Featured Article: Evaluating Smartphone-Based Virtual Reality to Improve Chinese Schoolchildren's Pedestrian Safety: A Nonrandomized Trial

Applying the multiphase optimization strategy to evaluate the feasibility and effectiveness of an online road safety education intervention for children and parents: a pilot study

BACKGROUND

Reports of children's engagement in active transportation outline low participation rates in many countries despite many associated mental, physical, and social health benefits. One of the main contributors to this phenomenon is a cited lack of education and knowledge among children regarding active travel (AT), specifically road safety. To address this issue, the aim of this study was to evaluate the feasibility and effectiveness of an online road safety education intervention to promote AT among children and their parents.

METHODS

Applying the Multiphase Optimization Strategy (MOST) for intervention development, implementation, and evaluation, we designed and assessed a four-module online road safety education intervention with a sample of 57 parent-child dyads using a 23 factorial design featuring both qualitative and quantitative analyses.

RESULTS

Main intervention feasibility findings include positive and critical feedback on the program's content and design, and moderate participant engagement as reflected by program retention and completion rates. With respect to the preliminary intervention effectiveness on children, a significant improvement in road safety knowledge scores was observed for groups that feature the "wheeling safety and skills" module. Slight improvements in AT knowledge scores across all the intervention groups were observed, but were not of significance. Preliminary intervention effectiveness on select parental AT practices and perceptions saw significant improvements in some groups. Groups that featured the 'wheeling safety and skills' module exhibited significantly higher guided choice scores upon completion of the program than those who did not receive this component.

CONCLUSION

The MOST framework allowed us to design and evaluate the feasibility and preliminary effectiveness of an online road safety education intervention. The developed intervention has demonstrated that it has the potential to improve children's road safety knowledge and some areas of parental AT practices and perceptions, to which improvements may be attributed to the inclusion of the "wheeling safety and skills" module, suggesting that the targeted focus on cycling skills is a prioritized area. AT programming and practice implications are discussed. Future research is encouraged to refine modules to better reflect the priorities of children and parents and to test these refined components among larger samples.

WORD COUNT

9,391 (excludes abstract, tables, figures, abbreviations, and references).

Teaching children pedestrian safety in virtual reality via smartphone: a noninferiority randomized clinical trial

OBJECTIVE

To evaluate whether child pedestrian safety training in a smartphone-based virtual reality (VR) environment is not inferior to training in a large, semi-immersive VR environment with demonstrated effectiveness.

METHODS

Five hundred 7- and 8-year-old children participated; 479 were randomized to one of two conditions: Learning to cross streets in a smartphone-based VR or learning in a semi-immersive kiosk VR. The systems used identical virtual environments and scenarios. At baseline, children's pedestrian skills were assessed in both VR systems and through a vehicle approach estimation task (judging speed/distance of oncoming traffic on monitor). Training in both conditions comprised at least six 30-min sessions in the randomly assigned VR platform and continued for up to 25 visits until adult-level proficiency was obtained. Following training and again 6 months later, children completed pedestrian safety assessments identical to baseline. Three outcomes were considered from assessments in each VR platform: Unsafe crossings (collisions plus close calls), time to contact (shortest time between child and oncoming simulated traffic), and missed opportunities (unselected safe opportunities to cross).

RESULTS

Participants achieved adult-level street-crossing skill through VR training. Training in a smartphone-based VR system was generally not inferior to training in a large semi-immersive VR system. There were no adverse effects.

CONCLUSIONS

Seven- and 8-year-old children can learn pedestrian safety through VR-based training, including training in a smartphone-based VR system. Combined with recent meta-analytic results, the present findings support broad implementation and dissemination of child pedestrian safety training through VR, including smartphone-based VR systems.

Child pedestrian safety training in virtual reality: How quickly do children achieve adult functioning and what individual differences impact learning efficiency?

INTRODUCTION

Pedestrian injuries represent a leading cause of child death globally. One prevention strategy is teaching children street-crossing skills. Virtual reality (VR) has emerged as a strategy to offer repeated street-crossing practice and overcome ethical barriers of training children in live traffic. This study addressed two questions pertinent to implementation of child pedestrian safety training within VR: (a) how much training do children require to achieve adult street-crossing competency, and (b) what individual differences might facilitate children to acquire that competency more efficiently?

METHODS

Five hundred 7- and 8-year-olds were recruited. Children completed pedestrian safety training within VR for up to 25 thirty-minute training sessions until they achieved adult levels of mastery. At baseline, four cognitive-perceptual skills (visual memory, visual perception, processing speed, working memory) and parent-reported externalizing symptomatology were assessed.

RESULTS

On average, children achieved adult pedestrian safety competency after 10.0 training sessions (SD = 4.8). Just one child (<1%) failed to achieve adult pedestrian functioning after 25 training sessions. In univariate analyses, boys took slightly longer than girls to achieve adult functioning, and visual memory, visual perception, processing speed, working memory, and fewer externalizing symptoms were all positively associated with shorter time to mastery. In a multivariable model, only child age was a statistically significant predictor.

CONCLUSION

Almost all participants achieved adult street-crossing skills competency through VR training, although they required about 10 sessions on average. Analysis of predictor variables confirmed that nearly all 7- and 8-year-olds are trainable.

PRACTICAL APPLICATION

Implementation of VR pedestrian safety training is recommended, but must be conducted cautiously to ensure children are not permitted to engage independently in traffic until they are assessed and demonstrate sufficient skills.

Safety of virtual reality use in children: a systematic review

The study aimed to systematically review available literature regarding the safety of virtual reality (VR) use via head-mounted display in children under 14 years of age. The study was a systematic review including all study designs. A search was conducted in January 2023 in PubMed and EMBASE using key terms referring to 'virtual reality', 'paediatrics' and 'safety'.  Following title and abstract and full-text screening, data were extracted and a narrative synthesis undertaken. Twenty-six studies met criteria for inclusion in the final review.  Limited data suggest that VR may cause mild cybersickness symptoms (not severe enough to cause participants to discontinue use of VR) and that for children with existing amblyopia using VR may result in double vision, which resolves on cessation of VR exposure.  Two randomised control trials did not report differences in adverse events between the intervention (VR use) and control groups. Reporting of safety data was poor; only two studies used a validated measure, and in the remaining studies, it was often unclear how adverse events were defined (if at all), how they were categorised in terms of severity and how they were recorded.     Conclusion: There is limited evidence regarding any potential harms from short exposure to VR in children under 14 years under supervision. Additional research is required to understand increases in cybersickness during and after VR exposure, and the impact of repeated exposure.  Adverse events need to be accurately and routinely recorded to determine any hitherto unknown safety concerns for children < 14 years using VR. What is Known: • Virtual reality (VR) is increasingly being applied in paediatrics, with benefits in terms of anxiety reduction, improved pain management associated with procedures, as an adjunct to physiotherapy and supporting treatments in autistic spectrum disorder.. • Safety guidance in relation to VR use, particularly in younger children, is limited. What is New: • A systematic review of available literature regarding the safety of VR use via head-mounted display in children under 14 years of age demonstrated limited evidence regarding any potential harms from short exposure to VR.. • Studies rarely report safety data and adverse side effects are poorly defined, measured and/or reported. • The lack of a validated measure for evaluating VR-associated symptoms in children compounds the challenging ethical issues of undertaking research into the effects of VR on younger children.

Roadside experiences of parents of children with developmental coordination disorder and/or attention deficit hyperactivity disorder

Introduction

Pedestrians are a vulnerable group at the roadside and previous research has identified that children with DCD and ADHD are at a heightened risk of pedestrian injuries. Despite this, limited research has explored parental perspectives of the pedestrian risks faced by children with DCD and/or ADHD. Understanding parents' perspectives provides a unique insight into the challenges children face every day and the concerns that parents perceive regarding their children's safety as pedestrians. Therefore, the aim of this study was to explore parents' perspectives of the pedestrian risks faced by their children with DCD and/or ADHD.

Methods

Semi-structured interviews were conducted with 14 parents of primary school and early secondary school aged children with age range 7-17. The participants were divided into three groups based on their children's conditions: DCD group (10-17 years, n = 3), ADHD group (7-13 years, n = 5), and co-occurring group (7-16 years, n = 6). All parents confirmed an existing diagnosis and completed the SNAP-IV and DCDQ as screening tools. The interviews explored parents' perspectives regarding their children's pedestrian behaviors, parents' concerns and preventative measures taken to improve the pedestrian safety of their children with DCD and/or ADHD. Reflexive thematic analysis was undertaken to analyze the interviews, from which three themes were developed.

Results

The first theme related to the challenges experienced by children at the roadside; parents emphasized the significance of structured and controlled pedestrian crossing sites, underlining their preference for designated crossings as safer options due to their heightened perceptions of risk associated with other road-crossing locations. The second theme: parental concerns and influences on children's road safety referred to their children's performance and safety at the roadside, leading to increased monitoring and a more protective approach to road crossing. The third theme: road safety education related to various strategies parents implemented to mitigate risks, while balancing independence and prioritizing their safety.

Discussion

While there were commonalities in the challenges faced by children with DCD and/or ADHD at the roadside, there were also notable differences. Parents of children with DCD discussed challenges with spatial awareness and motor skills, whereas parents of children with ADHD discussed challenges with impulsivity and inattention. Parents of children with co-occurring DCD and ADHD described a complex interplay of these challenges. It is evident from the interviews that children with DCD and/or ADHD require a distinct approach to develop their pedestrian skills effectively and parents reported specific strategies they used to address the risks associated with their children's roadside behavior. Promoting pedestrian safety for children with DCD and/or ADHD necessitates collaboration among parents, schools and local authorities to implement comprehensive measures ensuring their safety. These findings contribute to understanding parental experiences and needs, providing valuable guidance for targeted interventions and policies to enhance the road safety of children with DCD and/or ADHD.

A Systematic Review and Meta-Analysis on the Efficacy of Virtual Reality Pedestrian Interventions to Teach Children How to Cross Streets Safely

OBJECTIVE

Over 7,000 American children die from pedestrian injuries annually, and pedestrian injury ranks among the top 5 causes of unintentional child death. Prevention efforts are multifaceted. One strategy, use of virtual reality (VR) to teach children to cross streets, is of growing interest to public health practitioners. The present study is a systematic review and meta-analysis that examined the efficacy of using VR to teach children pedestrian safety.

METHODS

Following PRISMA guidelines, searches among 7 databases were completed, followed by abstract/full-text screening and data extraction. Hedge's g was computed for the effect sizes of 3 outcomes: pedestrian knowledge, pedestrian-relevant cognition (attention to traffic, time to contact, start delay), and pedestrian behaviors (safe crossings, unsafe crossings). Risk of bias was assessed using Cochrane guidelines. Meta-regression analyses and subgroup analyses were conducted including 3 moderators: age, sex, and immersion level.

RESULTS

A total of 20 studies, reported in 24 articles, were included in the qualitative analysis. Meta-analysis of the 12 studies with sufficient quantitative data available showed a statistically significant medium effect of VR safety interventions on child pedestrian knowledge and behavior. Mixed results emerged for the effect of VR safety interventions on children's pedestrian-relevant cognition. Age and sex moderated the effect of VR training on pedestrian knowledge.

CONCLUSIONS

This synthesis of the literature on pediatric VR pedestrian safety interventions suggests an overall beneficial impact of VR interventions to teach children how to cross streets safely. Efforts should continue to develop and disseminate effective VR interventions.

REGISTRATION ID

CRD42022309352.

Evaluating the effectiveness of the safety experience room, an affordable interactive education intervention to prevent unintentional injury among rural preschoolers in China: protocol for a cluster randomized controlled trial

BACKGROUND

Interactive and experiential learning programs have proven effective to teach children safety and prevent child unintentional injury. However, previously-published programs were designed primarily to address safety concerns of children living in urban, well-resourced areas, and therefore might be less effective or economically infeasible to distribute to children in resource-limited areas, such as those living in rural areas or underdeveloped regions. This proposed study will evaluate the effectiveness of teaching children safety lessons to rural preschoolers in China through the preschool-based Safety Experience Room intervention that was developed based on relevant theories, the lessons of previous intervention research, the characteristics of child injuries in underdeveloped rural areas, and the needs and circumstances of rural families and preschools in China. The study will also evaluate the cost-effectiveness of delivering the program.

METHODS AND ANALYSIS

A single-blinded, 12-month follow-up, parallel-group cluster randomized controlled trial with a 1:1 allocation ratio will be implemented in two selected counties. In total, at least 2378 rural preschoolers aged 3-6 years old will be recruited from 12 preschools, 6 in Yang County and 6 in Shicheng County. Clusters will be randomized at the preschool level and allocated to the control group (routine school-based education) or the intervention group (routine school-based education plus the Safety Experience Room education). External support strategies will be implemented by local partners to minimize attrition. Data collection will be conducted at baseline and then every 3 months during a 12-month follow-up time period. Intention-to-treat (ITT) data analysis will be used. Generalized estimation equations (GEE) will evaluate the effectiveness of the program and generalized cost-effectiveness analysis (GCEA) will evaluate the cost-effectiveness of it. A per-protocol (PP) sensitivity analysis will assess the robustness of ITT results. Subgroup analyses will be performed to evaluate the impact of socio-demographic factors on the intervention effect, following the same strategies as the primary analyses.

DISCUSSION

The newly-designed Safety Experience Room program is expected to be feasible, effective, and financially beneficial. If these hypotheses prove true, we will take steps to disseminate the program to rural preschools across China.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ( http://www.chictr.org.cn ), CHiCTR2000038025, registered on 8 September 2020.

Interventions to prevent road traffic injuries among pedestrians: a systematic review

Road traffic injuries (RTIs) are a serious public health problem and are an important cause of disability and death worldwide. A significant proportion of traffic injuries and fatalities are among pedestrians. Reviewing and evaluating related interventions can be a practical step to implementing appropriate methods to prevent RTIs among pedestrians, a highly vulnerable group of road users.

The search of articles was conducted in the electronic databases of Scopus, PubMed, ISI, Safety Lit, and CDC. Other papers were also reviewed using forward citation and backward citation. The search strategy was for studies examined from the first years of database creation until January 10, 2021, in all languages in journals with matched judgment according to the type of population, type of interventions, comparators, and results. Joanna Briggs Institute (JBI) checklists were used to determine articles' quality and assess possible biases depending on the type of study.

The initial search resulted in finding 16,272 abstracts. Finally, 25 studies, including 17 randomized clinical trials (RCTs) studies, seven studies pretest/post-test interventions (PPI), and one study controlled pretest/post-test interventions (cPPI) met the inclusion criteria. Among these preventive interventional studies, 20 studies were conducted in high-income countries, three were in lower middle-income countries, one study was in upper middle-income country, and only one study was conducted in a low-income country. Most interventional studies in the field of prevention of RTIs (15 studies) had an educational/behavioral approach, designed to change pedestrian behavior and the use of this approach was also effective in improving pedestrian behavior. The legislation/law enforcement approach was used in one study and two studies used an engineering/technology approach. In studies with an engineering approach after engineering reforms, pedestrian injuries in children decreased by 37.5%. In seven studies, multifaceted interventions were used. The interventional studies that used this approach were able to improve pedestrian safe behavior.

The majority of studies were based on educational/behavioral approaches and pedestrians' behavior improved notably. In addition, the majority of interventional studies were conducted in countries with high income levels. Therefore, programming for preventive interventions to attenuate RTIs is highly important in low/middle-income countries to reduce the risk of injury to vulnerable road users. These findings can be applied by policy-makers to develop educational, engineering, environmental, and law enforcement interventions and attenuate injuries sustained by pedestrians.

Road-Crossing Behavior in Complex Traffic Situations: A Comparison of Children With and Without ADHD

All children are vulnerable to pedestrian injuries, but previous research suggests children diagnosed with ADHD may have elevated risk. Child pedestrian injury risk also increases with increasing traffic volume and speed. The current study examined three hypotheses: (a) Pedestrian behavior of children with ADHD is riskier than that of typically-developing children; (b) Children's pedestrian behavior is riskier with increased traffic complexity; and (c) Pedestrian behavior of children with ADHD is influenced more by complex traffic situations than behavior of typically-developing children. A sample of 38 children ages 8-12 years, 45% diagnosed with ADHD, completed 21 virtual street-crossings, 7 in each of three levels of traffic complexity. Outcome measures included unsafe crossings, ratio of looking at traffic by time, start-delay to enter the road, time to contact with oncoming vehicles, and time waiting to cross. A repeated measure MANOVA and follow-up tests showed that all children had more unsafe crossings, shorter start-delays and shorter TTCs when exposed to increased traffic complexity compared to lighter traffic. Children with ADHD had more unsafe crossings than typically-developing children. Further, compared to typically-developing children, ADHD children had comparatively more unsafe crossings, lower time to contact and longer wait-time in more complex traffic environments. Executive function deficits among children with ADHD likely influence their behavior in complex traffic environments. Implications of the results for policy-making and preventive strategies are discussed.

Using virtual reality to identify and modify risky pedestrian behaviors amongst Chinese children

Objective: China has a high fatality rate for child pedestrians, which highlights the necessity of implementing more effective pedestrian safety training programs in elementary schools. We thus investigated the efficacy of using virtual reality (VR) as an instructional technology to identify and modify risky pedestrian behaviors among Chinese children.Methods: Seventy-nine children (grades 1 through 3) from three elementary schools in Hubei province participated and were categorized into urban (n = 20), migrant (n = 29), or rural (n = 30) students based on the schools' locations. They completed a VR program comprising three street-crossing challenges to measure five pedestrian behaviors. The participants first attempted to complete the challenges by themselves in the first-time trial (T1) and then engaged in a personalized debriefing session before undertaking the challenges a second time (T2). Pedestrian performance for the two trials was compared by school location and grade level as between-subjects factors, and the rationale behind risky pedestrian behaviors was inductively analyzed.Results: Three risky pedestrian behaviors were observed in the program: dashing into the street, crossing on a blinking green light, and failing to check for traffic. Potential reasons for these behaviors included a lack of knowledge of road signs and traffic rules and the absence of daily adult supervision. The overall pedestrian performance increased from T1 to T2 with a moderate effect size (Ƞ_p² = 0.59, p < .001). A significant main effect of the trials was found for the three pedestrian behaviors (for all values, p < .001); however, interactions of trial by location and trial by grade were nonsignificant in all univariate tests (for all values, p ≥ .05).Conclusions: VR is an effective technology to diagnose and correct risky pedestrian behaviors among Chinese children when accompanied with individual debriefing and repetitive practices. School location and grade level had no significant influence on children's pedestrian performance and learning outcomes, indicating the ubiquity of the pedestrian safety problem and the need for more effective instructional interventions.