do medical students who calim to be using deep learning strategies perform better at then forensic medicine examination ?
(2009) Marambe, Kosala N.; Edussuriya, Deepthi H.; Somaratne, P. D. Indika S. Somaratne; Piyaratne, Chathura
Literature reveals that frequent use of deep learning strategies and meaning orientation generally relates to academic performance positively, while the reproducing orientation is usually negatively associated with academic performance. The objective of this study was to investigate possible associations between reported learning strategies and performance at different components of the Forensic Medicine examination between two successive batches of medical students at the Faculty of Medicine, University of Peradeniya, Sri Lanka. Reported learning strategies of two successive groups of medical students were measured using the adapted Sri Lankan version of the Inventory of Learning Styles, the Adyayana Rata Prakasha Malawa (ARPM). The inventory scale scores were computed for each student and entered into a data base. The scores for each component of the Forensic Medicine examination namely; essay, multiple choice questions and viva voce and the total score were added to the data base. The Spearman rank correlation test was performed to identify possible associations between learning strategy scores and performance at different components of the examination. The number of respondents was 142 out of 173 of the 2003/2004 (82%) and 107 out of 188 students (57%) of the 2002/ 2003A batches of fourth year medical students having completed three terms of work in Forensic Medicine. Contrary to expectations, the results failed to show a significant association between academic performance and frequent use of deep processing strategies or self regulation. Since examinations drive the learning process it could be that the assessment demands promote the students to use both surface and deep learning strategies to the same extent
Estimation of the basic reproduction number (R0) for the novel coronavirus disease in Sri Lanka
(Elsevier, 2020) Samath Dharmaratne; Supun Sudaraka; Ishanya Abeyagunawardena; Kasun Manchanayake; Mahen Kothalawala; Wasantha Gunathunga
Background: The basic reproduction number (R0) is the number of cases directly caused by an infected individual throughout his infectious period. R0 is used to determine the ability of a disease to spread within a given population. The reproduction number (R) represents the transmissibility of a disease. Objectives: We aimed to calculate the R0 of Coronavirus disease-2019 (COVID-19) in Sri Lanka and to describe the variation of R, with its implications to the prevention and control of the disease. Methods: Data was obtained from daily situation reports of the Epidemiology Unit, Sri Lanka and a compartmental model was used to calculate the R0 using estimated model parameters. This value was corroborated by using two more methods, the exponential growth rate method and maximum likelihood method to obtain a better estimate for R0. The variation of R was illustrated using a Bayesian statistical inference-based method. Results: The R0 calculated by the first model was 1.02 [confidence interval (CI) of 0.75-1.29] with a root mean squared error of 7.72. The exponential growth rate method and the maximum likelihood estimation method yielded an R0 of 0.93 (CI of 0.77-1.10) and a R0 of 1.23 (CI of 0.94-1.57) respectively. The variation of R ranged from 0.69 to 2.20. Conclusion: The estimated R0 for COVID-19 in Sri Lanka, calculated by three different methods, falls between 0.93 and 1.23, and the transmissibility R has reduced, indicating that measures implemented have achieved a good control of disease.
Forensic aspect of dental attrition and age estimation
(2005) Ranasinghe, Ranasinghe Arachchige Sisira Kumara
Estimation of age in the living and dead is an important task in routine medico-legal practice. Age could be estimated by studying the stages of tooth development and eruption by histological, morphological and radiological methods up to 18 — 20 years of age. The only macroscopic method in which age could be estimated using teeth after the age of 18 years is by dental attrition which is defined as wearing of the tooth surface due to masticatory forces. Available literature reveals several studies on the estimation of age using dental attrition in other countries but no studies have been carried out in Sri Lanka. The present study was carried out in two medical institutions in the Gampaha District during the period from January 2002 to December 2003. The study sample consisted of 500 patients selected on a random basis from 2250 individuals attending the out patient’s departments (OPD). The sample was divided into 5 different age groups. A Data Recording Sheet was used to collect the socio-demographic and attrition data. Attrition scores were recorded by the investigator throughout the study using Takei’s method with certain modifications. Individuals under 20 years of age, living outside the Gampaha District, in severeillnesses and marked malocclusion and jaw deformities were excluded from the study. In addition some were excluded due to inadequate number of teeth in the oral cavity and poor compliance. Mean attrition scores were calculated separately for males and females in each age group. In general, differences in the attrition scores between males and females were not statistically significant. Comparison o f attrition s cores b etween different educational groups did not show any significant differences. Mean attrition scores between betel chewers and non-betel chewers were also compared. Although the attrition scores in betel chewers were higher differences between the the values were not statistically significant. Further studies are recommended with larger samples. Regression lines were drawn using attrition scores for three groups of teeth separately for maxilla and mandible for all five age groups. With the help ofthe regression c urves equations were obtained to estimate age of individuals having different groups of teeth. Common attrition patterns s were prepared in a form of a chart separately for maxillary and mandibular teeth. The equations and charts obtained from this study could be used in the estimation of age in the living and dead especially in medico-legal work.
Predictors of the development of myocarditis or acute renal faliure in patients with leptospirosis
(2012) Dassanayake, Dinesh L. B.; Wimalaratna, Harith; Nandadewa, Damith; Nugaliyadda, Asanka; Ratnatunga, Champa N.; Agampodi, Suneth B.
Background: Leptospirosis has a varied clinical presentation with complications like myocarditis and acute renal failure. There are many predictors of severity and mortality including clinical and laboratory parameters. Early detection and treatment can reduce complications. Therefore recognizing the early predictors of the complications of leptospirosis is important in patient management. This study was aimed at determining the clinical and laboratory predictors of myocarditis or acute renal failure. Methods: This was a prospective descriptive study carried out in the Teaching Hospital, Kandy, from 1st July 2007 to 31st July 2008. Patients with clinical features compatible with leptospirosis case definition were confirmed using the Microscopic Agglutination Test (MAT). Clinical features and laboratory measures done on admission were recorded. Patients were observed for the development of acute renal failure or myocarditis. Chi-square statistics, Fisher’s exact test and Mann-Whitney U test were used to compare patients with and without complications. A logistic regression model was used to select final predictor variables. Results: Sixty two confirmed leptospirosis patients were included in the study. Seven patients (11.3%) developed acute renal failure and five (8.1%) developed myocarditis while three (4.8%) had both acute renal failure and myocarditis. Conjunctival suffusion - 40 (64.5%), muscle tenderness - 28 (45.1%), oliguria - 20 (32.2%), jaundice - 12 (19.3%), hepatomegaly - 10 (16.1%), arrhythmias (irregular radial pulse) - 8 (12.9%), chest pain - 6 (9.7%), bleeding - 5 (8.1%), and shortness of breath (SOB) 4 (6.4%) were the common clinical features present among the patients. Out of these, only oliguria {odds ratio (OR) = 4.14 and 95% confidence interval (CI) 1.003-17.261}, jaundice (OR = 5.13 and 95% CI 1.149-28.003), and arrhythmias (OR = 5.774 and 95% CI 1.001-34.692), were predictors of myocarditis or acute renal failure and none of the laboratory measures could predict the two complications. Conclusions: This study shows that out of clinical and laboratory variables, only oliguria, jaundice and arrhythmia are strong predictors of development of acute renal failure or myocarditis in patients with leptospirosis presented to Teaching Hospital of Kandy, Sri Lanka. Keywords: Myocarditis, Acute renal failure, Leptospirosis
Prevealence of behavioral and emotional problems among seven to eleven year old children in selected schools in Kandy district, Sri Lanka
(Elsivier, 2014) Ginige, P.; Tennakoon, S. U. B.; Wijesinghe, W. H. M. K. J.; Liyanage, L.; Herath, P. S. D.; Bandara, K.
Prevealence of behavioral and emotional problems among seven to eleven year old children in selected schools in Kandy district, Sri Lanka
(Elsivier, 2014) Ginige, P.; Tennakoon, S. U. B.; Wijesinghe, W. H. M. K. J.; Liyanage, L.; Herath, P. S. D.; Bandara, K.
Background Behavioral and emotional problems comprising internalizing, externalizing and mixed disorders consist of psychiatric disorders in childhood and adolescents. Prevalence rates of 8.3% for preschoolers, 12.2% for preadolescents and 15.0% for adolescents have been reported from around the world. This study aimed to measure the prevalence of emotional and behavioral disorders in 7–11 year-old school children studying in Kandy District Sri Lanka which was a first for the geographic area. Method This was a community based study at the primary section of the selected schools. The questionnaire, Child behavior Checklist-Sinhala (CBCL-S) was administered in a group setting to the main caregiver of 562 subjects selected randomly. The questionnaire identified problems in 8 subscales under three main sub categories : internalizing, externalizing and other. Data were analyzed using The Syndrome Scales for Boys and Girls developed for analyzing the questionnaire CBCL. Results Indicated a prevalence of 13.8% of emotional and behavioral problems in the study population. 8.8% of children showed internalizing problems and 8.8% externalizing problems. These findings are in line with the prevailing rates from previous studies of the world. Children in school types 1AB and 1C had less emotional and behavioral problems compared to type 2 and 3 schools. Limitations Only 20 schools in KEZ and Sinhala speaking population of the Kandy were studied. Conclusions This study showed the extent of childhood emotional and behavioral problems and also confirms that the schools with advanced level classes have lesser problems amongst primary children
Relationship between gestational age & anthropometric parameters of neonates
(2011) Fernando, D. M. G.; Weerakkody, I. R.; Ranmohottige, U. S. N.; Gamage, S. M. K.; Kumarasiri, P. V. R.
Introduction: In cases of infanticide, surreptitious disposals, still births and spontaneous or induced abortions, the accurate age of the infant needs to be calculated. Furthermore, in cases of sexual abuse, the court may need to know the period of gestation of the infant, to date the crime. However, for assessment of gestational age Sri Lankan anthropometric data is not available. Therefore this study helps to fill this void. Objective: Establish the relationship between the gestational age and Weight, Occipito-Frontal Circumference (OFC), Hand length (HL), and Foot Length (FL) of neonates. Methodology: Following ethical clearance, data was collected at Teaching Hospital Peradeniya, from neonates of gestational ages ranging from 33 – 40 weeks, within 48 hours of birth by two pre-intern doctors. We excluded those suffering from anomalies which cause distortion of the anthropometric parameters. The weight recorded at birth was taken while a non-stretchable, standard tape was used to measure the OFC. HL and FL were measured with an electronic Vernier caliper. Results: The total sample size of 108 babies consisted of 76 term babies and 32 pre term babies. The values ranged from 1300g to 3850g for weight, 25cm to 36.4cm for OFC, 34.4mm to 72.16mm for HL and 55mm to 87.7mm for FL. The detailed age specific data will be discussed, graphed and compared with available British and USA data. Conclusion and Suggestions: The findings of this preliminary study indicate that the gestational age can be estimated using anthropometric measurements. We suggest the need to expand this study to other areas of Sri Lanka in order to prepare graphs of anthropometric measurements applicable to Sri Lanka.
Repeated episodes of physical child abuse
(2010) Fernando, D. M. G.; Dayaratne, K. M. P. L.
INTRODUCTION According to Berard Knight the ‘child abuse syndrome” exists when an infant or child suffers repetitive physical injuries inflicted by a parent or guardian, in circumstances that exclude accident.' Physical abuse represents approximately 70% of child abuse cases and may range from minor bruises to fatal hacmatomas. We report a case where the child has been repeatedly released into the same hazardous environment, in spite of a diagnosis of physical child abuse being made by pediatricians and judicial medical officers. The child has been subjected to repeated abuse resulting in multiple hospital admissions with 7 long bone frictures, multiple rib fractures and other life threatening injuries in her short life span of 20 months,
Use of seat belts
(2011) Fernando, Dinesh M. G.,Kaluarachchi, C. I.
Today, seat belts are an accepted part of routine vehicle operation for millions of drivers and passengers. But the modern three-point automotive seat belt has only been around since 1959; and it saved thousands of lives since its introduction1. Fatalities and serious injuries from road traffic accidents are increasing in Sri Lanka. In 2008, 2009 & 2010 the number of fatalities was 2176, 2263 & 2579 and grievous injuries were 4941, 5379 & 6124 respectively2. One of the reasons for the rise in fatalities and serious injuries is non usage of safety measures in vehicles such as seat belts. Car seat belts did not serve the designed purpose in U.S.A. till the time most of the states made it mandatory to fasten seat belts under threat of penalties under law. Even though the usage of seat belts in Sri Lanka was made mandatory in October 2011, many Sri Lankans are unaware of the importance of the safety measures in vehicles. The usage and reasons for not wanting to use seat belts in vehicles prior to it being a legal requirement was studied

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