Slicing Through the Layers of Pediatric Unintentional Injury With the Swiss Cheese Model: A Topical Review.

Pediatric unintentional injury significantly burdens children, families, and society. Behavioral researchers have examined the problem for decades, identifying many risk factors and greatly enhancing knowledge of the injury antecedent process. Approaches using theories and models to guide inquiry into etiology and prevention are still needed. We offer an approach borrowed from the field of human factors to enhance understanding and prevention. We focus our exploration on an error modeling and accident investigation tool called the Swiss Cheese Model. We first introduce the basic elements of the model. Next, we apply error modeling concepts to example scenarios drawn from real unintentional incidents and discuss the implications for understanding etiology and prevention. Finally, potential future directions are discussed to illustrate paths for the advancement of injury etiology and prevention.

A Risk Appraisal Framework for Injury Etiology.

Unintentional injury is a significant worldwide health concern. Researchers have called on several occasions for conceptual frameworks to guide work on unintentional injury. Using conceptual approaches to organize our inquiry is one way to advance our knowledge of injury etiology. To this end, we suggest a risk appraisal framework for examining enactment or avoidance of injury risk behaviors. Our framework comprises broad antecedents, focusing on the evaluative stage preceding behaviors. Four categories influencing efficacy related to injury risk behavior are included: environmental context, experience, social context, and strategy. In this article, we explain the categories and concepts in our framework, discuss each in terms of etiology, briefly discuss interrelations between the categories, and suggest future paths using the framework.

Why do you keep them there? A qualitative assessment of firearms storage practices.

Thousands of children are killed or injured each year in the United States after gaining access to firearms. Storage methods are inconsistent and influenced by various contextual factors in the home. We explored reasons underlying parents' choices of firearm storage. Thirty individuals were interviewed regarding firearm storage methods used in their homes and reasons for choosing those methods. Storage practices varied within and across households. Qualitative results suggested that storage practices were related to child presence and age, intended use of firearms, and perception of risk associated with potential access by unsafe individuals. Implications for injury prevention are discussed.

Systematic review and meta-analysis of behavioral interventions to improve child pedestrian safety.

OBJECTIVE: Pedestrian injuries represent a pediatric public health challenge. This systematic review/meta-analysis 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.

Predicting behavioral intentions for unsafe off-highway vehicle use.

INTRODUCTION: Hundreds of adults are killed or injured each year while operating off-highway vehicles. Four common risk-taking behaviors were identified on off-highway vehicles in the literature and examined intention to engage in such behaviors within the context of the Theory of Planned Behavior. METHOD: One hundred and sixty-one adults completed measures of experience on off-highway vehicles and injury exposure followed by a self-report created according to the predictive structure of the Theory of Planned Behavior. Behavioral intentions to engage in the four common injury risk behaviors on off-highway vehicles were predicted. RESULTS: Similar to research on other risk behaviors, perceived behavioral control and attitudes emerged as consistently significant predictors. Subjective norms, the number of vehicles operated, and injury exposure showed varying relationships to the four injury risk behaviors. Results are discussed in the context of similar studies, intrapersonal predictors of injury risk behaviors, and with regard to implications for injury prevention efforts.

The impact of artificial vehicle sounds for pedestrians on driver stress.

Electrically based vehicles have produced some concern over their lack of sound, but the impact of artificial sounds now being implemented have not been examined in respect to their effects upon the driver. The impact of two different implementations of vehicle sound on driver stress in electric vehicles was examined. A Nissan HEV running in electric vehicle mode was driven by participants in an area of congestion using three sound implementations: (1) no artificial sounds, (2) manually engaged sounds and (3) automatically engaged sounds. Physiological and self-report questionnaire measures were collected to determine stress and acceptance of the automated sound protocol. Driver stress was significantly higher in the manually activated warning condition, compared to both no artificial sounds and automatically engaged sounds. Implications for automation usage and measurement methods are discussed and future research directions suggested. PRACTITIONER SUMMARY: The advent of hybrid- and all-electric vehicles has created a need for artificial warning signals for pedestrian safety that place task demands on drivers. We investigated drivers' stress differences in response to varying conditions of warning signals for pedestrians. Driver stress was lower when noises were automated.

BASE: Pragmatic Injury Prevention for Practitioners.

Unintentional injury remains a leading health problem in developed nations, making injury prevention imperative. Practitioners are primary stakeholders in the injury prevention process but rarely can devote significant time to complicated prevention efforts. Furthermore, theory-based approaches to support injury prevention are less common than atheoretical approaches. We propose a simple method for injury prevention grounded in concepts found in antecedent models. Barriers, attitudes, social context, and environmental factors (or BASE) are suggested as a simple injury prevention model practitioners can follow when working with patients. We present each component of BASE and offer examples of how the approach can be applied to risk factors associated with several types of injury risk behavior.

Assessing pedestrian safety across modalities via a simulated vehicle time-to-arrival task.

Pedestrians must use a variety of visual and auditory cues when determining safe crossing opportunities. Although vision has received a bulk of the attention in research on pedestrian safety, the examination of both vision and audition are important to consider. Environmental, intrapersonal, and cognitive qualities of a pedestrian context may limit the use of one or both perceptual modalities. Across two experiments, we examined the impact of perceptual constraints on pedestrian safety by measuring the accuracy of vehicle time-to-arrival estimates in a virtual environment when vehicles were only visible, only audible, or both visible and audible. In both experiments, participants estimated the time-to-arrival of vehicles moving at one of two speeds (8-kph, 40-kph). In the second experiment, we introduced ambient traffic noises to examine the impact of environmentally relevant traffic noises on pedestrian perception. Results suggest seeing a vehicle is more advantageous than hearing a vehicle when interacting with traffic, especially in the presence of ambient sound. Both experiments resulted in more accurate time-to-arrival estimates in the visual and mixed conditions than in the auditory-only condition. Implications for pedestrian safety and future research are discussed.

Developmental Aspects of Unintentional Injury Prevention Among Youth: Implications for Practice.

Unintentional injuries, the leading cause of morbidity and mortality among youth in the United States, are burdensome and costly to society. Continued prevention efforts to reduce rates of unintentional injury remain imperative. We emphasized the role of practitioner influence across a linear concept of injury prevention comprising delivery, practice, and application/generalization and within the context of child developmental factors. Specific strategies for injury prevention tailored to the cognitive development stage of the patient are provided. This information may be useful to health care practitioners, who have significant interaction with youth and their families.

Individual difference factors in risky driving among older adults.

INTRODUCTION: Motor-vehicle crashes kill roughly 4,500 American adults over the age of 75 annually. Among younger adults, one behavioral factor consistently linked to risky driving is personality, but this predictor has been overshadowed by research on cognitive, perceptual, and motor processes among older drivers. METHOD: In this study, a sample of 101 licensed drivers, all age 75 and over, were recruited to complete self-report measures on personality, temperament, and driving history. Participants also completed a virtual environment (VE) course designed to assess risk-taking driving behavior. State records of motor-vehicle crashes were collected. RESULTS: Results suggest both a sensation-seeking personality and an undercontrolled temperament are related to risky driving among older adults. Sensation-seeking was particularly related to history of violations and tickets, while temperamental control was more broadly related to a number of risky driving measures. Methodological and crash prevention issues are discussed.

Effects of secondary tasks on auditory detection and crossing thresholds in relation to approaching vehicle noises.

Research suggests an association between distracting environmental sound stimuli and poorer performance in detecting and localizing approaching vehicles using auditory cues. However, no studies have investigated the distractive potential posed by intrapersonal distractors in the context of pedestrian auditory perception. We examined the effects of holding naturalistic vocal and texting cell phone conversations on participants' auditory detection of approaching vehicles and crossing thresholds in a non-visual simulated setting. Ninety-nine adults were randomly assigned to conditions of vocal conversation, texting conversation, or a control group and completed an auditory vehicle detection task. Participants in the vocal cell phone conversation group detected vehicles at significantly shorter distances than participants in the control group. The concurrence of a secondary task did not affect the distances at which participants deemed vehicles noise too close for them to safely cross (i.e., crossing thresholds). Implications for future research and injury prevention are discussed.

Detection and Direction Determination of Approaching Vehicle Noises Among Older Adults.

We examined detection and direction determination of auditory cues from a pedestrian environment among a sample of older and younger adults. Review of relevant research suggests normal aging is associated with declines in physical, cognitive, and perceptual abilities. Relatively, few studies have examined the impact of such developmental changes on pedestrian safety among older adults, and none have examined such factors in relation to use of auditory cues. Thirty-five younger and 35 older adults completed cognitive measures and a pedestrian auditory detection task. Some results by speed were similar to past research that examined younger samples. Interactions were discovered between age and speed conditions within the auditory task. Results are discussed in the context of past research and with regard to informing future injury prevention efforts.

Developmental differences in auditory detection and localization of approaching vehicles.

Pedestrian safety is a significant problem in the United States, with thousands being injured each year. Multiple risk factors exist, but one poorly understood factor is pedestrians' ability to attend to vehicles using auditory cues. Auditory information in the pedestrian setting is increasing in importance with the growing number of quieter hybrid and all-electric vehicles on America's roadways that do not emit sound cues pedestrians expect from an approaching vehicle. Our study explored developmental differences in pedestrians' detection and localization of approaching vehicles. Fifty children ages 6-9 years, and 35 adults participated. Participants' performance varied significantly by age, and with increasing speed and direction of the vehicle's approach. Results underscore the importance of understanding children's and adults' use of auditory cues for pedestrian safety and highlight the need for further research.

The roles of child, parent and environmental factors in pedestrian supervision.

Pedestrian injuries are a significant health risk to children, particularly those 5-9 years of age. Surprisingly, few studies have explored parent-related factors that may moderate this risk. We examined parental supervision choices in the context of child pedestrian experience, parent perceptual factors and varying levels of environmental risk. A series of street crossing scenarios were used to examine the roles of child, parent and environmental factors in determining parents' supervision choices. Parents recognised differing levels of risk across environmental conditions and altered their supervision choices accordingly. Child age and parental risk perception were significantly predictive of supervision choices. Our results demonstrate that parents assess multiple factors when determining the intensity of supervision necessary for their children. Notably, parents adjust their supervision in direct relation to changes in the physical environment. Implications of these findings for injury prevention and future research are discussed.

Auditory detection and localization of approaching vehicles.

Pedestrians must use a variety of cues when making safe decisions, many of which require processing of auditory information. We examined detection and localization of approaching vehicles using auditory cues. 50 adults ages 18-49 were presented with actual sounds of vehicles approaching at 5, 12, 25, and 35 mph. Three indices were of interest: the distance at which vehicles were detected, participants' decision regarding the direction from which vehicles were approaching, and their determination of the vehicles' arrival at their location. Participants more easily detected vehicles moving at higher speeds and vehicles approaching from the right. Determination of the direction of approach reached 90% accuracy or better when vehicles were traveling at, or greater than, 12 mph, and were more approaching from the right. Determination of vehicle arrival deteriorated significantly as speeds increased. Implications of the use of auditory cues in pedestrian settings, and future directions, are discussed.

Examining the impact of traffic environment and executive functioning on children's pedestrian behaviors.

The process of integrating visual information and planning a safe crossing is cognitively demanding for many young children. We assessed relations between traffic characteristics, aspects of children's executive functioning (EF), and pedestrian behavior, with the aim being to determine whether well-developed EF would predict safer pedestrian behaviors beyond the contributions of child demographic and traffic environment factors. Using the pretend road method, we studied a sample of 83 children aged 6-9 in a series of 5 crossing trials beside a real road in response to actual traffic conditions. Traffic characteristics and pedestrian behaviors were observed and measured across crossing trials. Both traffic characteristics and EF, most notably cognitive efficiency, were strongly related to children's pedestrian crossing behaviors. Traffic characteristics were also found to interact with children's ability to monitor their crossing performance. Examining developmental influences in pedestrian injury etiology broadens researchers' knowledge of and ability to prevent injuries by moving beyond describing what happens to children and examining why pedestrian injuries occur.

Development of the BACKIE questionnaire: a measure of children's behaviors, attitudes, cognitions, knowledge, and injury experiences.

OBJECTIVE: The objective of this study was to develop a standardized questionnaire (BACKIE) that would assess the Behaviors (B), Attitudes (A), Cognitions (C), Knowledge (K), and Injury Experiences (IE) that elementary-school children possess pertaining to seven types of injuries, including: falls; motor vehicle collisions; burns; drowning; choking/suffocation; poisoning; and bicycle/pedestrian injuries. METHODS: Over 500 children in grades two through seven completed the questionnaire, with a sub-sample repeating it two months later to assess test-retest reliability of the measure. RESULTS: Psychometric assessment of the instrument revealed acceptable internal and test-retest reliabilities and results of a Confirmatory Factor Analysis provided support for the hypothesized factor structure. CONCLUSION: Having a psychometrically sound measure that allows one to assess attitudes, cognitions, and knowledge is an essential first step to exploring the relative influence of these factors on children's risk and safety practices.

Child pedestrian safety: parental supervision, modeling behaviors, and beliefs about child pedestrian competence.

Pedestrian injuries are a significant health risk to children, particularly those 5-9 years of age. Surprisingly, few studies have explored parent-related factors that may moderate this risk. The present study used naturalistic observations of parent-child pairs crossing at uncontrolled intersections and a short interview to examine parental supervision of children during crossings, modeling of safe-crossing behaviors, beliefs about how children come to cross streets safely, and whether child attributes (age, sex) relate to parental practices and beliefs. Results revealed that parents more closely supervised younger than older children, they modeled safer crossing practices for sons more than daughters, particularly younger sons, and although over half the sample believed children need to be explicitly taught how to cross safely, few actually provided any instruction when crossing with their children. Providing parents both with guidelines for how to accurately appraise their child's readiness for crossing independently and with information about best practices for teaching children how to cross safely may facilitate parents' implementing these practices, particularly if this is coupled with public advocacy highlighting the important role they could play to reduce the risk of child pedestrian injury.

The influences of demographics and individual differences on children's selection of risky pedestrian routes.

OBJECTIVE: Thousands of American children under the age of 10 are injured annually as pedestrians. Despite the scope of this public health problem, knowledge about behavioral factors involved in the etiology of child pedestrian injury remains sparse. The present study considered the roles of age, gender, ethnicity, family income, and inhibitory control on children's selection of safe pedestrian routes. METHODS: Children's selections of risky pedestrian routes were examined in two laboratory analogue tasks. Multiple behavioral and self-report methods were used to measure temperamental inhibitory control. RESULTS: Children from lower-income families, children of ethnic minority background, younger children, and those with less temperamental control selected riskier pedestrian routes. CONCLUSIONS: Prevention efforts might be tailored to focus on children at higher risk for pedestrian injury, such as younger, under-controlled children.

The roles of age, gender, inhibitory control, and parental supervision in children's pedestrian safety.

OBJECTIVE: Thousands of American children are injured or killed each year as pedestrians, but behavioral factors in pedestrian injury etiology remain poorly understood. We examined the roles of children's individual differences (age, gender, and inhibitory control) and parental supervision in children's pedestrian behaviors. METHODS: Using the pretend road method, a sample of 85 children and 26 adults crossed a pretend crosswalk set adjacent to a real road. Safety of crossing the pretend road was determined based on actual traffic on the real road. Adults also crossed the real road. RESULTS: Adults' behavior on the real road paralleled that on the pretend road, supporting validity of the method. On the pretend road, younger children, boys, and children with less behavioral control engaged in riskier pedestrian behaviors. Children with less behavioral control responded more noticeably to increases in parental supervision. CONCLUSION: Results are discussed in relation to children's development and injury prevention.