Inexperience and risky decisions of young adolescents, as pedestrians and cyclists, in interactions with lorries, and the effects of competency versus awareness education

Preventing Unintentional Injuries in School-Aged Children: A Systematic Review

BACKGROUND AND OBJECTIVES

Unintentional injuries constitute the leading causes of death and long-term disabilities among children aged 5 to 15 years. We aimed to systematically review published literature on interventions designed to prevent unintentional injuries among school-aged children.

METHODS

We searched MEDLINE, PubMed, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO and screened the reference lists of included studies and relevant reviews. We included randomized controlled trials, controlled before-and-after studies, and interrupted time series studies. The focus of included studies was on primary prevention measures. Two reviewers collected data on type of study design, setting, population, intervention, types of injuries, outcomes assessed, and statistical results.

RESULTS

Of 30 179 identified studies, 117 were included in this review. Most of these studies were conducted in high-income countries and addressed traffic-related injuries. Evidence from included studies reveals that multicomponent educational interventions may be effective in improving safety knowledge, attitudes, and behaviors in school-aged children mainly when coupled with other approaches. Laws/legislation were shown to be effective in increasing cycle helmet use and reducing traffic-related injury rates. Findings reveal the relevance of infrastructure modification in reducing falls and improving pedestrian safety among children.

CONCLUSIONS

Additional studies are needed to evaluate the impact of unintentional injury prevention interventions on injury, hospitalizations, and mortality rates and the impact of laws and legislation and infrastructure modification on preventing unintentional injuries among school-aged children.

Children's fear in traffic and its association with pedestrian decisions

INTRODUCTION

Research on risk for child pedestrian injury risk focuses primarily on cognitive risk factors, but emotional states such as fear may also be relevant to injury risk. The current study examined children's perception of fear in various traffic situations and the relationship between fear perception and pedestrian decisions.

METHOD

150 children aged 6-12-years old made pedestrian decisions using a table-top road model. Their perceived fear in the pedestrian context was assessed.

RESULTS

Children reported greater emotional fear when they faced quicker traffic, shorter distances from approaching traffic, and red rather than green traffic signals. Children who were more fearful made safer pedestrian decisions in more challenging traffic situations. However, when the least risky traffic situation was presented, fear was associated with more errors in children's pedestrian decisions: fearful children failed to cross the street when they could have done so safely. Perception of fear did not vary by child age, although safe pedestrian decisions were more common among the older children.

CONCLUSIONS

Children's emotional fear may predict risk-taking in traffic. When traffic situations are challenging to cross within, fear may appropriately create safer decisions. However, when the traffic situation is less risky, feelings of fear could lead to excessive caution and inefficiency. Practical applications: Child pedestrian safety interventions may benefit by incorporating activities that introduce realistic fear of traffic risks into broader safety lessons.

Social environment versus cycling competency predicting risk-taking in 11- to 13-year-old cyclists in The Netherlands

Objectives: From age 12 onwards, cycling injuries begin rising in The Netherlands. A known contributing factor is younger children's underdeveloped competency to deal with complex and hazardous traffic situations, and their exposure to such situations strongly increases after transitioning to secondary school. Little is known about intentional risk-taking as a contributing factor. In this developmental stage, children become increasingly vulnerable because of intentional risk-taking, affecting their safety and health. The incidence, predictors in the child's social environment, and trends of such risks are systematically monitored; for instance, for alcohol use, smoking, and cyber bullying. Such monitors do not include risky road behavior. This exploratory field study examined the frequency of intentional risky cycling, its relationship with the perceived social environment, and relative to cycling competency measured as the ability to detect emerging hazards quickly.Methods: Three hundred thirty-five students between 11 and 13 years of age (51% male) completed computerized tests of hazard perception skill and surveys on crashes, risk-taking, peer pressure, perceived risk-taking by parents or friends, and exposure to risky driving as passenger.Results: Frequent risk-taking was associated with higher crash frequency. Stepwise regression confirmed that children who more often took risks on the road were also more sensitive to peer pressure, had more often been passengers of risky drivers, had parents and friends who exhibited risky behaviors in traffic more often, and perceived hazards as less dangerous but, in contrast to expectations, did not do worse on the detection of hazards. The predictors explained 28% of the variance in total risk-taking but varied from 6 to 20% depending on the specific risk-taking behavior concerned.Conclusions: At least 20% of children sometimes or more often take risks in traffic. Children who feel peer pressure to behave in a risky manner, observe parents and friends behaving in a risky manner in traffic, and have been exposed as passengers to risky driving more often take risks in traffic themselves. These results provide support for including items on risky road behavior in health monitors and to design interventions that address the risk factors in the child's perceived social environment.

The Road User Behaviours of Chinese Adolescents: Data From China and a Comparison With Adolescents in Other Countries

OBJECTIVES

Adolescents experience high rates of road traffic injuries and deaths as pedestrians and cyclists. One likely reason for adolescents' elevated traffic injury risk is their risky behaviour on the road. This study examined Chinese adolescents' road behaviour using a nationwide survey.

METHODS

Across 7 Chinese provinces, 4,794 adolescents completed the Chinese version of the Adolescent Road User Behaviour Questionnaire (ARBQ). Results from t-tests and ANOVAs described the road behaviours of Chinese adolescent subgroups, and meta-analytic techniques and Kendall's correlation analysis compared adolescent road behaviours between China and other countries (Iran and a high-income country composite).

RESULTS

Replicating previous reports from other countries, male adolescents in China generally reported more risk-taking on the road than females, and adolescents aged 15 years and over behaved in a riskier manner than younger ones. Adolescents in rural China reported more risky road behaviours than those who lived in cities, and adolescents who lived only with grandparents behaved more riskily than those who lived with parents only or with parents and grandparents. Adolescents previously involved in a traffic injury also reported riskier road behaviours. In cross-national comparisons, Chinese adolescents' scores on unsafe road behaviours were lower, and scores on safe road behaviours were higher, than those in other nations. However, there were also several commonalities in how adolescents across countries ranked the frequency of engaging in specific risky road behaviours.

CONCLUSIONS

Gender, age, living environment, and traffic injury experience affect adolescents' reports of their risky road behaviour. Chinese adolescents reported more cautious behaviour than those in high-income countries and in Iran. Traffic injury interventions for adolescents should consider adolescent development as part of pedestrian safety training; results also have implications for guiding parents on how to supervise adolescents near traffic and on what infrastructure development strategies might best protect adolescents in traffic situations.

Higher-order cycling skills among 11- to 13-year-old cyclists and relationships with cycling experience, risky behavior, crashes and self-assessed skill

INTRODUCTION

In the Netherlands, young cyclists are extremely vulnerable in traffic, which may partly be due to their still underdeveloped higher-order cycling skill. So far, knowledge on their actual level of skill is lacking. Using a computerized test battery mimicking real-life risky traffic conditions, this study assessed the level of higher-order cycling skill in children 11 and 12 years of age and tested the hypothesis that these skills show caveats. Furthermore, factors potentially influencing the development and impact of these skills were studied, such as cycling experience, risky road behavior, crash involvement, and self-assessed skill.

METHOD

A total of 335 students (49% female) completed computerized tests on hazard perception, gap acceptance, blind spot strategies, and priority decisions in traffic, and completed questionnaires on cycling experience, risky cycling behavior, crashes, and self-assessment of cycling skill.

RESULTS

On the hazard perception test, one-third of the participants missed at least half of the number of hazards. They made errors in about 50% of the priority decisions, accepted critical gaps when crossing the road, and conversely rejected safe gaps; only 1% of the participants identified all blind spots of a truck correctly, while 69% made unsafe decisions when interacting with trucks in traffic scenarios. Overall, in complex traffic situations performance was worse than in simple ones. The hypothesis of lack of skills was therefore accepted. However, the study failed to demonstrate consistent relationships between subtest performance and cycling experience, risky behavior, crashes, and self-assessed skill, which weakens the theoretical assumptions concerning the subtests.

CONCLUSIONS

The results suggest that children at the end of primary school are still lacking elementary skills for safe cycling, calling for measures to accelerate skill development.

PRACTICAL APPLICATIONS

Test batteries are essential tools for systematically monitoring skill development in cyclists, evaluating education programs, and for guiding the development of effective road safety education. The next step is the validation of such batteries.

School-based education programmes for the prevention of unintentional injuries in children and young people

BACKGROUND

Unintentional injuries are the leading cause of death in children aged four to 18 years and are a major cause of ill health. The school setting offers the opportunity to deliver preventive interventions to a large number of children and has been used to address a range of public health problems. However, the effectiveness of the school setting for the prevention of different injury mechanisms in school-aged children is not well understood.

OBJECTIVES

To assess the effects of school-based educational programmes for the prevention of injuries in children and evaluate their impact on improving children's safety skills, behaviour and practices, and knowledge, and assess their cost-effectiveness.

SEARCH METHODS

We ran the most recent searches up to 16 September 2016 for the following electronic databases: Cochrane Injuries Group Specialised Register; Cochrane Central Register of Controlled Trials; Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations; Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R); Embase and Embase Classic (Ovid); ISI Web of Science: Science Citation Index Expanded; ISI Web of Science Conference Proceedings Citation Index-Science; ISI Web of Science: Social Sciences Citation Index; ISI Web of Science: Conference Proceedings Citation Index - Social Sciences & Humanities; and the 14 October 2016 for the following electronic databases: Health Economics Evaluations Database (HEED); Health Technology Assessment Database (HTA); CINAHL Plus (EBSCO); ZETOC; LILACS; PsycINFO; ERIC; Dissertation Abstracts Online; IBSS; BEI; ASSIA; CSA Sociological Abstracts; Injury Prevention Web; SafetyLit; EconLit (US); PAIS; UK Clinical Research Network Study Portfolio; Open Grey; Index to Theses in the UK and Ireland; Bibliomap and TRoPHI.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (non-RCTs), and controlled before-and-after (CBA) studies that evaluated school-based educational programmes aimed at preventing a range of injury mechanisms. The primary outcome was self-reported or medically attended unintentional (or unspecified intent) injuries and secondary outcomes were observed safety skills, observed behaviour, self-reported behaviour and safety practices, safety knowledge, and health economic outcomes. The control groups received no intervention, a delayed injury-prevention intervention or alternative school-based curricular activities. We included studies that aimed interventions at primary or secondary prevention of injuries from more than one injury mechanism and were delivered, in part or in full, in schools catering for children aged four to 18 years.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors identified relevant trials from title and abstracts of studies identified in searches and two review authors extracted data from the included studies and assessed risk of bias. We grouped different types of interventions according to the outcome assessed and the injury mechanism targeted. Where data permitted, we performed random-effects meta-analyses to provide a summary of results across studies.

MAIN RESULTS

The review included 27 studies reported in 30 articles. The studies had 73,557 participants with 12 studies from the US; four from China; two from each of Australia, Canada, the Netherlands and the UK; and one from each of Israel, Greece and Brazil. Thirteen studies were RCTs, six were non-RCTs and eight were CBAs. Of the included studies, 18 provided some element of the intervention in children aged four to 11 years, 17 studies included children aged 11 to 14 years and nine studies included children aged 14 to 18 years.The overall quality of the results was poor, with the all studies assessed as being at high or unclear risks of bias across multiple domains, and varied interventions and data collection methods employed. Interventions comprised information-giving, peer education or were multi-component.Seven studies reported the primary outcome of injury occurrence and only three of these were similar enough to combine in a meta-analysis, with a pooled incidence rate ratio of 0.73 (95% confidence interval (CI) 0.49 to 1.08; 2073 children) and substantial statistical heterogeneity (I² = 63%). However, this body of evidence was low certainty, due to concerns over this heterogeneity (inconsistency) and imprecision. This heterogeneity may be explained by the non-RCT study design of one of the studies, as a sensitivity analysis with this study removed found stronger evidence of an effect and no heterogeneity (I² = 0%).Two studies report an improvement in safety skills in the intervention group. Likewise, the four studies measuring observed safety behaviour reported an improvement in the intervention group relative to the control. Thirteen out of 19 studies describing self-reported behaviour and safety practices showed improvements, and of the 21 studies assessing changes in safety knowledge, 19 reported an improvement in at least one question domain in the intervention compared to the control group. However, we were unable to pool data for our secondary outcomes, so our conclusions were limited, as they were drawn from highly diverse single studies and the body of evidence was low (safety skills) or very low (behaviour, safety knowledge) certainty. Only one study reported intervention costs but did not undertake a full economic evaluation (very low certainty evidence).

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine whether school-based educational programmes can prevent unintentional injuries. More high-quality studies are needed to evaluate the impact of educational programmes on injury occurrence. There is some weak evidence that such programmes improve safety skills, behaviour/practices and knowledge, although the evidence was of low or very low quality certainty. We found insufficient economic studies to assess cost-effectiveness.

Quantifying the influence of safe road systems and legal licensing age on road mortality among young adolescents: steps towards system thinking

Based on existing literature, a system thinking approach was used to set up a conceptual model on the interrelationships among the components influencing adolescent road mortality, distinguishing between components at the individual level and at the system level. At the individual level the role of risk behaviour (sometimes deliberate and sometimes from inexperience or other non-deliberate causes) in adolescent road mortality is well documented. However, little is known about the extent to which the 'road system' itself may also have an impact on younger adolescents' road mortality. This, by providing a safe or unsafe road environment for all road users (System-induced exposure) and by allowing access to high-risk vehicles at a young or older age through the legal licensing age. This study seeks to explore these relationships by analysing the extent to which the road mortality of 10 to 17 year olds in various jurisdictions can be predicted from the System-induced Exposure (SiE) in a jurisdiction and from its legal licensing age to drive motor vehicles. SiE was operationalized as the number of road fatalities per 10(5) inhabitants/all ages together, but excluding the 10 to 17 year olds. Data on road fatalities during the years 2001 through 2008 were obtained from the OECD International Road Traffic Accident Database (IRTAD) and from the USA NHTSA's Fatality Analysis Reporting System (FARS) database for 29 early and 10 late licensing jurisdictions. Linear mixed models were fitted with annual 'Adolescent road mortality per capita' for 2001 through 2008 as the dependent variable, and time-dependent 'SiE' and time-independent 'Licensing system' as predictor variables. To control for different levels of motorisation, the time-dependent variable 'Annual per capita vehicle distance travelled' was used as a covariate. Licensing system of a jurisdiction was entered as a categorical predictor variable with late licensing countries as a baseline group. The study found support for the protective effects of SiE on adolescent safety. If SiE increased by one unit, the mortality rate of 10 to 17 year olds increased by 0.487 units. No support was found for a protective effect of late licensing for this age group. Thus, compared to young adolescents who are allowed to drive motor vehicles in early licensing jurisdictions, late licensing does not provide extra protection for pre-license adolescents. This finding is probably the result of the high risks associated with alternative transport modes, such as moped riding and bicycling. Also, the fact that the study only included risks to young adolescents themselves and did not include the risks they might pose to other road users and passengers may have contributed to this finding, because such risks are greater when driving a motor vehicle than riding a moped or a bicycle. Therefore, to advance our understanding of the impact of licensing systems, more study is needed into the benefits of early or late licensing, thereby considering these wider effects as well.

Five road safety education programmes for young adolescent pedestrians and cyclists: a multi-programme evaluation in a field setting

A practical approach was developed to assess and compare the effects of five short road safety education (RSE) programmes for young adolescents that does not rely on injury or crash data but uses self reported behaviour. Questionnaires were administered just before and about one month after participation in the RSE programmes, both to youngsters who had participated in a RSE programme, the intervention group, and to a comparable reference group of youngsters who had not, the reference group. For each RSE programme, the answers to the questionnaires in the pre- and post-test were checked for internal consistency and then condensed into a single safety score using categorical principal components analysis. Next, an analysis of covariance was performed on the obtained safety scores in order to compare the post-test scores of the intervention and reference groups, corrected for their corresponding pre-test scores. It was found that three out of five RSE programmes resulted in significantly improved self-reported safety behaviour. However, the proportions of participants that changed their behaviour relative to the reference group were small, ranging from 3% to 20%. Comparisons among programme types showed cognitive approaches not to differ in effect from programmes that used fear-appeal approaches. The method used provides a useful tool to assess and compare the effects of different education programmes on self-reported behaviour.