Systematic Review and Meta-Analysis of Behavioral Interventions to
Improve Child Pedestrian Safety
David C. Schwebel,1 PHD, Benjamin K. Barton,2 PHD, Jiabin Shen,1 MED , Hayley L. Wells,1 BA,
Ashley Bogar,2 BS, Gretchen Heath,2 BS, and David McCullough,2 MS
1
Department of Psychology, University of Alabama at Birmingham and 2Department of Psychology and
Communication Studies, University of Idaho
All correspondence concerning this article should be addressed to David C. Schwebel, PHD, Department of
Psychology, University of Alabama at Birmingham, 1720 2nd Avenue S, HHB 571, Birmingham, AL 35294
USA. E-mail: [email protected]
Received October 28, 2013; revisions received and accepted April 7, 2014
Objective Pedestrian injuries represent a pediatric public health challenge. This systematic review/metaanalysis evaluated behavioral interventions to teach children pedestrian safety. Methods Multiple strategies derived eligible manuscripts (published before April 1, 2013, randomized design, evaluated behavioral
child pedestrian safety interventions). Screening 1,951 abstracts yielded 125 full-text retrievals. 25 were retained for data extraction, and 6 were later omitted due to insufficient data. In all, 19 articles reporting 25
studies were included. Risk of bias and quality of evidence were assessed. Results Behavioral interventions generally improve children’s pedestrian safety, both immediately after training and at follow-up several
months later. Quality of the evidence was low to moderate. Available evidence suggested interventions targeting dash-out prevention, crossing at parked cars, and selecting safe routes across intersections were effective.
Individualized/small-group training for children was the most effective training strategy based on available
evidence. Conclusions Behaviorally based interventions improve children’s pedestrian safety. Efforts
should continue to develop creative, cost-efficient, and effective interventions.
Key words accidents and injuries; evidence-based practice; meta-analysis; prevention/control; public health;
systematic review.
Pediatric unintentional injury is a significant public health
problem worldwide. In the United States, >3,000 children
aged 1–14 years die annually from unintentional injuries
(National Center for Injury Prevention and Control
[NCIPC], 2013). Morbidity rates are also enormous, with
>6 million hospital visits annually in the United States and
a tremendous financial burden placed on society. For example, in 2005, the total cost of medical expenses and lost
wages for U.S. children aged 1–14 years who were hospitalized following unintentional injury was >15 billion
dollars (NCIPC, 2013).
The present focus is on pedestrian injury, the fifth
leading cause of unintentional injury death to U.S. children
aged 1–14 years (NCIPC, 2013) and an even more significant public health challenge internationally. Although
pedestrian injuries comprise just 11% of road traffic fatalities in the United States (>100 pediatric fatalities annually
and 11,000 medically attended injuries; NCIPC, 2013),
they account for >50% of road traffic fatalities in a range of
nations, including Bangladesh (54%), Ethiopia (55%),
Mozambique (68%), and Peru (78%) (World Health
Organization [WHO], 2009). Also notable are the high
rates of pedestrian injuries among road traffic fatalities in
the world’s most populated nations (China 26%, India
13%), in high-income countries (Japan 32%, United
Kingdom 21%), and in the most populated U.S. territory,
Puerto Rico (32%) (WHO, 2009).
Pediatric pedestrian injuries pose a serious public
health concern for at least two reasons. First, the nature
of such injuries is often severe, with trauma typically to the
Journal of Pediatric Psychology 39(8) pp. 826–845, 2014
doi:10.1093/jpepsy/jsu024
Advance Access publication May 26, 2014
Journal of Pediatric Psychology vol. 39 no. 8 ß The Author 2014. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: [email protected]
Child Pedestrian Safety
lower extremities and head resulting from contact with a
vehicle and the road surface. Second, many communities
are actively trying to increase the use of walking as a mode
of transportation through efforts such as Safe Routes to
School, Walking School Buses, and via transportation engineering within the concept of ‘‘complete streets.’’ Thus,
although promotion of walking is a desirable goal that will
increase overall health of a community, the safety of
children must be intertwined within such efforts. Young
children often lack the cognitive skills and experience necessary to negotiate pedestrian routes safely (Barton, 2006).
Efforts to reduce child pedestrian injuries are not new.
In 1937, Mansfield, Ohio Traffic Commissioner Frend
Boals and kindergarten teacher Ruth Robbins developed
the first Safety Town program, a free community program
designed to teach young children about traffic safety
(http://mansfieldpolicedepartment.com/stown.html). Since
then, hundreds of programs have been concocted, with
varying success, to reduce the risk of children suffering
injury or death from motor vehicles. Our present goal is
to analyze those efforts that have been evaluated empirically and rigorously and to consider which components of
pedestrian safety and which types of behavioral interventions are more and less effective at teaching children to be
safer pedestrians.
One key aspect of our review is our objective to consider pedestrian safety not just as a whole but as a set of
components. Crossing a street safely is a complex cognitive-perceptual task that requires multiple steps. Children
must choose an appropriate location to judge traffic from,
must judge the location and speed of oncoming traffic in
multiple directions, and must cross the street in an appropriate manner. Cognitive-perceptual tasks vary at intersections (also called junctions) and at mid-block locations.
Among younger children, dash-out incidents, where children enter roadways without even stopping to attempt a
safe route selection and crossing, are of concern. We reasoned that existing interventions may be more effective for
some aspects of pedestrian safety (e.g., route selection,
dash-out prevention, judging oncoming traffic) than
others.
Several scholars have previously reviewed the child
pedestrian safety literature (Duperrex, Bunn, & Roberts,
2002; Hotz, Kennedy, Lutfi, & Cohn, 2009;
Rothengatter, 1984; Schwebel, Davis, & O’Neal, 2012;
Stevenson & Sleet, 1996). Of those, only one (Duperrex,
Bunn, & Roberts, 2002) was framed as a systematic review;
results were also published as a Cochrane review
(Duperrex, Roberts, & Bunn, 2002). In general, previous
reviews concluded that available evidence suggests pedestrian safety training can improve children’s safety but
critiqued the state of current evidence as lacking high-quality research studies, having no evidence of translation to
actual pedestrian injury reduction, and being conducted
only in high-income countries (e.g., Duperrex, Bunn, &
Roberts, 2002). There is some indication that multifaceted
interventions targeting multiple aspects of child pedestrian
safety in multiple ways may be most effective (Schwebel,
Davis, & O’Neal, 2012).
No previous reviews used meta-analytic techniques,
and no previous reviews considered carefully the multiple
components of pedestrian safety. Our review, conducted
according to Cochrane Review recommendations, extends
previous work in the following ways: (a) by conducting a
meta-analysis rather than just a systematic review, (b) by
considering the efficacy of different types of behavioral interventions, (c) by considering the efficacy of training in
different aspects or components of pedestrian safety, and
(d) by updating advancements in the literature in the 10
years since previous systematic reviews were published
(Duperrex, Bunn, & Roberts, 2002; Duperrex, Roberts,
& Bunn, 2002).
Methods
Search Strategy
The following databases were searched: MEDLINE
(PubMed), PsycINFO, and SafetyLit. We used the following search term for all searches: ‘‘(pedestrian or street) and
(injury or injuries or safety) and (prevention or intervention
or train* or education or educating or teach*) and (child*
or pediatric or paediatric)’’. To supplement those searches,
we contacted prominent authors in the field, posted inquiries on relevant scientific society listservs, reviewed our
personal libraries, and followed references in relevant articles and books. We also searched databases of the
Transport Research Laboratory in the United Kingdom
and the National Highway Traffic Safety Administration
in the United States and conducted a post hoc review of
abstracts in the ProQuest database, which yielded no new
relevant sources. The review protocol is unregistered and
available from the authors upon request.
Manuscript Inclusion Criteria
This systematic review and meta-analysis included all randomized trials in which children aged 1–14 years were
randomly assigned to two or more conditions, including
no-contact control groups, for training in one or more components of pedestrian safety. We did not include older
children because most children are safe pedestrians by
the age of 10 years (AAP Committee on Injury, Violence,
and Poison Prevention, 2009), and it is developmentally
827
828
Schwebel et al.
illogical to train typically developing adolescents in pedestrian safety. Studies published at any date before April 1,
2013 were included. At least one experimental condition
was required to include a component designed to change
the behavior or cognition of a child pedestrian in streetcrossing settings (henceforth, ‘‘behavior change’’). Thus,
studies including only environmental change (e.g., traffic
engineering) mechanisms were excluded, as were studies
focused on changing parent or supervisor behavior only.
We also excluded studies with <10 participants in any
treatment arm and studies without behavioral outcomes
(e.g., those with only knowledge-based questionnaire outcomes or with reports of behavioral intention rather than
actual or simulated behavior). Studies were included from
all regions of the world. Manuscripts written in languages
other than English were included if suitable translators
with expertise in the field could be located; we located
suitable translators to examine manuscripts written in
Farsi, French, German, Russian, and Spanish but not in
Dutch.
Manuscript Inclusion
As shown in Figure 1, manuscript inclusion and data extraction occurred in four steps. First, two authors independently screened 1,951 manuscript abstracts for relevance.
Two authors reviewed each abstract and excluded those
that were not eligible based on inclusion criteria.
Interrater reliability was strong ( > .9), and differences
were resolved by retaining any studies rated by either reviewer as one that should be included. Full-text manuscripts were obtained when abstracts were absent or vague.
Second, for the 125 manuscripts retained as relevant
from the first step, full articles were retrieved for more
detailed evaluation. Two authors reviewed each manuscript
and excluded those that were not eligible based on inclusion criteria. Interrater reliability was strong ( > .9), and
differences were resolved by retaining any studies rated by
either reviewer as one that should be included. Bilingual
experts in the field were consulted as needed to assist with
this process (the authors had sufficient ability in French
and Spanish themselves and consulted experts for assistance with other languages). Figure 1 lists reasons for
exclusion.
Data Extraction
The third step of manuscript inclusion and data extraction
was to extract data using a standardized form. This was
conducted for the 25 manuscripts retained from the
second step. Two researchers extracted data for each manuscript. Rare disagreements were resolved by discussion
between both of the data extracters and a third researcher.
Extracted data included bibliographic information,
country where data were collected, demographic information concerning the intervention and control groups,
sample sizes allocated to groups and studied at each time
of assessment, type(s) of intervention, type(s) of behavioral
outcome measures focused on children, and results for
each time of assessment and outcome measure.
Data Processing
Seven of the 25 articles eligible for inclusion lacked sufficient data required to compute effects (Fisk & Cliffe, 1975;
McComas, MacKay, & Pivik, 2002; Reading, 1973;
Rothengatter, 1984; Rothengatter, Dijkstra, & de Ruyter,
1979; Sandels, 1968/1975; Thomson et al., 2005). In
those cases, extensive attempts to locate and obtain data
from the authors were made. Two authors were located,
and a third was identified as deceased; of those, one author
had data still available to share (Thomson et al., 2005). The
other authors could not be located and were presumed to
be deceased or no longer active in scholarship.
Therefore, 19 articles reporting 25 studies were included in the quantitative analysis. Data were entered
into the Review Manager 5.2 software (Revman; Review
Manager, 2012) to compute effect sizes.
Type of Outcome Measures
We included studies targeting any aspect of child behavior
or cognition surrounding pedestrian safety on roads. After
data processing was complete, three researchers examined
and discussed outcome measures used in each of the 25
included studies, matching them to a priori outcomes
outlined in the study protocol. The lead researcher proposed two decisions: which outcome measure was primary
and which component of pedestrian safety it assessed.
Two other researchers reacted to those proposals, and
rare disagreements were resolved through discussion
until consensus was reached. Primary outcomes were components of pedestrian safety that were determined primarily by the authors of the original study, who emphasized or
highlighted one result most prominently. The component
of pedestrian safety being assessed was never disputed
among the researchers and fell into six categories: crossing
safely at mid-block locations, crossing at junctions (intersections), crossing between parked cars, preventing dashout crossings, judging the speed of oncoming traffic, and
selecting safe routes to cross intersections.
Table I lists outcome measures, each a component of
pedestrian safety, used in each study. Mid-block crossings
were generally assessed using real or simulated crossings at
actual roadside locations, yielding outcome measures such
as simulated crashes with traffic, times until impact with
Idenficaon
Child Pedestrian Safety
Records idenfied
through database
searching (n=1866)
Records idenfied through
references of included
studies (n=41)
Records idenfied from
personal libraries, contacts,
and listservs (n=44)
Potenally relevant arcles idenfied and screened for retrieval (n=1951)
Screening
Full-text arcles excluded, with
reasons (n=100)
Arcles excluded during
abstract screening (n=1826)
Eligibility
Full arcles retrieved for
more detailed evaluaon
(n=125)
Included
Studies included in
qualitave synthesis (n=25)
Arcles included in
quantave synthesis
(meta-analysis)
(n=19, reporng 25 studies)
No empirical data, n=8
Not intervenon research, n=2
Not focused on road pedestrians
(e.g., railroad crossings), n=3
Not behavioral intervenon,
n=24
Not focused on individual
behavior change, n=35
Focused only on parent/adult
behavior change, n=3
Included experimental arm with
< 10 parcipants, n=3
Not randomized trial, n=7
Unable to obtain full text via two
ILL services, internet, or author
contact, n=11
No qualified translator, n=1
Duplicate data and research
team with included study, n=3
Arcles excluded, with reasons
(n=6)
Author contacted but data
unavailable, n=1
Author deceased, n=1
Unable to locate author contact
informaon, n=4
Figure 1. PRISMA flow diagram of included studies. Note. ILL ¼ interlibrary loan.
oncoming vehicles, or decision times until entry into traffic
gaps. Junction/intersection crossing was typically assessed
in actual street situations, either with real or simulated
traffic and yielding outcome measures such as proper
looking at oncoming traffic and correct route selection
across intersections. Crossing between parked cars was
typically assessed by having children cross in simulated
real-traffic situations or showing researchers where they
would cross in actual situations, yielding outcome measures such as stopping in the correct location to view traffic
and looking properly at oncoming traffic. Dash-out behavior was most often assessed using simulations near roads,
with controlled traffic, and deceptively throwing a ball over
the child’s head and into the road. Outcome measures to
assess dash-out behavior included failure to stop at the
curb and appropriate looking before entering the road.
Judging the speed of oncoming traffic was assessed in
just one study, where children judged traffic that was
driven by researchers; the outcome measure was a dichotomous correct versus incorrect judgment of traffic speeds.
Selecting safe routes to cross intersections was assessed in
various ways across studies, including simulations,
pointing at actual street corners, and table-top model
tasks. Outcome measures were most often the frequency
and/or accuracy of choosing the correct route across the
intersection.
Some studies assessed primary outcomes continuously
and others dichotomously. It seemed artificial to convert
continuous measures to dichotomous ones, so we retained
the original authors’ measurement strategies and analyzed
continuous and dichotomous data separately in our
analyses.
829
21, 8.94, 7–11, 38
110, not reported, 6–7, 0
(all girls)
50, not reported, 6–7, not
reported
960, not reported, 5–11, not
Bart, Katz, Weiss, &
Josman, 2008
Colborne, 1971,
Experiment 2
Cross & Pitkethly, 1991
Downing & Spendlove,
658, not reported, 3–6, not
reported
79, not reported, 4–5, 56
Limbourg & Gerber,
1981, Final Training
Program
Nishioka et al., 1991
reported
58, not reported, 3–7, not
Limbourg & Gerber,
1981, Pilot Study I
459, not reported, 7–10, 52
third grade participated
ported, not reported; children in kindergarten to
870, not reported, not re-
Kendrick et al., 2007
Jones & Fleischer, 1979
reported
40, 4.7, 4–5, 50
Albert & Dolgin, 2010
1981
Sample N, M age in years,
range in years, % male
Author(s), year
Verbal instructions with
no caution about risk
training: verbal instruction
No-contact control
group
instruction only
Theoretical road safety
No-contact control
group
group
No-contact control
group
No-contact control
No-contact control
group
Classroom training
Played unrelated computer games
quencies of safe or unsafe behaviors after ball thrown into street by
researcher
on the same day
tions of distraction
Prevent dash-out (dichotomous): freposttest 4 weeks later
Verbal instruction differing in content
regarding dash-out behaviors;
posttraining evaluation conducted
Prevent dash-out (dichotomous):
stopping at the curb under condi30-min video and behavioral training
delivered by parents; pretest and
action to ball thrown into street
by researcher
street crossing, including stopping
at curb, looking left and right; re-
mixed with a few bicycling skills
Prevent dash-out (dichotomous): real
measures taken 126 days apart
Eight sessions of training between
pre and posttesting
Mid-block cross (continuous): demonstration of safe pedestrian skills
looking properly during actual
crossings
Risk Watch program delivered in
class by teachers; pre and posttest
total during October; posttesting
in early November
year; instruction by teachers over
1 month ranging from 1 to 7.5 h
playground
Cross at junctions (dichotomous):
parked vehicles in simulation on
August; pretesting in May, posttesting in June
Pretesting in first weeks of school
percent of stopping and looking
both ways at curbs and near
Cross at parked cars (dichotomous):
by researchers
media campaign and school classroom instruction from May to
period
Children and drivers exposed to
proaching controlled vehicles; pretest and posttest for a 2–3-week
Judge speed (continuous): Judging
speed and distance of cars driven
traffic garden, scored as correct or
incorrect
traffic garden; posttest 1 week
later
Separate tests in which children
judged distance and speed of ap-
Select safe routes (dichotomous): two
crossings at an intersection in the
with the Street Crossing checklist
Mid-block cross (continuous): behaviors assessed on a real crossing
ing behaviors on a real street
Mid-block cross (continuous): walk-
Outcomes
40-min session delivered by police officer; training in classroom versus
20-min sessions with posttest 2
weeks later
follow-up at 6 months
Baseline test, post test at 1 week and
Read unrelated stories as
part of normal lessons
Methodology and procedure
Comparison groups
Individualized or small-group
Film or video training: behavioral
training
and theoretical safety training
Film or video training: behavioral
Classroom training: Risk Watch
program
and behavioral pedestrian
safety curriculum
Classroom training: knowledge
and school-level ‘‘Operation
Dashout’’ campaign
Classroom training: community
understanding of speed and
distance
Classroom training: interactive
classroom training to improve
‘‘traffic garden’’
Individualized or small-group
training: outdoor training in a
sessions in a virtual street
crossing simulation
Computer-based or virtual reality
training: series of 1–3 20-min
and song delivered over 4
weeks
Classroom training: game, story,
Intervention description
Table I. Characteristics of Studies Included in the Meta-Analysis
(continued)
Japan
Germany
Germany
United Kingdom
United States
United Kingdom
Australia
Austria
Israel
United States
Country
830
Schwebel et al.
Intervention description
Thomson & Whelan,
1997, Chapter 7
2
Thomson & Whelan,
1997, Chapter 6, Year
1
Thomson & Whelan,
1997, Chapter 6, Year
104, not reported, not reported, ‘‘balanced for
Thomson & Whelan,
1997, Chapter 4
88, 6 years, 3 months, not
reported, not reported
gender’’
91, 6 years 0 months, not reported, ‘‘balanced for
gender’’
102, 6 years 1 month, not
reported, ‘‘balanced for
gender’’
30, 5.46, 5 year olds, 50
231, 8.0, 7–8, 43
Thomson et al., 1992
2014a
Schwebel & McClure,
231, 8.0, 7–8, 43
Comparison groups
Outcomes
traffic
later
based on Social Learning
Theory
Cross at junctions (dichotomous):
stopping at curb, correct position
at curb, adequate view of traffic,
attention to traffic, and selection
of a safe route
of three in five sessions across 5
weeks; immediate posttest and
follow-up at unspecified interval
position, search, identify alternatives, and apply safe behaviors at intersections
Individualized or small-group
training: teaching children to
Pretesting apparently in roadside simulation; children trained in groups
No-contact control
group
ing stopping at the curb, correct
walking speed, and attending to
per week for 4 weeks; immediate
posttest; follow-up 2–3 months
of teaching children to safely
cross near parked vehicles;
Individualized or small-group
training: step-by-step method
Cross at parked cars (dichotomous):
multiple behavioral indices includ-
traffic
ing stopping at the curb, correct
walking speed, and attending to
Cross at parked cars (dichotomous):
multiple behavioral indices includ-
Pretest in roadside simulation 1 week
before training; then training once
later
Pretest in roadside simulation 1 week
before training; then training once
lections; immediate posttesting,
and follow-up 2–3 months later
Select safe routes (dichotomous): selection of routes on real streets
pointing
ing, and follow-up 2 months later
Pretesting; six training sessions over
6 weeks, comprising 24 route se-
route selections chosen on real
streets and table-top models by
Select safe routes (dichotomous):
routes chosen on table-top models
Select safe routes (continuous):
close calls in roadside simulation
task
Mid-block cross (continuous): hits/
simulation in gymnasium
Mid-block cross (continuous): transfer of learning using street-crossing
searcher over several weeks, in
small groups; immediate posttest-
ment 6 months later
Pretesting; six sessions by a re-
ment, six training sessions of
30 min each, follow-up assess-
6 months later
Pre and immediate posttest assess-
ment, six training sessions of
30 min each, follow-up assessment
Pre and immediate posttest assess-
based on Social Learning
Theory
No-contact control
group
Methodology and procedure
Two 3-hr sessions with immediate
posttesting
per week for 4 weeks; immediate
posttest; follow-up 2–3 months
No-contact control
group
No-contact control
group
group
No-contact control
group
No-contact control
group
No-contact control
No-contact control
group
of teaching children to safely
cross near parked vehicles;
Individualized or small-group
training: step-by-step method
routes
trained volunteers to help children recognize and select safer
Individualized or small-group
training: interaction with
safer routes and considering
visual occlusions
training: training in small
groups focused on choosing
Individualized or small-group
training
Film or video training: video
virtual reality and street-side
training
Multiple intervention strategies:
Severson, 2014b
Renaud, 1988)
Schwebel, McClure, &
Board games or peer-group activities: board games/activities
simulating route selections
and street crossings
136, not reported, 5, not
reported
Renaud & Suissa, 1989
(data also reported in
Renaud &
Stolovitch,1988;
Sample N, M age in years,
range in years, % male
Author(s), year
Table I. Continued
Country
(continued)
United Kingdom
United Kingdom
United Kingdom
United Kingdom
United Kingdom
United States
United States
Canada
Child Pedestrian Safety
831
Intervention description
Carcary, Jones, &
Larter, 2001
Zeedyk, Wallace,
Skill 3
Whelan et al., 2008,
Skill 2
Whelan et al., 2008,
47, not reported, 5–6, 53
121, 6, 4–7, 48
284, 6, 4–7, 49
Individualized or small-group
400, 6, 4–7, 50
Whelan, Towner,
Errington, & Powell,
2008, Skill 1
Multiple intervention strategies:
adult- and peer-guided groups
50, 6 years 9 months, 5–8,
64
ties: knowledge-building
activities
Board games or peer-group activi-
training: Kerbcraft; crossing
safely at intersections
Individualized or small-group
training: Kerbcraft; crossing
safely near parked cars
Individualized or small-group
training: Kerbcraft; recognizing
safe crossing places
group
No-contact control
group
No-contact control
group
No-contact control
group
No-contact control
No-contact control
group
Outcomes
in potential for injury risk
with board game, playmat model,
or flip-chart; posttest at
unspecified interval
choices of crossing location and
strategy at three locations varying
intersections
Mid-block cross (dichotomous):
looking in the correct directions
when stopping at actual
day; intervention involved single
20-min peer-group activity session
2–4 months later
Pretest and intervention on same
sions occurring once per week; immediate posttesting and follow-up
crossings
Cross at junctions (continuous):
the curb, and checking status of
parked cars during actual
2–4 months later
Roadside pretesting; 4–6 training ses-
proportions of safe behaviors such
as looking at traffic, stopping at
Cross at parked cars (dichotomous):
routes selected in roadside
simulation
Select safe routes (dichotomous):
Mid-block cross (continuous): tight
fits at roadside simulation
Mid-block cross (continuous): tight
fits at roadside simulation
route selections chosen on real
streets by pointing
Select safe routes (dichotomous):
sions occurring once per week; immediate posttesting and follow-up
2–4 months later
Roadside pretesting; 4–6 training ses-
sions occurring once per week; immediate posttesting and follow-up
7–10 days after training
Roadside pretesting; 4–6 training ses-
worked together to identify safe
crossing opportunities; posttesting
Pretesting; 14 scenarios in blocks of
three; children and adults or peers
crossings; follow-up 8 months
later
Roadside evaluations preintervention,
postintervention, four 30–40-min
testing; follow-up 40 days later
several weeks at roadside and on
table-top models; immediate post-
six 30-min sessions led by parents
with groups of three children over
delays/tight fits
No-contact control
group
group
Methodology and procedure
Pretesting 2 weeks before training;
training sessions in small groups
to complete computer-simulated
Tolmie et al., 2005,
Study 1
Comparison groups
No-contact control
improve recognition of speed,
planning, and reduce start
Computer-based or virtual reality
training: teaching children to
189, 9, 7–11, ‘‘balanced
by gender’’
Thomson et al., 2005
sidering visual occlusions
group), not reported,
‘‘balanced by gender’’
Individualized or small-group
training: training focused on
choosing safer routes and con-
60, 5 years 6 months (inter-
Thomson et al., 1998
vention group) and 5
years 7 months (control
Sample N, M age in years,
range in years, % male
Author(s), year
Table I. Continued
Country
United Kingdom
United Kingdom
United Kingdom
United Kingdom
United Kingdom
United Kingdom
United Kingdom
832
Schwebel et al.
Child Pedestrian Safety
Type of Intervention
Three researchers also determined the type of intervention
used in each study, using a strategy similar to determination of the outcome measures. The lead researcher proposed the category, and two other researchers reacted to
the proposal. No disagreements emerged. Studies were divided into five categories: individualized or small-group
training, classroom training, computer-based or virtual reality training, board games or peer-group activities, and
film or video training. A sixth category was used for studies
that included multiple intervention strategies either across
or within groups of children. The categories were created
because they relied on similar educational processes to
teach children about pedestrian safety. Thus, all computer-based and virtual reality programs relied on repeated
practice of the cognitive/perceptual task of crossing a
street. All board games and peer-group activities involved
shared learning via peer mentoring and discussion.
Risk of Bias Assessment
Two forms of bias can exist in a systematic review and
meta-analysis, bias at the level of the meta-analysis and
bias at the level of the individual included studies. At the
meta-analysis level, our systematic review was conducted
to locate and include all research, including unpublished
studies, so we believe there to be minimal risk of bias
across studies based on publication bias.
At the study level, risk of bias was assessed using
guidelines in the Cochrane Handbook for Systematic
Reviews of Interventions (Higgins & Green, 2011). Our
goal was to identify any systematic biases in the way included studies were conducted that could influence results
and therefore overestimate or underestimate the effect of
the intervention. Bias can emerge through a wide range of
factors. Following Cochrane recommendations (Higgins &
Green, 2011), we rated each included study on selection
bias (potential bias in allocating participants into intervention groups, evaluated based on random sequence generation and allocation concealment), detection bias (potential
bias in how study outcomes are assessed or determined,
evaluated based on blinding of the outcome assessment),
attrition bias (potential bias in participant withdrawal from
the study, evaluated based on incomplete outcome data),
and reporting bias (potential bias in authors reporting significant rather than nonsignificant study results, evaluated
based on selective reporting). We also noted other biases
that were present. Evaluation of risk of bias was conducted
by the lead author. Two other researchers reviewed all
evaluations and noted any discrepancies, which were
resolved through discussion. Interrater reliability was
strong ( > .9).
Quality of Research Assessment
Quality of the research was assessed using GRADE guidelines (Guyatt et al., 2011). As recommended by GRADE
guidelines, the quality of research ratings indicate our confidence that effect size shown in the study represents the
actual effect of the intervention. Quality was downgraded
based on five factors: poor methodological quality (risk of
bias within the study), indirect evidence of results, heterogeneity of results (tested with I2 statistic, following
Palermo, Eccleston, Lewandowski, Williams, & Morley,
2010), imprecision of results based on wide confidence
intervals (CIs), and risk of publication bias. I2, a standard
measure of heterogeneity between intervention studies, indicates how much variability in the effect estimates is a
result of heterogeneity rather than sampling error.
Consistent with Palermo and colleagues (2010), we considered an I2 > 50% as indicative of substantial heterogeneity. Evaluation of quality of the research was conducted
by one researcher. Two other researchers reviewed all evaluations and noted any discrepancies, which were resolved
through discussion. Interrater reliability was strong
( > .9).
Data Analysis
Data analysis proceeded in six steps. First, descriptive data
on each included study were reviewed. Second, overall
‘‘omnibus’’ tests of the effect of all behavioral interventions
on all aspects of pedestrian safety were computed. For all
meta-analyses presented, two results are provided, one for
dichotomous (categorical) outcomes and a second for continuous outcomes. All studies were weighted according to
sample size using a least-squares approach, such that studies with larger samples were weighted more heavily than
those with smaller samples. Categorical results are reported
as risk ratios (RRs) and continuous results as standardized
mean differences (SMDs; after standardizing results and
reversing the direction of measures as needed, the difference in mean outcome between groups over standard deviation of outcome among participants), both with 95%
CIs. The effect sizes of SMDs were interpreted according
to Cohen’s (1988) criteria, with an SMD of 0.2 considered
a small effect size, an SMD of 0.5 a medium effect size, and
an SMD of 0.8 a large effect size. In all cases, positive
effects favor the active intervention group achieving safer
behavior.
Third, we considered included articles based on
the component of pedestrian safety targeted in the
intervention. Six pedestrian safety components were
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considered: crossing safely at mid-block locations, crossing
at junctions or intersections, crossing between parked cars,
preventing dash-out crossings, judging the speed of oncoming traffic, and selecting safe routes to cross intersections. Fourth, we considered included articles based on the
intervention implemented, without regard to the component of pedestrian safety used as an outcome. Five types of
interventions were considered: individualized or smallgroup training, classroom training, computer-based or virtual reality training, films or videos, and multiple intervention strategies combined.
Fifth, we considered both the targeted component of
pedestrian safety and the intervention approach used to
train children in that component of safety. Last, we rated
each included study for risk of bias. Risk of bias was
unclear for most categories in most studies based on insufficient information, and we retained all studies in
analyses.
Results
Characteristics of Included Studies
Table I lists the studies included in the systematic review
and meta-analysis. As shown, 25 studies from 19 manuscripts were included. All studies, including those published in the same manuscript, used independent
samples. Data were collected in eight countries: Austria,
Australia, Canada, Germany, Israel, Japan, the United
States, and the United Kingdom, with the majority (14 of
25, or 56%) occurring in the United Kingdom. Child participants ranged in age from 3–11 years, with the bulk of
studies on crossing behavior targeting children aged 6–9
years and studies targeting route selection and especially
dash-out behavior focused on younger children (e.g., aged
3–6 years). These targets are developmentally sensible
given the cognitive development of skills relevant for
such behaviors as well as the pedestrian injury risks at
those developmental stages. No information was reported
in any of the included articles to indicate there had been
adverse events.
Overall Meta-Analysis Results
Table II shows the overall results of the meta-analysis, including all studies and all outcomes, divided into continuous and dichotomous outcomes and studies with
immediate postintervention assessment (all 25 studies)
and those with a follow-up assessment several months
later (13 studies). As shown, the standardized mean pedestrian safety score among intervention groups was 0.31
higher than that of control groups (95% CI ¼ 0.12–0.50),
for studies with continuous outcomes (10 studies and
1,052 participants), indicating a small to medium effect
Table II. Summary of Results for all Studies Together, Testing Efficacy of Behavioral Interventions to Improve Children’s Pedestrian Safety
Illustrative comparative risksa (95% CI)
Outcomes
Assumed risk
Control
Corresponding risk
Overall
Pedestrian safety
The mean pedestrian safety (continuous)
(continuous)
in the intervention groups was 0.31
higher (0.12–0.50 higher)
Pedestrian safety
(continuous, follow-up)
The mean pedestrian safety
Relative effect
(95% CI)
Number of
participants
(studies)
Quality of the
evidence (GRADE)
1,052 (10 studies)
€ moderateb
563 (five studies)
€ moderateb
(continuous, follow-up) in the
intervention groups was 0.17 higher
(0.00–0.34 higher)
Pedestrian safety
86 per 1,000 296 per 1,000 (177–495)
RR 3.44 (2.06–5.75) 2,720 (15 studies)
€€ lowb,c
(dichotomous)
Pedestrian safety
74 per 1,000 217 per 1,000 (147–309)
(dichotomous, follow-up)
RR 2.88 (1.89–4.39) 744 (eight studies) € moderateb
Note. CI ¼ confidence interval; RR ¼ risk ratio; OR ¼ odds ratio.
GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
a
Assumed risk is based on control group risks reported in included studies. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group
and the relative effect of the intervention (and its 95% CI).
b
There is moderate amount of risk of bias for this outcome.
c
The I2 statistic indicates high inconsistency in results across studies.
Child Pedestrian Safety
size. For studies with dichotomous outcomes, the RR was
3.44 (95% CI ¼ 2.05–5.75; number needed to treat to benefit [NNTB] ¼ 4.77). Data for each study are displayed
graphically in Forest plots (See Figures 2–5). Taken together, these findings suggest behavioral interventions to
improve children’s pedestrian safety are effective.
Results of follow-up assessments also indicate efficacy
for behavioral pedestrian safety interventions. Continuous
outcomes showed an SMD of 0.17 (95% CI ¼ 0.00–0.34;
five studies and 563 participants), indicating a small effect
size favoring interventions over controls, and dichotomous
outcomes showed an RR ¼ 2.88 (95% CI ¼ 1.89–4.39;
eight studies and 744 participants; NNTB ¼ 7.19), indicating safe behaviors were significantly more likely among
participants in intervention groups than participants in
control groups.
Meta-Analysis Results: Targeted Component of
Pedestrian Safety
We next considered the included articles based on the
component of pedestrian safety the research targeted. As
discussed above, pedestrian safety is multifaceted, requiring multiple cognitive, perceptual, and motoric functions
for safe engagement. Included studies targeted six components of pedestrian safety: crossing safely at mid-block
locations (eight studies), crossing at junctions or intersections (three studies), crossing between parked cars (four
studies), preventing dash-out crossings (three studies),
judging the speed of oncoming traffic (one study), and
selecting safe routes to cross intersections (six studies).
Table III presents results across each of the six components of pedestrian safety, measured separately for continuous and dichotomous outcomes and for
postintervention and follow-up assessments. As shown,
and replicating the overall results of Table II, there was a
tendency for interventions to be effective compared with
controls. Results for many components are challenging to
interpret because they are based just on few studies, but
there was a general trend for interventions to prevent dashouts, to cross at parked cars, and to select safe routes to be
effective across multiple studies.
Meta-Analysis Results: Type of Intervention
Table IV presents meta-analysis results organized by the
type of intervention that was implemented. Included studies used individualized or small-group training (11 studies), classroom training (5 studies), computer-based or
virtual reality training (2 studies), board games or peergroup activities (2 studies), films or videos (3 studies), or
multiple intervention strategies combined (2 studies).
When sufficient studies were available to permit valid
interpretation, some types of interventions were generally
more effective than others. Individualized or small-group
training in particular tended to be the most effective intervention strategy with data available from multiple studies.
Meta-Analysis Results: Targeted Component of
Pedestrian Safety and Intervention Approach
The next analytic step examined both the targeted component of pedestrian safety and the intervention approach to
train children in that domain. There were five combinations of pedestrian safety component and intervention approach with data available from more than one study at
immediate postintervention assessment (and two others at
follow-up assessment). Of those, the largest effects appeared from individualized or small-group training to
Figure 2. Forest plots demonstrating clinical significance of child pedestrian safety interventions (studies with continuous outcome, immediate
postintervention assessment).
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Figure 3. Forest plots demonstrating clinical significance of child pedestrian safety interventions (studies with continuous outcome, assessment at
follow-up several months following intervention).
Figure 4. Forest plots demonstrating clinical significance of child pedestrian safety interventions (studies with dichotomous outcome, immediate
postintervention assessment).
train children to cross at parked cars (RR ¼ 4.93, 95% CI
2.43–10.00, based on three studies and 422 participants;
NNTB ¼ 6.06) and to select safe routes (RR ¼ 3.83, 95%
CI 1.05–13.95, based on five studies and 610 participants;
NNTB ¼ 2.54). Those same two outcomes also showed
significant effects at follow-up assessment (RR ¼ 2.92,
95% CI 1.50–5.65, k ¼ 3, N ¼ 325, NNTB ¼ 7.13 and
RR ¼ 2.77, 95% CI 1.60–4.80, k ¼ 4, N ¼ 331,
NNTB ¼ 6.35, respectively).
Quality of the Evidence
All meta-analysis results must be interpreted with the quality of the evidence ratings in mind. Following GRADE
guidelines (Guyatt et al., 2011), we downgraded all four
outcomes based on risk of bias; there was poor methodological quality among all outcomes. All comparisons in the
studies were direct, so no outcomes were downgraded
based on indirect evidence. One outcome (dichotomous
postintervention outcome) was downgraded for inconsistency (I2 > 50%).
We assessed imprecision based on sample size and
CIs. All outcomes had sufficient sample size based on
GRADE criteria. GRADE criteria indicate outcome quality
should be downgraded even if sample size is adequate
when there is both no effect and appreciable benefit or
appreciable harm. Three outcomes had an effect so were
not downgraded. For the fourth outcome (continuous outcomes at follow-up), the effect was borderline (starts at
Child Pedestrian Safety
Figure 5. Forest plots demonstrating clinical significance of child pedestrian safety interventions (studies with dichotomous outcome, assessment
at follow-up several months following intervention).
Table III. Summary of Meta-Analytic Results for Behavioral Interventions to Improve Children’s Pedestrian Safety, Separated by Target Component
of Pedestrian Behavior
Continuous outcome
k
Total N
SMD
95% CI
I2
Mid-block cross, postintervention
Mid-block cross, follow-up
7
3
665
317
0.23
0.18
0.03, 0.44
0.07, 0.43
30%
11%
Cross at junctions, postintervention
1
230
0.48
0.22, 0.74
NA
Cross at junctions, follow-up
1
139
0.21
0.13, 0.54
NA
Judge speed, postintervention
1
50
0.93
0.34, 1.52
NA
Select safe routes, postintervention
1
107
0.06
0.32, 0.44
NA
Select safe routes, follow-up
1
107
0.12
0.26, 0.50
NA
RR
95% CI
I2
Dichotomous outcome
k
Total N
Mid-block cross, postintervention
1
47
0.83
0.26, 2.73
NA
Cross at junctions, postintervention
2
795
6.07
0.35, 106.26
NA
Cross at junctions, follow-up
1
88
4.97
0.28, 89.32
NA
Cross at parked cars, postintervention
4
698
7.42
3.77, 14.60
12%
Cross at parked cars, follow-up
Prevent dash-out, postintervention
3
3
325
570
2.92
2.90
1.50, 5.65
2.22, 3.78
0%
0%
Select safe routes, postintervention
5
610
3.83
1.05, 13.95
83%
Select safe routes, follow-up
4
331
2.77
1.60, 4.80
0%
Note. SMD ¼ standardized mean differences; CI ¼ confidence interval; RR ¼ risk ratio.
0.00), but the upper confidence limit was not appreciable
(upper CI < 0.50), so we did not downgrade the outcome.
Given the rigor of our systematic review, we did not downgrade any outcomes based on publication bias.
The final column of Table II shows quality of research
evidence ratings for our outcomes. Quality of research evidence was low for the dichotomous pedestrian safety outcome immediately postintervention and moderate for the
other outcomes. Those evaluations rated as having low
quality must be interpreted with great caution; the
Cochrane Library suggests this about low-quality ratings:
‘‘further research is very likely to have an important impact
on our confidence in the estimate of effect and is likely to
change the estimate’’. Those with moderate quality offer
somewhat greater confidence in the estimates but still must
be interpreted cautiously. Future research with strong
methodology is needed in the field.
Risk of Bias
Ratings for risk of bias were made in five categories:
random sequence generation, allocation concealment,
blinding of outcome assessment, incomplete outcome
data, and selective reporting. Ratings for each included
study appear in Figure 6, with individualized tables and
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Schwebel et al.
Table IV. Summary of Meta-Analytic Results for Behavioral Interventions to Improve Children’s Pedestrian Safety, Separated by Type of
Intervention
95% CI
I2
Pedestrian safety as continuous outcome
k
Total N
SMD
Individualized or small-group training, postIV
1
230
0.48
0.22, 0.74
Individualized or small-group training, follow-up
1
139
0.21
0.13, 0.54
NA
Classroom training, postIV
3
250
0.54
0.08, 1.00
56%
NA
NA
Classroom training, follow-up
1
40
0.64
0.09, 1.38
Computer-based or virtual reality training, postIV
2
149
0.14
0.22, 0.50
5%
Computer-based or virtual reality training, follow-up
1
118
0.22
0.16, 0.59
NA
Board games or peer-group activities, postIV
1
128
0.62
0.20, 1.04
NA
Film or video training, postIV
Film or video training, follow-up
1
1
107
107
0.06
0.12
0.62, 0.44
0.26, 0.50
NA
NA
Multiple intervention strategies, postIV
2
188
0.02
0.32, 0.28
0%
Multiple intervention strategies, follow-up
1
159
0.04
0.28, 0.37
NA
Pedestrian safety as dichotomous outcome
Individualized or small-group training, postIV
k
Total N
RR
95% CI
I2
80%
10
1,191
3.79
1.79, 8.02
Individualized or small-group training, follow-up
8
744
2.88
1.89, 4.39
0%
Classroom training, postIV
3
1,424
7.03
0.75, 66.12
81%
Board games or peer-group activities, postIV
1
47
0.83
0.26, 2.73
NA
Film or video training, postIV
1
58
3.80
1.64, 8.80
NA
Note. SMD ¼ standardized mean differences; CI ¼ confidence interval; IV ¼ intervention; RR ¼ risk ratio.
ratings available in Supplementary Tables 1–25. As shown,
a large portion of the manuscripts provided insufficient
data to rate evidence for risk of bias. Specifically, of the
25 studies, the following number had insufficient data in
each category: 17 studies for random sequence generation,
22 studies for allocation concealment, 22 studies for
blinding of outcome assessment, 12 studies for incomplete
outcome data, and 23 studies for selective reporting. When
evidence was available, it was mixed. Five studies had high
selection risk based on random sequence generation, and
two studies had high detection risk based on blinding of
outcome assessments. Low risk was rated for 3 studies in
random sequence generation, 3 studies for allocation concealment, 1 study for blinding of outcome assessment, 13
studies for incomplete outcome data, and 2 studies for
selective reporting. Although it was unclear based on materials written in the manuscripts, there is reason to presume significant risk of bias in several categories for most
of the included studies.
Discussion
Results of this systematic review and meta-analysis demonstrate that behavioral interventions targeting children’s pedestrian safety by improving children’s behaviors and
cognitions in pedestrian environments are generally effective. Behavior generally became safer both immediately following the intervention program and, to a somewhat
reduced degree, at follow-up several months later. These
results replicate and extend those reported in previous reviews (e.g., Duperrex, Bunn, & Roberts, 2002; Schwebel,
Davis, & O’Neal, 2012). Child pedestrian safety remains a
significant pediatric global health challenge, and efforts to
reduce the impact of child pedestrian crashes on pediatric
morbidity and mortality are urgently needed.
Beyond our omnibus finding that behavioral interventions are generally effective, available evidence suggested
that some components of child pedestrian safety may be
more responsive to behavioral interventions than others.
Pedestrian safety is not a unique and single action but
rather a multilayered complex cognitive-perceptual-motoric
task. Developing children are likely to struggle with various
aspects of that complex task.
Our systematic literature review yielded intervention
research targeting six different aspects of pedestrian
safety. Some intervention programs—especially those designed to reduce dash-out behavior, to cross at parked cars,
and to select safe routes across intersections—were generally effective in improving children’s pedestrian safety.
Other components of pedestrian safety appeared to improve also through behavioral intervention, although evidence was poor because of the small number of
randomized trials conducted with most types of outcomes.
Our third goal was to determine whether some types
of behavioral intervention are more effective than others.
Included articles considered five types of interventions:
individualized or small-group training, classroom training,
computer-based or virtual reality training, board games or
Child Pedestrian Safety
Manuscript
Random
sequence
generaon
(selecon bias)
Allocaon
concealment
(selecon bias)
Blinding of
outcome
assessment
(detecon
bias; all
outcomes)
Incomplete
outcome data
(arion bias;
all outcomes)
Selecve
reporng
(reporng
bias)
Albert & Dolgin, 2010
Bart et al., 2008
Colborne, 1971
Cross & Pitkethly, 1991
Downing & Spendlove, 1981
Jones & Fleischer, 1979
Kendrick et al., 2007
Limbourg & Gerber, 1981,
Pilot Study I
Limbourg & Gerber, 1981,
Final Training Program
Nishioka et al., 1991
Renaud & Suissa, 1989
Schwebel et al., in press
Schwebel & McClure, 2014
Thomson et al., 1992
Thomson et al., 2005
Thomson et al., 1998
Thomson & Whelan, 1997,
Chapter 4
Thomson & Whelan, 1997,
Chapter 6, Year 1
Thomson & Whelan, 1997,
Chapter 6, Year 2
Thomson & Whelan, 1997,
Chapter 7
Tolmie et al., 2005
Whelan et al., 2008,
Secon 5.1 (Skill 1)
Whelan et al., 2008,
Secon 5.2 (Skill 2)
Whelan et al., 2008,
Secon 5.3 (Skill 3)
Zeedyk et al., 2001
Figure 6. Risk of bias ratings for articles included in the meta-analysis. Note. White circle indicates low risk; fading gray indicates unclear risk; solid
black circle indicates high risk.
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peer-group activities, and films or videos. In general, individualized or small-group training strategies were effective.
Other types of interventions typically showed mixed results, often with poor evidence for evaluation due to the
number of studies implementing them.
The inconsistent findings from other intervention
strategies, and especially from classroom and computer/
virtual reality training, may result from individual study
differences among the few randomized studies available.
Perhaps some types of classroom interventions and some
types of computer-based interventions are more effective
than others. For example, it may be that computer-based
interventions, which offer repeated practice at the cognitive-perceptual task of street crossing but fail to address
other aspects of pedestrian safety, are most effective
when supplemented with other learning modes that
teach basic road safety rules (Schwebel & McClure,
2014b). Similarly, classroom interventions may be effective
when combined with multimodal pedestrian safety training
(e.g., Downing & Spendlove, 1981) that incorporates lessons addressing multiple aspects of pedestrian safety. The
poor evidence from studies using films and videos indicates more interactive health behavior change mechanisms
might be required. Evidence from board games and peergroup activities is intriguing, as those sorts of interventions
are comparatively rare in the pediatric public health literature and might be explored further to prevent child pedestrian injury as well as in other domains.
The finding that individualized and small-group training programs were effective is encouraging, as they have
been studied for many years and have been described as
the most effective child pedestrian safety strategy targeting
children rather than adults or the pedestrian environment
(Schwebel & McClure, 2010). Unfortunately, such interventions also are highly expensive and labor intensive to
implement. An appeal of alternatives such as films and
videos is that, once developed, they are easy and inexpensive to disseminate widely. Given our findings that some
peer-group, board game, and computer/virtual reality interventions were effective in individual studies, continued efforts to develop such interventions that are effective and
can be disseminated widely for low cost should be pursued. Such programs, if theoretically based and carefully
evaluated, hold excellent promise to replace labor-intensive
individualized training as the first choice for child pedestrian safety intervention programming.
Several of the included studies included long-term data
assessing retention of learned skills two to eight months
after the intervention. Results from such long-term followups tended to mimic those immediately postintervention,
although effect sizes were lower and sometimes
nonsignificant. This suggests children retain over time
some of the pedestrian skills they learn via behavioral interventions, although other learning is lost. This result is promising for prevention programming, as it indicates that
learned pedestrian skills may be retained over time.
All results must be considered with respect to quality
of evidence ratings. Included studies often had low quality
of evidence ratings, and some effect estimates may change
as further evidence is gathered.
Pedestrian Safety From the Perspective of Child
Development
Our results highlight the need to consider pedestrian safety
from the perspective of child development. Dash-out behavior (also called dart-out behavior), which creates
particularly high risk of pedestrian safety from about ages
5–9 years (Agran, Winn, & Anderson, 1994), was successfully reduced with fairly basic intervention strategies. In the
study by Limbourg and Gerber (1981), for example, behavioral strategies were used to train parents, who were then
expected to engage with their children to reduce children’s
dash-out behaviors. Nishioka and colleagues (1991) used a
different strategy. In their study, adults cautioned children
to be cautious about moving (simulated) traffic as they
played with a ball near the road. Compared with controls,
children who had recently been cautioned displayed safer
behavior in retrieving a ball the experimenter intentionally
threw over the children’s heads.
One component of pedestrian safety we studied that
was fairly resistant to the behavioral interventions was midblock crossings. One of the most cognitively complex
pedestrian tasks included, a mid-block crossing requires
children to judge speeds, distances, and acceleration/
deceleration of vehicles coming from at least two directions. Safe crossings also require estimation of the distance
across the road and the child’s own walking speed. Such
cognitive complexity may be developmentally impossible
for many 5- or 6-year-old children to accomplish, no
matter how much practice or training is provided. By the
age of 7 or 8 years, children may develop those skills with
training, and typically developing children may not master
the cognitive complexity of mid-block crossings until the
age of 10 years or later.
Future research must continue to approach pedestrian
safety from a multidimensional child development perspective to understand which relevant cognitive skills develop
and at what age, among trained and untrained children. In
doing so, we must be wary of Vygostky’s (1978) ‘‘zone of
proximal development.’’ Pedestrian safety intervention programs might push children’s cognitions to some degree,
but there will be a limit of that zone, and that limit may
Child Pedestrian Safety
vary across children and across pedestrian tasks. In the
end, the intervention goal must be to target children with
the cognitive complexity to learn what is being instructed,
but not those who have already learned the skills.
Interventions with explicit child developmental theory
underpinnings are rare in the literature. A small, but growing, body of research examines various aspects of cognitive
development in relation to pedestrian injury risk (e.g.,
Barton, Ulrich, & Lyday, 2012; Dunbar, Hill, & Lewis,
2001; Kovesdi & Barton, 2013; Whitebread & Neilson,
2000), but accumulating evidence has yet to be widely
applied in intervention development. As an example of
what might be developed, the intervention used by
Tolmie and colleagues (2005) explicitly drew on
Vygotskian principles of group interaction. Social interaction was harnessed to help children teach one another safe
pedestrian skills and also to promote conceptual growth.
Much potential remains to be realized in applying developmental knowledge to intervention. Future interventions
should continue to look toward developmental theory
and seek to tailor the delivery of interventions to developmental levels of the targeted children.
Pedestrian Safety From the Perspective of Global
Public Health
Our meta-analysis included 25 studies conducted in eight
different nations over the course of >40 years. The problem of child pedestrian safety is neither a new problem nor
one specific to a particular geographic locale. The greatest
risk lies in low- and middle-income countries (WHO,
2008, 2013), nations conspicuously absent from the
meta-analysis results. In those nations, traffic is often
more chaotic, children are left unsupervised on and near
roadways more often, and trauma care postcrash is often
inferior. As scientists and interventionists move toward
preventing child pedestrian injuries, the focus must be international in scope. Many of the successes of high-income
countries can and should be adapted to other cultures so
that child pedestrians can be protected worldwide.
Measurement Issues in Pedestrian Safety
The articles included in our meta-analysis used a range of
clever and innovative strategies to assess children’s pedestrian behavior and safety. Of course, such innovation was
necessary because of the ethical challenges of placing children in real streets, with real traffic, for research purposes.
Some studies used simulation to gauge children’s pedestrian behavior—simulation was done with models (e.g.,
three-dimensional table-top models of street environments)—in gymnasiums and parks with real or remotecontrolled vehicles and with virtual reality. Some studies
used real roads but vehicles operated by researchers and
controlled in their movement. Other studies used real
roads and real traffic, having children make judgments
but not crossing streets in most cases. One glaring omission emerges: no studies used actual pedestrian injuries as
an outcome measure. This is not surprising given that
pedestrian injuries are rare events, and an extremely large
sample size would be required, but ultimately this methodological challenge must be addressed by scholars in the
field.
Limitations
Like all research, this study had limitations. We focused
only on behavioral interventions targeting child cognition
and/or behavior. This artificially isolates child pedestrian
safety as impingent only on the child, ignoring the street
environment children might cross within, the behavior of
drivers who might strike child pedestrians, the role of parents, crossing guards, and other adults who might supervise children near traffic, and many other variables that
play a role in individual crash events. Our analysis was
also limited by including only randomized trials. Rich
data are available from pre–post research designs that
lack control groups, from descriptive and epidemiological
research, and from other research designs on child pedestrian safety. The included trials had mostly no-contact control groups, but several had active control groups that may
have learned some relevant lessons also. Further, we were
unable to include information on the many communitybased pedestrian safety programs that are in practice globally but have not been subject to empirical evaluation.
Interventionists should consider the broad picture of
child pedestrian safety along with the issues raised in
this review.
As in any meta-analysis, we merged studies that used
different methodology and different outcomes into groupings. We did so judiciously and thoughtfully, working to
create logical categories, but still we merged studies that
were somewhat unlike. The computer-based and virtual
reality training strategy, for example, included both
nonimmersive two-dimensional computer-based simulation learning and semiimmersive three-dimensional learning in a virtual pedestrian environment. Similarly, in some
categories, such as the selecting safe routes outcome, we
combined studies that assessed the outcome with real or
simulated crossings in actual street crossings and studies
that assessed the outcome using table-top models.
Finally, we were limited by our inability to obtain data
from authors of six studies that were eligible for inclusion.
Most of those studies were older—five of the six were published between 1968 and 1984—but still reported rich
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experimental designs and findings that would contribute to
the present results.
Implications
Behavioral interventions should be one facet of society’s
strategy to reduce the global burden of child pedestrian
injuries (Damashek & Kuhn, 2014; Gielen, Sleet, &
DiClemente, 2006; Liller, 2012). Implementation of such
interventions might be conducted by local, regional, or
national government bodies; by nonprofit agencies; by
school districts; or by any number of other interested
stakeholders. Creative strategies like use of volunteers
such as retired individuals to train children in safe pedestrian skills (Thomson & Whelan, 1997), development of
virtual reality programs that might be disseminated broadly
over the internet (Schwebel, McClure, & Severson, 2014a),
or other techniques that will deliver safety lessons broadly,
efficiently, and economically are a necessity.
In comparison with many domains of pediatric psychology, child pedestrian safety is not a new science. Child
pedestrian safety training efforts began at least as early as
the 1930s initiation of Safety Town in Ohio, and empirical
evaluation of such efforts were pioneered by Stina Sandels’
inspiring work in 1960s Sweden (Sandels, 1968/1975).
Despite the comparatively long history of child pedestrian
injury prevention, much work remains to be done.
Children are dying on our streets at an alarming rate,
and behavioral strategies appear to improve safety. Work
should continue to prioritize identification of the most
cost-efficient and effective prevention strategies.
Simultaneously, dissemination efforts must be considered.
The act of balancing identification of the most effective
strategies with dissemination of strategies known to be effective is always challenging, but preventionists must be
content to disseminate programs that are effective rather
than squandering time—and children’s lives—awaiting
identification of the optimal program.
Of course, behavioral strategies designed to improve
children’s decisions in pedestrian settings cannot be implemented in isolation. Other proven strategies to improve
child pedestrian safety, including construction of pedestrian-friendly built environments, reducing risky driving
behaviors, improving adult supervision of child pedestrians, and many others must be implemented in conjunction with behavioral strategies targeting children
themselves (WHO, 2013).
Conclusion
Our results generally match those of previous nonsystematic reviews (Hotz, Kennedy, Lutfi, & Cohn, 2009;
Rothengatter, 1984; Schwebel, Davis, & O’Neal, 2012;
Stevenson & Sleet, 1996) as well as the only systematic
review previously published (Duperrex, Bunn, & Roberts,
2002; Duperrex, Roberts, & Bunn, 2002). Behavioral interventions can teach children safer pedestrian skills. Some
components of pedestrian safety appear to be more successfully taught via behavioral strategies than others, and
some intervention strategies seem to be more effective than
others. All strategies and outcomes could benefit from further research of high rigor, especially research conducted
with attention to child development, to global needs, and
to interventions that might be disseminated broadly at
low cost.
Supplementary Data
Supplementary data can be found at: http://www.jpepsy.
oxfordjournals.org/
Acknowledgments
Thanks to the following colleagues for assistance with
translation: Andrea Eckhardt (German), David Skotko
(Russian), and Zahra Tabibi (Farsi). Thanks to James
Thomson for sharing data from his 2005 manuscript.
Thanks to the Interlibrary Loan Services of University of
Alabama at Birmingham and University of Idaho for assistance in locating obscure manuscripts.
Funding
The authors were partially supported by Award Number
R01HD058573 from the Eunice Kennedy Shriver
National Institute of Child Health & Human
Development. The content is solely the responsibility of
the authors and does not necessarily represent the official
views of the Eunice Kennedy Shriver National Institute of
Child Health & Human Development or the National
Institutes of Health.
Conflict of interest: None declared.
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