Child Pedestrian Injury: A Review of Behavioral Risks and Preventive Strategies

Injury patterns in motor vehicle collision-youth pedestrian deaths

OBJECTIVE

The objective of this study was to describe fatal pedestrian injury patterns in youth aged 15 to 24 years old and correlate them with motor vehicle collision (MVC) dynamics and pedestrian kinematics using data from medicolegal death investigations of MVCs occurring in the current Canadian motor vehicle (MV) fleet.

METHODS

Based on a systematic literature review, MVC-pedestrian injuries were collated in an injury data collection form (IDCF). The IDCF was coded using the Abbreviated Injury Scale (AIS) 2015 revision. The AIS of the most frequent severe injury was noted for individual body regions. The Maximum AIS (MAIS) was used to define the most severe injury to the body overall and by body regions (MAISBR). This study focused on serious to maximal injuries (AIS 3-6) that had an increasing likelihood of causing death. The IDCF was used to extract collision and injury data from the Office of the Chief Coroner for Ontario (OCCO) database of postmortem examinations done at the Provincial Forensic Pathology Unit (PFPU) in Toronto, Canada, and other provincial facilities between 2013 and 2019. Injury data were correlated with data about the MVs and MV dynamics and pedestrian kinematics.The study was approved by the Western University Health Science Research Ethics Board (Project ID: 113440; Lawson Health Research Institute Approval No. R-19-066).

RESULTS

There were 88 youth, including 54 (61.4%) males and 34 (38.6%) females. Youth pedestrians comprised 13.1% (88/670) of all autopsied pedestrians. Cars (n = 25/88, 28.4%) were the most frequent type of vehicle in single-vehicle impacts, but collectively vehicles with high hood edges (i.e., greater distance between the ground and hood edge) were in the majority. Forward projection (n = 34/88, 38.6%) was the most frequent type of pedestrian kinematics. Regardless of the type of vehicle, there was a tendency in most cases for the median MAISBR ≥ 3 to involve the head and thorax. A similar trend was seen in most of the pedestrian kinematics involving the various frontal impacts. Of the 88 cases, at least 63 (71.6%) were known to be engaged in risk-taking behaviors (e.g., activity on roadway). At least 12 deaths were nonaccidental (8 suicides and 4 homicides). Some activities may have been impairment related, because 26/63 (41.3%) pedestrians undertaking risk-taking behavior on the roadway were impaired. Toxicological analyses revealed that over half of the cases (47/88, 53.4%) tested positive for a drug that could have affected behavior. Ethanol was the most common. Thirty-one had positive blood results.

CONCLUSION

A fatal dyad of head and thorax trauma was observed for pedestrians struck by cars. For those pedestrians hit by vehicles with high hood edges, which were involved in the majority of cases, a fatal triad of injuries to the head, thorax, and abdomen/retroperitoneum was observed. Most deaths occurred from frontal collisions and at speeds more than 35 km/h.

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.

Social and economic factors associated with child unintentional injury mortality in high-income countries

INTRODUCTION

Recognising the connection between country-level social determinants of health, and child unintentional injury mortality can contribute to better resource allocation for child safety. This cross-sectional country-level study aims to investigate such a link where the role of income inequality (Gini Index) is examined alongside education expenditure, current health expenditure and gross national income (GNI) per capita.

METHODS

A total of 49 high-income countries were studied, using the WHO Global Health Estimates 2016, the World Bank's World Development Indicators for education and GNI per capita, and the standardised world income inequality database to compile estimates of child unintentional injury mortality rates and selected socioeconomic characteristics.

RESULTS

A wide range of childhood mortality rates from unintentional injury was observed (1.3-10.0 deaths per 100 000 children). Such risk is strongly associated with income inequality (0.50), GNI per capita (-0.35) and education expenditure (-0.01) (mediated by income inequality). No association was found to current health expenditure. The results explain 52% of the variance in child unintentional injury mortality.

CONCLUSIONS

In countries with higher overall economic activity and lower-income inequality, child mortality from unintentional injuries is lower. Allocation of education expenditure is one contributor to reducing income inequality; other factors need further exploration.

Injury and fatality risks for child pedestrians and cyclists on public roads

BACKGROUND

Pedestrians and cyclists are often referred to as "vulnerable road users," yet most research is focused on fatal crashes. We used fatal and nonfatal crash data to examine risk factors (i.e., relationship to an intersection, urbanicity, crash circumstances, and vehicle type) for police-reported pedestrian and cyclist injuries on public roads among children aged 0-9 and aged 10-19. We also compared risk factors among these two age groups with adults aged 20-29 and aged 30-39.

METHODS

Crash data were obtained for 2016-2020 from the National Highway Traffic Safety Administration's Fatality Analysis Reporting System for fatal crash injuries and Crash Report Sampling System for nonfatal crash injuries. We collected data on victim demographics, roadway, and vehicle- and driver-related factors. Descriptive analyses were conducted between and within pedestrian and cyclist victims.

RESULTS

We analyzed 206,429 pedestrian injuries (36% in children aged 0-19) and 148,828 cyclist injuries (41% in children aged 0-19) from 2016 to 2020. Overall, child pedestrians had lower injury rates than adults, but children aged 10-19 had greater cycling crash rates than adults. Almost half of the pedestrian injuries in children aged 0-9 were "dart-out" injuries (43%). In the majority of the cyclist injuries, children in both age groups failed to yield to vehicles (aged 0-9 = 40% and aged 10-19 = 24%). For children and all ages included in the study, the fatality risk ratio was highest when pedestrians and cyclists were struck by larger vehicles, such as trucks and buses. Further exploration of roadway factors is presented across ages and transportation mode.

CONCLUSION

Our findings on child, driver, vehicle, and roadway factors related to fatal and nonfatal pedestrian and cyclist injuries may help to tailor prevention efforts for younger and older children.

Longitudinal and Concurrent Effortful Control as Predictors of Risky Bicycling in Adolescence: Moderating Effects of Age and Gender

OBJECTIVE

Collisions between bicycles and motor vehicles are one of the leading risk factors for injury and death in childhood and adolescence. We examined longitudinal and concurrent effortful control (EC) as predictors of risky bicycling behavior in early- to mid-adolescence, with age and gender as moderators. We also examined whether EC was associated with parent-reported real-world bicycling behavior and all lifetime unintentional injuries.

METHODS

Parent-reported EC measures were collected when children (N = 85) were 4 years old and when they were either 10 years (N = 42) or 15 years (N = 43) old. We assessed risky bicycling behavior by asking the adolescents to bicycle across roads with high-density traffic in an immersive virtual environment. Parents also reported on children's real-world bicycling behavior and lifetime unintentional injuries at the time of the bicycling session.

RESULTS

We found that both longitudinal and concurrent EC predicted adolescents' gap choices, though these effects were moderated by age and gender. Lower parent-reported early EC in younger and older girls predicted a greater willingness to take tight gaps (3.5 s). Lower parent-reported concurrent EC in older boys predicted a greater willingness to take gaps of any size. Children lower in early EC started bicycling earlier and were rated as less cautious bicyclists as adolescents. Adolescents lower in concurrent EC were also rated as less cautious bicyclists and had experienced more lifetime unintentional injuries requiring medical attention.

CONCLUSION

Early measures of child temperament may help to identify at-risk populations who may benefit from parent-based interventions.

Objective and Perceived Traffic Safety for Children: A Systematic Literature Review of Traffic and Built Environment Characteristics Related to Safe Travel

The literature on children’s active transportation has shown the influence of the built environment characteristics on walking and crashes. Various reviews have examined those two questions. One influence on walking is the perception of traffic safety. However, it is not clear how, or even if, the built environment affects such perceptions. This research aims to understand which traffic and built environment characteristics influence objective and subjective/perceived traffic safety for children based on the analysis of previous studies in the field. Two types of research were used: the first examines the association between traffic and built environment characteristics and child pedestrian and/or cyclist collisions/injuries; the second relates to the perception of safety by parents and children for active transportation and, where studied, its relationship with built environment characteristics. A systematic review was conducted using five electronic databases. The total number of articles retrieved was reduced to 38 following the eligibility criteria and quality assessment, where 25 articles relate to injuries among children and 13 articles pertain to perception of safety. The results showed that high traffic volume and high vehicle speed are the main reasons children and parents feel unsafe when children use active travel, which matches the main findings on objective safety. Few articles on perception of safety related to the objective built environment were found. However, consistent findings exist. The presence of sidewalk was related to the safety of children. The presence of a crossing guard was positively related to perceived safety but was associated with higher rates of injuries among children. Intersection density was related to unsafe perceptions but was not statistically associated with objective traffic safety. Additionally, population density was found to be positively related to injuries among children, but not to perception of safety. The results help policy strategy to enhance the safety of children when using active transport modes.

The effects of pedestrian gestures on driver yielding at crosswalks: A systematic replication

Applied research on decreasing pedestrian injuries often focuses on how to increase driver yielding behavior but rarely studies what pedestrians can do to increase their safety. There is a lack of empirical research focusing on how pedestrians can effectively signal their need to cross the street when there is no traffic light directing the pedestrian and oncoming traffic. As a replication and extension of Crowley-Koch et al. (2011), this study examined the effects of two pedestrian gestures, an extended arm and raised hand, on driver yielding behavior at 3 crosswalks in Oklahoma City. Research assistants implemented gestures prior to crossing the street as cars approached the crosswalk. Data were collected on the percentage of drivers yielding to the pedestrian. Both pedestrian gestures increased driver yielding across all 3 sites when compared to no gesture. Results were discussed in terms of future research and practical solutions towards increasing pedestrian safety.

Analysis of Child Traffic Safety near Primary School Areas Using UAV Technology

Road safety in primary school areas is a delicate issue due to the vulnerability of children as road users. They are inexperienced traffic participants and sometimes their behavior in traffic situations is unpredictable. This paper reports a safety analysis conducted using video processing of conflict trajectories of vehicles and active transportation users (AT users). The videos were collected using unmanned aerial vehicles (UAVs) as this technology does not affect the actual behavior of traffic participants. Due to their airborne position, UAVs can conveniently gather information about driving behaviors and the exact positions of various participants. The safety analysis was conducted using surrogate indicators suitable for evaluating the risk of potential collisions as they incorporate both spatial proximity and speed. Three conflict indicators were used in the safety analysis: (i) time-to-collision, (ii) post-encroachment time, and (iii) heavy braking. The methodology was tested in a primary school area in the city of Zagreb. With the applied methodology, a total of 43 potential conflicts were identified in the school area (14 time-to-collision, 23 post-encroachment time, and 6 heavy braking). Based on the determined potential conflicts, safety measures were proposed to decrease the number and severity of potential conflicts and to increase traffic safety near school areas.

Child-Pedestrian Traffic Safety at Crosswalks—Literature Review

Child pedestrians make up 30% of the total number of children injured in road traffic in the EU. They are a particularly vulnerable subgroup because they exhibit specific traffic behavior related to cognitive and physical development, sociodemographic characteristics, and environmental conditions. This paper provides an overview of research of parameters that affect the safety of children in the conflict zones of the intersection—crosswalks. The overview was undertaken targeting available research mostly conducted in the last 10 years all over the world, related to the identification of parameters that affect the safety of child-pedestrians, and models developed for the prediction of pedestrian and child-pedestrian behavior. Research conducted on various urban networks provides insight into locally and more widely applicable impact parameters connected to child characteristics and infrastructural and traffic elements, but also distractors (e.g., electronic devices) as new phenomena influencing children’s road safety. A review of pedestrian behavior-prediction models suggests that models are being developed for the general population, and models for children’s behavior, with specific parameters, are missing. For further research, more detailed analysis of the impact of distractors and of COVID–19 pandemic non-mobility, as well as an analysis of possible infrastructural solutions to increase children’s road traffic safety, is suggested.

How Do Child ADHD Symptoms and Oppositionality Impact Parent-Child Interactions When Crossing Virtual Roads?

OBJECTIVE

This study examined how parents and children interact when crossing virtual roads together. We examined (1) whether children's inattention/hyperactivity and oppositionality and children's failure to jointly perform the task interfered with parents' efforts to scaffold children's road-crossing skill and (2) whether experience with the joint road-crossing task impacted children's subsequent performance in a solo road-crossing task.

METHODS

Fifty-five 8- to 10-year-old children with and without attention-deficit/hyperactivity disorder and their parents first jointly crossed a lane of traffic in an immersive pedestrian simulator. Children then completed the same road-crossing task alone. Parents completed questionnaires about children's symptoms of inattention/hyperactivity and oppositionality.

RESULTS

Analyses of the joint road-crossing task showed that when parents and children crossed different gaps, parents suggested and opposed more gaps and were less likely to use a prospective gap communication strategy (i.e., communicating about a crossable gap prior to its arrival). Crossing different gaps was also associated with increased expressions of negative affect among parents and children and an increase in collisions among children. Children's level of parent-reported oppositionality also predicted an increase in child defiance and parental redirection of child behavior. Analyses of children's subsequent crossing performance indicated that parents' use of a prospective gap communication strategy during the joint road-crossing task predicted selection of larger gaps during the solo crossing task.

CONCLUSIONS

Not crossing through the same gap and increased levels of child oppositionality interfered with the scaffolding process, potentially informing future parent-based intervention efforts for increasing children's road-crossing safety.

Do Inattention/Hyperactivity and Motor Timing Predict Children's Virtual Road-Crossing Performance?

OBJECTIVE

The goal of this investigation was to examine how individual variation in inattention and hyperactivity is related to motor timing difficulties and whether children's performance on simple laboratory timing tasks is related to their performance on a virtual road-crossing task using a head-mounted virtual reality display system.

METHODS

Participants were a community sample of 92 9- to 11-year-old children. Parents completed questionnaires assessing their child's inattention and hyperactivity. Children completed two simple motor timing tasks (duration discrimination and synchronization-continuation) and crossed roads with continuous traffic in a head-mounted VR system.

RESULTS

Higher parent-reported inattention and hyperactivity predicted poorer performance in the duration discrimination and synchronization-continuation tasks, but not the virtual pedestrian road-crossing task. Children with higher tap onset asynchrony in the synchronization-continuation task had poorer timing of entry into the gap in the virtual pedestrian road-crossing task.

CONCLUSIONS

The findings provide further evidence that timing deficits are associated with individual differences in inattention and hyperactivity and that timing difficulties may be a risk factor for functional difficulties in everyday life.

Pediatric Traffic Injuries on Halloween in the United Kingdom: Prevalence and Injury Severity

The study results serve as a reminder for parents, children, and drivers to be alert to the danger of traffic crashes on Halloween. The aim of this study was to examine whether Halloween is associated with a higher incidence of traffic injuries and whether traffic injuries sustained on Halloween are more severe than those sustained on other days. The U.K. STATS19 database, including the data of all road traffic crashes occurring from 1990 to 2017, was employed. A total of 73,587 pediatric traffic casualties (involving pedestrians, cyclists, and moped riders) were included. Between 17:00 and 19:00 (17:00~18:59) on Halloween, the number of casualties was higher than that on other public holidays and usual days. The logistic regression model revealed that, between 17:00 and 18:00 (17:00~17:59), the risk of being killed or seriously injured on Halloween was 34.2% higher (odds ratio = 1.342; 95% CI = 1.065–1.692) than that on other days. Pediatric crashes occurring on Halloween are associated with a higher number of injuries and increased injury severity.

On the Safety of Mobile Robots Serving in Public Spaces

Since 2014, a specific standard has been dedicated for the safety certification of personal care robots, which operate in close proximity to humans. These robots serve as information providers, object transporters, personal mobility carriers, and security patrollers. In this article, we point out the shortcomings concerning EN ISO 13482:2014, which encompasses guidelines regarding the safety and design of personal care robots. In particular, we argue that the current standard is not suitable for guaranteeing people's safety when these robots operate in public spaces. Specifically, the standard lacks requirements to protect pedestrians and bystanders. The guideline implicitly assumes that private spaces, such as households and offices, present the same hazards as in public spaces. We highlight the existence of at least three properties pertaining to robots’ use in public spaces. These properties include (1) crowds, (2) social norms and proxemics rules, and (3) people's misbehaviours. We discuss how these properties impact robots’ safety. This article aims to raise stakeholders’ awareness on individuals’ safety when robots are deployed in public spaces. This could be achieved by integrating the gaps present in EN ISO 13482:2014 or by creating a new dedicated standard.

Developmental differences across the lifespan in the use of perceptual information to guide action-based decisions

Perceptual information about unfolding events is important for guiding decisions about when and how to move in real-world action situations. As an exemplary case, road-crossing is a perceptual-motor task where age has been shown to be a strong predictor of risk due to errors in action-based decisions. The present study investigated age differences between three age groups (Children: 10-12 years old; Adults: 19-39 years old; Older Adults: 65 + year olds) in the use of perceptual information for selection, timing, and control of action when crossing a two-way street in an immersive, interactive virtual reality environment. Adults and children selected gaps to cross that were consistent with the use of a time-based information variable (tau), whereas older adults tuned less into the time-based variable (tau) to guide road-crossing decisions. For action initiation and control, children and adults also showed a strong ability to precisely time their entry with respect to the lead vehicle maximising the available time to cross and coordinating walking movements with the tail vehicle to ensure they were not on a collision course. In contrast, older adults delayed action initiation and showed difficulty coordinating self-movement with the approaching vehicle. This study and its results tie together age-based differences in the three components of action decision-making (selection, timing and control) within a unified framework based on perceptual information. The implications of these age-related differences in action decisions and crossing behaviours are discussed in the context of road safety.

The effect of a heavy backpack on children's street-crossing performance

PURPOSE

The current study examined how wearing a heavy backpack influences children's street crossing behaviors.

METHOD

Using a fully-immersive virtual reality system, numerous indices of children's street crossing behaviors (7-13 years) were measured both when wearing a heavy backpack (12% of bodyweight) and when not doing so.

RESULTS

A heavy backpack slowed walking speed. However, any potential increase in risk from this was counteracted by compensatory actions that included: the selection of larger inter-vehicle gaps to cross into; greater efficiency in initiating the crossing (reduced start delay); and increased walking speed when in the path of the approaching vehicle. Ultimately, there was no greater risk outcome (time left to spare) compared to children's performance when not wearing a backpack. There were no age or sex differences.

CONCLUSION

When tested in ways that preserve perceptual-motor coupling in traffic situations, children strategically responded to maintain their safety despite wearing a heavy backpack that slowed their walking speed. Previous conclusions that a backpack increases pedestrian injury risk is likely an artifact of the testing method used.

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.

Comparative Analyses of Parameters Influencing Children Pedestrian Behavior in Conflict Zones of Urban Intersections

Children pedestrians make up 30% of the total number of children injured in road traffic in the EU. Research shows that children are injured more often in the urban areas, in residential areas near schools and parks, often at intersections and pedestrian crossings. In this study, children’s traffic behavior was analyzed by observation of signalized pedestrian crosswalks. According to the same methodology, the research was conducted in three cities in two countries (Enna, Italy, Osijek and Rijeka, Croatia) with different urban and traffic characteristics. A total of 900 measurements were analyzed, 300 in each of the cities at 18 pedestrian crosswalks located in an urban setting in the vicinity of primary schools. A detailed statistical analysis of the influence parameters shows that, as general influence parameters, pedestrian crosswalk length, movement in a group and the age of children can be distinguished. Factors that have proven to have a significant influence on the movement of children in two of the three cities observed are gender, supervision by adults, running and cellphone use. The result can serve as a valuable input for interventions in traffic education as well as a basis for the improvement of traffic conditions at intersections where children are regularly present.

Analysis of pedestrian-vehicle crash injury severity factors in Colorado 2006-2016

This paper investigates factors associated with the severity of pedestrian outcomes from motor vehicle crashes by analyzing a database of all 13,856 reported pedestrian crashes in Colorado over an 11-year period from 2006 to 2016. A total of 14,391 pedestrians were involved in these crashes, resulting in 612 (4.3%) pedestrian fatalities, 11,576 (80.4%) pedestrian injuries, and 2203 (15.3%) property damage only outcomes. The objective is to analyze crash records, as similarly compiled by other states, to show how lives potentially saved by improved factor levels can be estimated as needed for benefit-cost comparisons of alternative countermeasures. Odds ratios of fatal versus non-fatal pedestrian outcomes are computed both independently (unadjusted) and from logistic regression (adjusted) for each factor level accounting for possible correlations between factors. Also computed are odds ratios for fatal plus incapacitating injuries and odds ratios for just 2011-2016 versus all years. This study found that intersection proximity, lighting condition, vehicle type and speed, pedestrian age, pedestrian impairment, and driver impairment by drugs or alcohol were all significant factors associated with the severity of pedestrian outcomes from motor vehicle crashes. Risk ratios from these odds ratios are used to estimate lives potentially saved by having better factor levels present at the time of these crashes. These estimates reflect the relative magnitudes of benefits that might be achieved by potential countermeasures taking into account the number of cases affected.

State-of-the-art review: preventing child and youth pedestrian motor vehicle collisions: critical issues and future directions

Aim

To undertake a comprehensive review of the best available evidence related to risk factors for child pedestrian motor vehicle collision (PMVC), as well as identification of established and emerging prevention strategies.

Methods

Articles on risk factors were identified through a search of English language publications listed in Medline, Embase, Transport, SafetyLit, Web of Science, CINHAL, Scopus and PsycINFO within the last 30 years (~1989 onwards).

Results

This state-of-the-art review uses the road safety Safe System approach as a new lens to examine three risk factor domains affecting child pedestrian safety (built environment, drivers and vehicles) and four cross-cutting critical issues (reliable collision and exposure data, evaluation of interventions, evidence-based policy and intersectoral collaboration).

Conclusions

Research conducted over the past 30 years has reported extensively on child PMVC risk factors. The challenge facing us now is how to move these findings into action and intervene to reduce the child PMVC injury and fatality rates worldwide.

Children's Road-Crossing Behavior: Emotional Decision Making and Emotion-Based Temperamental Fear and Anger

OBJECTIVE

Child pedestrian injuries represent a global public health burden. To date, most research on psychosocial factors affecting children's risk of pedestrian injury focused on cognitive aspects of children's functioning in traffic. Recent evidence suggests, however, that emotional aspects such as temperament-based fear and anger/frustration, as well as executive function-based emotional decision making, may also affect children's safety in traffic. This study examined the role of emotions on children's pedestrian behavior. Three hypotheses were considered: (a) emotion-based temperament factors of fear and anger/frustration will predict children's risky decisions and behaviors; (b) emotional decision making will predict risky pedestrian decisions and behaviors; and (c) children's pedestrian decision making will mediate relations between emotion and risky pedestrian behavior. The role of gender was also considered.

METHODS

In total, 140 6- to 7-year-old children (M = 6.7 years, SD = 0.39; 51% girls) participated. Parent-report subscales of Child Behavior Questionnaire measured temperamental fear and anger/frustration. The Hungry Donkey Task, a modified version of Iowa Gambling Task for children, measured children's emotional decision making, and a mobile virtual reality pedestrian environment measured child pedestrian behavior.

RESULTS

Greater anger/frustration, lesser fear, and more emotional decision making all predicted poorer pedestrian decision making. The mediational model demonstrated that pedestrian decision making, as assessed by delays entering safe traffic gaps, mediated the relation between emotion and risky pedestrian behavior. Analyses stratified by gender showed stronger mediation results for girls than for boys.

CONCLUSIONS

These results support the influence of emotions on child pedestrian behavior and reinforce the need to incorporate emotion regulation training into child pedestrian education programs.

Death in childhood and adolescence: Accident!

In childhood and adolescence periods, individuals encounter many dangerous situations caused by not completing their biological and psychological development. Some of them are pathological deaths such as accidents, poisoning, and traumatic actions for children. Awareness of the number and causes of death is an indicator that reflects the health status of our society. It is also vital in-service planning for both preventive and therapeutic medical professions. The purpose of this article is to evaluate death cases between the ages of 0-18 in terms of forensic medicine. As a result, it has been understood that accidents are an important cause of death in childhood. In particular, developing policies to protect against common accidents will reduce the mortality rates of children.

Physiotherapy in children hospitalized with traumatic brain injury in a South African tertiary paediatric hospital

INTRODUCTION

Physical impairments following traumatic brain injury (TBI) may limit participation in daily living. Physiotherapy could assist in managing these limitations, however, there is a paucity of literature on the physiotherapy management of children in the acute phase of TBI.

OBJECTIVES

To describe the characteristics, course and outcome of children hospitalized with TBI, with specific reference to the role of physiotherapy.

METHODS

A retrospective folder review of all children (n = 130, median 5.37 years [IQR 1.88-7.88]) admitted in 2016 with a primary diagnosis of TBI was conducted at a tertiary paediatric hospital.

RESULTS

Most cases presented with mild TBI (66.2%). The most common cranial manifestation of the TBI was brain bleeds (80%) and most occurred as a result of road traffic accidents (50%, including both pedestrian and motor vehicle accidents). Physiotherapy was administered in 35 cases (26.9%), with functional interventions, such as mobilizations out of bed, the most common form of therapy (71.4%). Children involved in road traffic accidents, presenting with severe diffuse TBI, resulting in altered tone and coordination problems, admitted to intensive care, monitored with an intracranial pressure or Licox monitor, and receiving occupational therapy and/or been followed up by dieticians, were more likely to receive physiotherapy. The duration of hospitalization (median 4 days [IQR 2-9]) was associated with infections, severity of TBI, presence of an intracranial monitoring, and parietal lobe injury.

CONCLUSION

This is the first study in South Africa investigating standard physiotherapy care in children admitted with TBI. Physiotherapy was provided in a small portion of children and appeared to be well tolerated. However, due to the limited information recorded in the physiotherapy notes, results of this study need to be confirmed in larger, more well-documented studies before generalizations can be made.

Speeds of Young E-Cyclists on Urban Streets and Related Risk Factors: An Observational Study in Israel

In Israel, a growing use of electric bicycles by youngsters has been noted, with an increase in related injuries. In this study, an observational survey was conducted on typical urban streets, aiming to characterize the riding speeds of young e-cyclists compared to regular cyclists and the associated risk factors in their behaviors. The survey covered 39 sites in eight cities, and included 1054 cyclists. The results showed that mean speeds of young e-cyclists were higher than those of regular cyclists at all types of sites, with a difference of 6–9 km/h. The mean speeds of e-bicycles were below 25 km/h, as prescribed by law, but the 85-percentile speeds were higher. E-cyclist speeds depend on the type of street, road layout and place of riding. More e-cyclists used the roadway compared to regular cyclists, however, on divided roads, more e-cyclists used sidewalks in spite of the law prohibition, thus endangering pedestrians. The majority of cyclists did not wear helmets. The unsafe behaviors of teenage e-cyclists increase the injury risk for themselves and for other road-users. Thus, separate bicycle infrastructure should be promoted in the cities. Road safety education and training of young e-cyclists with stronger enforcement of traffic regulations are also needed.

A Model to Predict Children’s Reaction Time at Signalized Intersections

Traffic accident statistics in urban areas, both locally in Croatia and at the European level, identify children as a group of vulnerable road users. The analysis of the parameters that influence the interaction of child pedestrians and other road users requires special attention. This paper presents the results of research about the reaction time of children, measured both in laboratory conditions, via a computer reaction time test, and in actual traffic conditions. The results of the reaction time test in a situation with expected stimuli (a computer test) of children aged 6 to 10 years were compared with the results of the reaction time of adult traffic participants, drivers, who also took part in the computer test. Standard deviations of the reaction times between the control group (drivers, adults) and each subgroup of children were significantly different (p < 0.05). The results suggest that the largest developmental jump occurs between preschool children and first-grade children. In actual traffic conditions, the reaction time of children aged 4 to 16 years at the signalized intersection was measured. The model for predicting the reaction time of children in real traffic conditions was created using a neural network. The model prediction results matched well with the values measured in actual traffic conditions, for the observed intersection (correlation coefficient is 94.56%) and for the validation intersection (correlation coefficient is 92.29%). Parameters influencing children’s reaction times in real traffic conditions were identified by applying both statistical analysis and the neural network model developed. Using both methods, the same key distractors were identified—the movement of children in the group and the use of mobile phones. The case study was conducted at selected signalized intersections in the city of Osijek, Croatia.

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.

Pedestrian-vehicle crashes: Risk perception and responsibility attribution among children, adolescents and adults

Background:

Child pedestrian injuries in China result from crashes not just with cars. We considered how Chinese youth and young adults perceive pedestrian risk from four vehicle types-bicycles, electric bicycles, cars, buses—evaluating perceptions for two factors that may influence pedestrian behavior and risk-taking, perception of road environment risk and responsibility to avoid crashes. Understanding how pedestrians perceive risk, and how these perceptions change as children grow older, could guide prevention efforts.

Methods:

383 children (grades 3-4, 5-6, 8) and university students completed self-report surveys. We analyzed overall responses, plus age/gender differences in risk perception and responsibility attribution, across vehicle types and number of vehicles approaching, using multivariate analysis of variance (MANOVA) and generalized estimating equation (GEE) models.

Results:

Overall, larger vehicles were perceived as riskier (p less than .001). Compared tochildren, university students perceived bicycles and electric bicycles as less risky (Mean=2.66 vs. 3.69, 3.34 vs. 3.62, respectively, p less than .05). Cars and buses were perceived as equally risky across age groups. Across all vehicle types and number of vehicles traversing the road, both children and young adults perceived more pedestrian responsibility to avoid collisions relative to drivers (p less than .001). Children attributed less personal responsibility to avoid pedestrian-vehicle crashes than university students (e.g., buses odds ratio (OR)=0.20, p less than .001; OR=0.26, p less than .01; OR=0.28, p less than .01 for third/fourth, fifth/sixth, eighth graders, respectively). University students and fifth/sixth graders also identified greater pedestrian responsibility to avoid collisions with multiple vs. one vehicle approaching (e.g., university students/cars OR=4.17, p less than .001).

Conclusions:

We discuss cognitive and perceptual development factors in childhood, adolescence, and young adulthood that may contribute to differences in risk perception and responsibility attribution among Chinese pedestrians and suggest future research should explore those processes and subsequently develop evidence-based interventions to reduce pedestrian injury risk.

A Pilot Randomized Controlled Trial Testing the Effectiveness of a Pedestrian Training Program That Teaches Children Where and How to Cross the Street Safely

Objective

Pedestrian injury is a leading cause of injury-related mortality for children. This pilot randomized controlled trial tested the efficacy of a training program to teach where and how to cross safely.

Methods

Using fully immersive virtual reality technology, 142 children 7-10 years of age were recruited, with 130 completing crossing measures before (pretest) and immediately after (posttest) training. Training comprised 1.5 hr, was tailored to each child's performance over trials, and focused on either where to cross (n = 44 children completed testing) or how to cross safely (n = 43); corresponding control groups comprised 22 and 21 children, respectively. Following training, children in the intervention groups completed additional tasks to test conceptual knowledge and generalization of learning. Children in the control groups spent the same time as those in training groups but played a video game that used the same game controller but provided no training in street crossing.

Results

The primary outcomes were errors in crossing at posttest, controlling for pretest error scores. Children in the intervention group made from 75% to 98% fewer errors at posttest than control children for all pedestrian safety variables related to where and how to cross safely, with effect sizes (incidence rate ratios) varying between 0.02 and 0.25. They also showed a generalization of what they had learned and applied this knowledge to novel posttraining situations.

Conclusion

Training within a virtual pedestrian environment can successfully improve children's conceptual understanding and crossing behaviors for both where and how to cross streets safely.

Roles of individual differences and traffic environment factors on children's street-crossing behaviour in a VR environment

OBJECTIVE

Pedestrian injuries are among the most common cause of death and serious injury to children. A range of risk factors, including individual differences and traffic environment factors, has been investigated as predictors of children's pedestrian behaviours. There is little evidence examining how risk factors might interact with each other to influence children's risk, however. The present study examined the independent and joint influences of individual differences (sex and sensation seeking) and traffic environment factors (vehicle speeds and inter-vehicle distances) on children's pedestrian safety.

METHODS

A total of 300 children aged 10-13 years were recruited to complete a sensation-seeking scale, and 120 of those were selected for further evaluation based on having high or low sensation-seeking scores in each gender, with 30 children in each group. Children's pedestrian crossing behaviours were evaluated in a virtual reality traffic environment.

RESULTS

Children low in sensation seeking missed more opportunities to cross and had longer start gaps to enter the roadway compared with those high in sensation seeking, and these effects were more substantial when vehicles were spread further apart but travelling slowly. Interaction effects between inter-vehicle distance and vehicle speed were also detected, with children engaging in riskier crossings when the car was moving more quickly and the vehicles were spread further than when the vehicles were moving quickly but were closer together. No sex differences or interactions emerged.

CONCLUSION

Both sensation seeking and traffic environment factors impact children's behaviour in traffic, and there are interactions between traffic speeds and inter-vehicle distances that impact crossing behaviour.

The Effect of Interactive Education with 3-Dimensional Puzzles on the Injury-Prevention Behaviours of School-Age Children

The aim of this quantitative study was to identify the effect of interactive education with 3-dimensional puzzles on the injury-prevention behaviours of school-age children in Bekasi, Indonesia. This study used a pre-post group design to select the intervention group and the control group. Of the 120 elementary school students included, 60 were placed in the intervention group and 60 in the control group. Multistage random sampling determined the schools, and simple random sampling determined the subjects. The results showed that interactive education with 3-dimensional puzzles was significant for knowledge (p < 0.001), attitude (p < 0.001) and injury prevention skills (p < 0.001). Interactive education sessions with 3-dimensional puzzles significantly improved knowledge related to injury prevention. Therefore, interactive education with 3-dimensional puzzles may prevent injuries in school-age children. School nurses can use this technique to improve their health education programs.

Effects of Peers on Child Pedestrian Behaviors in a Virtual Traffic Context

OBJECTIVES

Research shows that school-aged children are at high risk of pedestrian injury when they cross streets with peers. How peers exert their influence is unknown. Using a fully immersive virtual reality pedestrian environment, this study examined the impact of peers on children's pedestrian behaviors.

METHODS

137 children were assigned either to a control, peer observer, or peer-safety or peer-risky modeling condition. Street-crossing behaviors were measured twice (baseline, postbaseline), with group comparisons (control vs. test condition) of postbaseline scores conducted.

RESULTS

Children who observed a peer modeling risky behaviors imitated this. No significant influences were found in the peer observation or safe modeling conditions.

CONCLUSIONS

Peers may elevate other children's risk of pedestrian injury through modeling risky crossings. Implications for prevention are discussed.

Effect of positive airway pressure therapy in children with obstructive sleep apnea syndrome: does positive airway pressure use reduce pedestrian injury risk?

INTRODUCTION

Treatment with positive airway pressure (PAP) therapy reduces injury risk among adults with obstructive sleep apnea syndrome (OSAS), but the effect of PAP therapy on children's injury risk is unknown. This study investigated whether treatment of OSAS with PAP reduces children's pedestrian injury risk in a virtual reality pedestrian environment.

METHODS

Forty-two children ages 8-16 years with OSAS were enrolled upon diagnosis by polysomnography. Children crossed a simulated street several times upon enrollment, prior to PAP treatment, and again after 3 months of PAP therapy. Children underwent sleep studies at all time points.

RESULTS

Children adherent with PAP had a significant reduction in hits by a virtual vehicle (P < .01) and less time to contact with oncoming vehicles (P < .01) following treatment. Those who were nonadherent did not show improved safety. There was no change in attention to oncoming traffic.

CONCLUSIONS

OSAS may have significant consequences on children's daytime functioning in a critical domain of personal safety: pedestrian skills. In pedestrian simulation, children with OSAS adherent to PAP therapy showed improvement in pedestrian safety and had fewer collisions with a virtual vehicle following treatment. Results highlight need for heightened awareness of the real-world benefits of treatment for pediatric sleep disorders.

LEVEL OF EVIDENCE

Level II Therapeutic Study.

Developing attentional control in naturalistic dynamic road crossing situations

In the last 20 years, there has been increasing interest in studying visual attentional processes under more natural conditions. In the present study, we propose to determine the critical age at which children show similar to adult performance and attentional control in a visually guided task; in a naturalistic dynamic and socially relevant context: road crossing. We monitored visual exploration and crossing decisions in adults and children aged between 5 and 15 while they watched road traffic videos containing a range of traffic densities with or without pedestrians. 5–10 year old (y/o) children showed less systematic gaze patterns. More specifically, adults and 11–15 y/o children look mainly at the vehicles’ appearing point, which is an optimal location to sample diagnostic information for the task. In contrast, 5–10 y/os look more at socially relevant stimuli and attend to moving vehicles further down the trajectory when the traffic density is high. Critically, 5-10 y/o children also make an increased number of crossing decisions compared to 11–15 y/os and adults. Our findings reveal a critical shift around 10 y/o in attentional control and crossing decisions in a road crossing task.

Child pedestrian behaviors: Influence of peer social norms and correspondence between self-reports and crossing behaviors

OBJECTIVE

The aims of this study were to determine if children's perception of peers' behavioral norms for crossing streets relates to their personal norms for doing so and if children's self-reports about crossing relates to their actual crossing in a virtual traffic situation.

METHOD

Children (8-10 years, N = 86) completed questionnaires about peer's norms and their personal norms about crossing streets, and also reported on their recent crossing behaviors. These self-reports about crossing were then related to children's actual crossing behaviors measured using a fully immersive virtual reality (VR) system.

RESULTS

Children's perception of peers' behavioral norms for crossing related to their personal norms for doing so, and their norms related to their reports of how they have crossed in the past few weeks. When crossing virtual streets, children with higher scores on self-reports about risky crossing behaviors selected smaller (riskier) inter-vehicle gap sizes to cross into, showed less start delay (less time appraising traffic before starting), and experienced more hits. Conclusion and practicalapplications: Children's perception of peers' behavioral norms for crossing are relevant to their crossing behaviors and may be one way that peers elevate children's risk of pedestrian injury. Children's self-reports about crossing risk may be useful for identifying at-risk youth and strategically targeting interventions to these children.

Exploring patterns of child pedestrian behaviors at urban intersections

Children are more vulnerable as pedestrians due to their cognitive, physical and behavioral traits. However, walking is one of the main forms of travel for children, particularly during leisure hours. Child pedestrian injury primarily occurs in urban areas, with a significant share at crosswalks. This study observed child pedestrian behaviors at crosswalks of urban intersections aiming to characterize their behavior patterns and identify risk factors that may lead to injury. Crossing behaviors of children and adolescents up to age 18, during leisure hours, were video-recorded at 29 crosswalks, on signalized and un-signalized intersections situated on collector roads. Some children used pedestrian crosswalks while riding a bicycle or other non-motorized means; they were also included in the sample. Behaviors of 2930 young road users were encoded and compared by age groups. Multivariate logistic regression models were adjusted to identify factors associated with crossing on red and with non-checking vehicle traffic at un-signalized crosswalks. The findings pointed to different behavior patterns for the various child age groups. Risk-taking behaviors are higher for older children; adolescents aged 14-17 cross more on red, without checking traffic, outside crosswalk boundaries and while distracted. At all types of sites, a fifth of children over the age of 9 crossed by riding, the probability of crossing on red and of non-checking traffic prior to crossing at an un-signalized crosswalk was higher for children riding an electric bicycle or kick-scooter. The non-checking of traffic was also higher when a child is distracted by a mobile phone or other electronic gadget, or carries a big object. Children under age 9 were usually accompanied by adults but still exhibited risk-taking behaviors that apparently mirrored those of the adults. Risk-taking behaviors of young road users should be taken into account in the development of injury prevention programs focusing on child and parent education and training, and by adapting the urban environment to better meet their needs.

A Review of Pediatric Lower Extremity Data for Pedestrian Numerical Modeling: Injury Epidemiology, Anatomy, Anthropometry, Structural, and Mechanical Properties

Pedestrian injuries are the fourth leading cause of unintentional injury-related death among children aged 1 to 19. The lower extremity represents the most frequently injured body region in car-to-pedestrian accidents. The goal of this study was to perform a systematic review of the data related to pedestrian lower extremity injuries, anatomy, anthropometry, structural, and mechanical properties, which can be used in the development of new pediatric computational models. The study began with a review of epidemiologic data related to pediatric pedestrian accidents. Anatomy of the child lower extremity and age-related anthropometry data were presented as well. Then, both the mechanical and structural properties of the lower extremity main components (e.g., bones, cartilages, knee ligaments, muscles, tendons, and growth plates) available in literature were summarized. The study concluded with a brief description of current child pedestrian models, which included a discussion about their limitations. We believe that data included in this review study can help in improving the biofidelity of current child models and support the development and validation of new child models used by safety researchers for protection of pediatric population.

Young drivers' perception of adult and child pedestrians in potential street-crossing situations

Despite overall improvements in road traffic safety, pedestrian accidents continue to be a serious public health problem. Due to lack of experience, limited cognitive and motoric skills, and smaller size, children have a higher injury risk as pedestrians than adults. To what extent drivers adjust their driving behaviour to children's higher vulnerability is largely unknown. To determine whether young male drivers' behaviour and scanning pattern differs when approaching a child and an adult pedestrian in a potential street-crossing situation, sixty-five young (18-24) male drivers' speed, lateral position and eye movements were recorded in a driving simulator. Results showed that fewer drivers responded by slowing down and that drivers had a higher driving speed when approaching a child pedestrian, although the time of the first fixation on both types of pedestrians was the same. However, drivers drove farther away from a child than an adult pedestrian. Additionally, fewer drivers who did not slow down fixated on the speedometer while approaching the child pedestrian. The results show that young drivers behave differently when approaching a child and an adult pedestrian, though not in a way that appropriately accounts for the limitations of a child pedestrian. A better understanding of how drivers respond to different types of pedestrians and why could contribute to the development of pedestrian detection and emergency braking systems.

The efficacy of a brief hazard perception interventional program for child bicyclists to improve perceptive standards

INTRODUCTION

Even though child bicyclists are highly vulnerable in traffic only few studies focused on providing child bicyclists with means to enhance their abilities to deal with the complexity of dynamic traffic situations. The current study therefore evaluated whether a brief hazard perception intervention might be effective to improve hazard perception skills in child bicyclists towards a level more comparable to adult bicyclists.

METHODS

Eighty children of the fourth grade (9.03 ± 0.43 years; 34 girls) and forty-six adults (34.67 ± 14.25 years age; 24 woman) first performed a Hazard Perception test for bicyclists. Response rate, reaction times, first fixation, duration of the first fixation, dwell time and total number of fixations on the events were measured. Next, the children took part in the HP intervention in which video clips of dangerous traffic situations were presented. The intervention comprised two classroom sessions of one hour (1/week). A post-test was performed one day after and the retention-test three weeks after the intervention.

RESULTS

Children responded to more covert hazards immediately after the intervention (p < 0.05), but did not improve their response rate for overt hazards. Reaction times for the covert hazards improved on the post-test (p < 0.001) compared to the pre-test but this effect was reduced on the retention test. There was no effect of the intervention for entry time of the first fixation but the duration of the first fixation increased for the covert hazards (p < 0.05). Children made fewer fixations on the event compared to adults (p < 0.001), except for the covert hazards on the retention-test. The training also increased the number of fixations for the overt hazards on the post-test (p < 0.001) and the retention-test (p < 0.001) but only increased on the retention test for the covert hazards (p < 0.001).

CONCLUSION

The results demonstrated that a brief intervention for training hazard perception skills in child bicyclists is able to improve children's situation awareness and hazard perception for potential dangerous situations. The training, however, was too short to improve children to higher adult levels.

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

Objective

This nonrandomized trial evaluated whether classroom-based training in a smartphone-based virtual reality (VR) pedestrian environment (a) teaches schoolchildren to cross streets safely, and (b) increases their self-efficacy for street-crossing.

Methods

Fifty-six children, aged 8-10 years, attending primary school in Changsha, China participated. Baseline pedestrian safety assessment occurred in the VR environment and through unobtrusive observation of a subsample crossing a street for 11 days outside school. Self-efficacy was assessed through both self-report and observation. Following baseline, children engaged in the VR for 12 days in their classrooms, honing complex cognitive-perceptual skills required to engage safely in traffic. Follow-up assessment replicated baseline.

Results

Probability of crash in the VR decreased posttraining (0.40 vs. 0.09), and observational data found the odds of looking at oncoming traffic while crossing the first lane of traffic increased (odds ratio [OR] = 2.4). Self-efficacy increases occurred in self-report (proportional OR = 4.7 crossing busy streets) and observation of following crossing-guard signals (OR = 0.2, first lane).

Conclusions

Pedestrian safety training via smartphone-based VR provides children the repeated practice needed to learn the complex skills required to cross streets safely, and also helps them improve self-efficacy to cross streets. Given rapid motorization and global smartphone penetration, plus epidemiological findings that about 75,000 children die annually worldwide in pedestrian crashes, smartphone-based VR could supplement existing policy and prevention efforts to improve global child pedestrian safety.

Parental supervision and discomfort with children walking to school in low-income communities in Cape Town, South Africa

OBJECTIVE

The risk of pedestrian injury is compounded for children living in low-income communities due to factors such as poor road and pedestrian infrastructure, reliance on walking as a means of transport, and compromised supervision. Parents play an important role in child pedestrian safety. The primary objective of this study was to examine the effects of child pedestrian variables on parental discomfort with regard to letting their child walk to and from school and on the frequency of adult supervision.

METHODS

A cross-sectional study was conducted using a convenience sample from 3 schools participating in a pedestrian safety school initiative. The schools are situated in low-income, high-risk communities in the City of Cape Town. A parent survey form was translated into isiXhosa and sent home with learners to those parents who had consented to participate. The response rate was 70.4%, and only parents of children who walk to and from school were included in the final sample (n = 359). Child pedestrian variables include the time taken to walk to school, parental rating of the child's ability to safely cross the road, and the frequency of adult supervision.

RESULTS

More than half of parents reported that their child walked to and from school without adult supervision. About 56% of children took less than 20 min to walk to school. Most parents (61%) were uncomfortable with their child walking to school, although the majority of parents (55.7%) rated their child's ability to cross the road safely as better or significantly better than average (compared to peers). The parents did not perceive any differences in pedestrian risk factors between boys and girls or between younger (6-9 years) and older (10-15 years) children. The time spent by a child walking to school and parents' perceptions of their child's road-crossing ability were found to be significant predictors of parental discomfort (in letting their child walk). Younger children and children who spent less time walking were more likely to be supervised by an adult.

CONCLUSIONS

Many South African schoolchildren have to navigate the roads without adult supervision from a young age. Caregivers, especially in low-income settings, often have limited options with regard to getting their child to school safely. Regardless of the child's age and gender, the time that they spend on the roads is an important factor for parents in terms of pedestrian safety.

Pedestrian navigation and public transit training interventions for youth with disabilities: a systematic review

Purpose: Being able to travel independently, whether as a pedestrian or by taking public transportation, is a critical element to maintaining quality of life and participation in the community. The objective of this systematic review is to understand the best practices and effective components of pedestrian and public transit training interventions for youth with disabilities. Method: Systematic searches of seven international databases identified 29 studies meeting our inclusion criteria. We analyzed these studies based on participant characteristics, methods, results, and quality of evidence. Results: Among the 29 studies, 857 participants (aged 5-39, mean 18.3 years) were represented across 10 countries. Although the intervention outcomes varied across the studies, 24 of them reported an improvement in at least one of the following: pedestrian and general navigation skills, pedestrian safety, landmark recognition, route knowledge, and public transportation skills. Conclusions: Our findings highlight that pedestrian and public transit interventions have the potential to improve the participation and quality of life of children and youth with disabilities. More rigorous, theoretically informed interventions, using standardized measures are needed to enhance pedestrian and transit training skills among youth with disabilities. Implications for rehabilitation Travel training interventions have the potential to effectively support youth with disabilities in learning pedestrian and public transportation navigation skills. Clinicians and educators should encourage youth with disabilities to participate in travel training programs enhance their independence skills and participation in the community. Clinicians, educators, and program managers can help to build relevant content for travel training programs and connect youth to programs.

Child Pedestrian Street-Crossing Behaviors outside a Primary School: Developing Observational Methodologies and Data from a Case Study in Changsha, China

BACKGROUND

Child pedestrian injury is a significant global public health challenge, and prevention programming requires an understanding of the context children face when crossing the street. Methods to understand children's behavior in real-world pedestrian settings are sparse in low- and middle-income countries.

METHODS

Children in grades 1-6 were videotaped crossing a three-lane street outside their school in Changsha, China. Tapes were coded to collect: (1) extent of adult supervision, (2) whom children crossed the street with, and (3) safe behaviors exhibited by children.

RESULTS

Observational videotape methods yielded data that could be reliably coded to understand Chinese children's behavior crossing the street outside their primary school. In total, we observed 216 child pedestrians crossing the street, including 105 girls, 105 boys, and 6 for whom gender could not be determined. 51% of observations occurred in the morning before school and 49% in the afternoon after school. Children encountered a busy and somewhat-chaotic traffic environment. Adults were always present to help, but children appeared to heed adult advice concerning the crossing only about 70% of the time. Fewer than 1/3 of children looked at oncoming traffic before they entered a lane and over 1/3 entered a lane with moving traffic approaching.

CONCLUSION

Observational methods of coding videotaped behavior proved effective to understand and code children's risk and safety while crossing the street outside their primary school. At the street environment we studied, we found that children's pedestrian behavior involved significant risk.

Accident frequency and unrealistic optimism: Children's assessment of risk

Accidental injury is a major cause of mortality and morbidity among children, warranting research on their risk perceptions. Three hundred and seven children aged 10-11 years assessed the frequency, danger and personal risk likelihood of 8 accidents. Two social-cognitive biases were manifested. The frequency of rare accidents (e.g. drowning) was overestimated, and the frequency of common accidents (e.g. bike accidents) underestimated; and the majority of children showed unrealistic optimism tending to see themselves as less likely to suffer these accidents in comparison to their peers, offering superior skills or parental control of the environment as an explanation. In the case of pedestrian accidents, children recognised their seriousness, underestimated the frequency of this risk and regarded their own road crossing skill as protection. These findings highlight the challenging task facing safety educators who, when teaching conventional safety knowledge and routines, also need to alert children to the danger of over-confidence without disabling them though fear.

Contributors to pedestrian distraction and risky behaviours during road crossings in Romania

OBJECTIVE

Pedestrian fatalities due to collisions with motor vehicles are a large public health problem in Romania, ranking them among the highest in Eastern Europe. The purpose of this study was to gain a better understanding of crash factors by examining how roadway and environmental characteristics contribute to pedestrian distraction and risky behaviours at pedestrian MVC (PMVC) locations in Cluj County, Romania.

METHODS

A sample of PMVC locations was selected from the 2010 Cluj County police reported crash database for on-site examination. A total of 100 sites were visited to collect details on site characteristics and typical pedestrian and driver behaviours. Variable distributions were examined and rate ratios of pedestrian distraction and risky behaviours were calculated.

RESULTS

Pedestrian distraction and risky behaviours were observed at rates of 6.3 and 24.3 per 100 observed pedestrians. The majority of distractions were related to electronic device use. Risky behaviours were evenly split between unpredictable, partial use of a crosswalk and midblock illegal crossings. Distractions and risky behaviours decreased as the number of pedestrians and average vehicle speeds at a site increased. RR of distraction was higher at intersections and locations with crosswalks.

CONCLUSIONS

Pedestrian distraction was highly correlated with pedestrian risky behaviours at PMVC locations in Romania. Higher pedestrian volume was protective against pedestrian distraction and risky behaviours. Locations with painted crosswalks had increased distraction. Targeted distraction prevention, particularly at intersections and crosswalk locations, may contribute to the prevention of PMVCs.

Appropriateness of different pedagogical approaches to road safety education for children with Developmental Coordination Disorder (DCD)

BACKGROUND

In 2016, 29% of pedestrians killed or seriously injured on the roads in Great Britain were under 15 years of age. Children with Developmental Coordination Disorder (DCD), a chronic disorder affecting the acquisition and execution of motor skills, may be more vulnerable at the roadside than typically developing (TD) children. Current methods used to teach road safety are typically knowledge-based and do not necessarily improve behaviour in real traffic situations. Virtual reality road crossing tasks may be a viable alternative.

AIMS/METHODS

The present study aimed to test the road crossing accuracy of children with and without DCD in virtual reality tasks that varied the viewpoint to simulate the teaching methods currently used in road safety educational programmes. Twenty-one children with DCD and twenty-one age and gender matched TD peers were required to locate the safest road crossing sites in two conditions: allocentric (aerial viewpoint) and egocentric (first-person viewpoint).

PROCEDURES/OUTCOMES

All children completed both conditions and were required to navigate either themselves or an avatar across the road using the safest crossing route. The primary outcome was accuracy defined as the number of trials, out of 10, on which the child successfully identified and used the safest crossing route.

RESULTS/CONCLUSIONS

Children with DCD performed equally poorly in both conditions, while TD children were significantly more accurate in the egocentric condition. This difference cannot be explained by self-reported prior road crossing education, practice or confidence.

IMPLICATIONS

While TD children may benefit from the development of an egocentric virtual reality road crossing task, multimodal methods may be needed to effectively teach road safety to children with DCD.

Examining how different measurement approaches impact safety outcomes in child pedestrian research: Implications for research and prevention

There has been a great deal of research aimed at understanding the causes of child pedestrian injury. Many different methods have been employed with the goal of designing simulations that produce rigorous assessment of children's behaviors without putting children at risk of actual pedestrian injury. Most research has assessed children's pre-crossing decision making and extrapolated crossing outcome measures from estimates of mean walking speed. This study explores the nature and extent of measurement bias that is introduced when average walking speed is used to produce estimates of outcomes versus measuring actual in-road behavior directly. Using a within-subjects design and a fully immersive virtual reality pedestrian simulator, both measures were taken. Comparisons based on regression models revealed the extent of differences in results produced by measurement bias. Results indicated that measurement bias is produced when average walking speed is used such that hits and high risk crossings are overestimated and missed opportunities are underestimated, resulting in an overall overestimate of children's risk for pedestrian injury. The discussion highlights how these two measurement approaches emphasize different underlying processes as determinants of child pedestrian injury risk.

Evaluating Otto the Auto: Does Engagement in an Interactive Website Improve Young Children's Transportation Safety?

Transportation-related injuries are a leading cause of pediatric death, and effective interventions are limited. Otto the Auto is a website offering engaging, interactive activities. We evaluated Otto among a sample of sixty-nine 4- and 5-year-old children, who participated in a randomized parallel group design study. Following baseline evaluation, children engaged with either Otto or a control website for 2 weeks and then were re-evaluated. Children who used Otto failed to show increases in transportation safety knowledge or behavior compared to the control group, although there was a dosage effect whereby children who engaged in the website more with parents gained safer behavior patterns. We conclude Otto may have some efficacy when engaged by children with their parents, but continued efforts to develop and refine engaging, effective, theory-driven strategies to teach children transportation safety, including via internet, should be pursued.