Behaviour of motorcyclists and bicyclists before and after a road safety campaign, China.

Objective: To examine changes in red-light running and distracted riding among motorcyclists and cyclists before and after the 2020 implementation of the One Helmet, One Seatbelt campaign in China. Methods: We obtained 192 hours of film before (2019) and after (2021) implementation of the campaign in eight road intersections in Changsha. We calculated percentages and ratios of red-light running and distracted riding. To assess the associations between these traffic behaviours and the campaign, we used multivariable logistic regression models to calculate adjusted odds ratios (aOR). Findings: We filmed 5256 motorcyclists and cyclists in 2019 and 6269 in 2021. Red-light running decreased from 45.1% to 41.5% during this period (ratio: 0.92; 95% confidence interval, CI: 0.88-0.96), while distracted riding increased from 3.5% to 5.0% (ratio: 1.42; 95% CI: 1.19-1.69). After adjusting for covariates, male riders were more likely to run a red light compared to female riders (aOR: 1.28; 95% CI: 1.06-1.55). Red-light running was also more likely among electric bicycle riders (aOR: 1.46; 95% CI: 1.10-1.95) and motorcyclists (aOR: 1.47; 95% CI: 1.13-1.90) compared to traditional cyclists. All types of riders were less prone to run a red light during peak hours than off-peak hours (aOR: 0.85; 95% CI: 0.73-0.99). Distracted riding was more common on weekends compared to weekdays (aOR: 3.01; 95% CI: 2.02-4.49). Conclusion: China's national road safety campaign, which focuses on helmet and seatbelt use, was associated with reduced red-light running. Strict enforcement and targeted modifications could improve the campaign's effectiveness.

Superhero Pretense, Superhero Identification, and Risk-Taking in Preschool-Aged Children.

OBJECTIVE: The preschool years represent a stage of rapid human development, hallmarked by exploring the environment through gross and fine motor movement and imaginative pretend play. This exploration is developmentally appropriate but also presents risks for injury, the leading cause of death for preschool-aged children. Common injuries reflect exploration and risk-taking exhibited during play, and play may be particularly risky when children imitate risky models like superheroes. Frequent exposure and subsequent identification with superheroes are concerning because the media glorifies superheroes, creating social learning effects on children and promoting play situations where children may attempt superhuman abilities and hurt themselves. This study examined the relations between pretend play, superhero identification, and children's risk-taking. METHODS: One hundred five children aged 4-5 years old were randomly assigned to either a superhero- or school-themed, story-based protocol. In both conditions, children engaged in three identical behavioral tasks to assess risk-taking. Identification with superheroes was measured using parent-report questionnaires and child interviews. RESULTS: Pretending to be a superhero was not associated with increased risk-taking behavior acutely, but identification with superheroes was associated in some analyses with preschool children's broader risk-taking behavior. Across risk-taking behavior tasks, children with high superhero identification pretending to be superheroes tended to take the most risks. CONCLUSIONS: Given the popularity of superhero media and the present results suggesting superhero identification may relate to injury-risk situations during play, prevention efforts should consider ways to reduce young children's exposure to superheroes and/or mitigate injury risk during active pretend play.

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.

Unintentional firearms mortality disparities across states-USA, 2001-2021.

BACKGROUND: Firearms kill over 130 Americans daily. Most deaths are the result of intentional acts, but in 2021, 549 deaths (1.5 deaths/day) were unintentional. Strategies to prevent unintentional versus intentional firearms deaths differ. This study describes unintentional firearm-related mortality across the US states and within individual states between 2001 and 2021 and considers factors that might explain disparities across states. METHODS: Unintentional firearms mortality from 2001 to 2021, both for the full country and by state, was obtained online along with data for five state-level predictors: rurality, non-white population, poverty, population and gun ownership. RESULTS: The highest unintentional firearm-related mortality rates clustered in Southeastern states, followed by states in the Northern Plains and Mountain West. The lowest rates were in the Northeast, followed by scattered states in the West and Midwest. At the state level, unintentional firearms mortality correlated positively with per cent below the poverty level (r=0.54, p<0.01), rural (r=0.59, p<0.01) and owning firearms (r=0.72, p<0.01). In a multivariable regression model predicting unintentional firearms mortality by state, three factors emerged as significant: per cent white (ß=-0.22, p<0.05), below the poverty level (ß=0.43, p<0.01) and owning firearms (ß=0.54, p<0.01). CONCLUSIONS: Large disparities exist across the 50 US states in unintentional firearms mortality. Crude rates in the most afflicted states are ~10 times those in the least afflicted states. Nationwide, over 12 000 lives were lost to unintentional firearms mortality between 2001 and 2021. Factors that create disparities are multifaceted and include rurality, poverty and firearms ownership.

Validity across four common street-crossing distraction indicators to predict pedestrian safety.

BACKGROUND: Multiple distraction indicators have been applied to measure street-crossing distraction but their validities in predicting pedestrian safety are poorly understood. METHODS: Based on a video-based observational study, we compared the validity of four commonly used distraction indicators (total duration of distraction while crossing a street, proportion of distracted time over total street-crossing time, duration of the longest distraction time, and total number of distractions) in predicting three pedestrian safety outcomes (near-crash incidence, frequency of looking left and right, and speed crossing the street) across three types of distraction (mobile phone use, talking to other pedestrians, eating/drinking/smoking). Change in Harrell's C statistic was calculated to assess the validity of each distraction indicator based on multivariable regression models including only covariates and including both covariates and the distraction indicator. RESULTS: Heterogeneous capacities in predicting the three safety outcomes across the four distraction indicators were observed: 1) duration of the longest distraction time was most predictive for the occurrence of near-crashes and looks left and right among pedestrians with all three types of distraction combined and talking with other pedestrians (Harrell's C statistic changes ranged from 0.0310 to 0.0335, P < 0.05), and for the occurrence of near-crashes for pedestrians involving mobile phone use (Harrell's C statistic change: 0.0053); 2) total duration of distraction was most predictive for speed crossing the street among pedestrians with the combination and each of the three types of distraction (Harrell's C statistic changes ranged from 0.0037 to 0.0111, P < 0.05), frequency of looking left and right among pedestrians distracted by mobile phone use (Harrell's C statistic change: 0.0115), and the occurrence of near-crash among pedestrians eating, drinking, or smoking (Harrell's C statistic change: 0.0119); and 3) the total number of distractions was the most predictive indicator of frequency of looking left and right among pedestrians eating, drinking, or smoking (Harrell's C statistic change: 0.0013). Sensitivity analyses showed the results were robust to change in grouping criteria of the four distraction indicators. CONCLUSIONS: Future research should consider the pedestrian safety outcomes and type of distractions to select the best distraction indicator.

The more peers are present, the more adventurous? How peer presence influences adolescent pedestrian safety.

Objective: Adolescence is a high-risk period for traffic injury. One factor that may impact adolescent safety in traffic is the presence of peers. We conducted a quasi-experimental research study to examine the impact of peer presence, peer familiarity, and peer group size on adolescent pedestrian risk-taking intentions in both sidewalk and street-crossing settings. Methods: 607 students aged 12-18 years from Nantong city, China, completed a questionnaire that presented 20 traffic scenarios. The scenarios varied based on a 3 (peer group size: no peer vs. one peer vs. multiple peers) x 2 (peer familiarity: familiar vs. unfamiliar) x 2 (traffic setting: crossing the street vs. walking on the roadside) experimental design. Adolescents' responses indicated safer vs riskier intentions in each situation. Results: Results found that: (1) Adolescents were safer when walking on the sidewalk than when crossing the street; (2) Whether crossing the street or walking on the sidewalk, adolescents' behavioral intentions were safer when there were peers present than when there were no peers present; (3) Adolescents' safety tended to be higher overall with unfamiliar peers than with familiar peers; (4) Adolescents were less safe when crossing the street with familiar peer(s) than with unfamiliar peer(s), but no differences emerged when walking on the sidewalk. Conclusions: Adolescents report safer behavior when walking with a peer or peers compared with walking alone. Familiar peers reduce adolescents' safety of behavior intentions in traffic, especially when crossing the street.

Road traffic death coding quality in the WHO Mortality Database.

Objective: To evaluate the precision and dependability of road traffic mortality data recorded in the World Health Organization Mortality Database and investigate how uncorrected data influence vital mortality statistics used in traffic safety programmes worldwide. Methods: We assessed country and territory-specific data quality from 2015 to 2020 by calculating the proportions of five types of nonspecific cause of death codes related to road traffic mortality. We compared age-adjusted road traffic mortality and changes in the average annual mortality rate before and after correcting the deaths with nonspecific codes. We generated road traffic mortality projections with both corrected and uncorrected codes, and redistributed the data using the proportionate method. Findings: We analysed data from 124 countries and territories with at least one year of mortality data from 2015 to 2020. The number of countries and territories reporting more than 20% of deaths with ill-defined or unknown cause was 2; countries reporting injury deaths with undetermined intent was 3; countries reporting unspecified unintentional injury deaths was 21; countries reporting unspecified transport crash deaths was 3; and countries reporting unspecified unintentional road traffic deaths was 30. After redistributing deaths with nonspecific codes, road traffic mortality changed by greater than 50% in 7% (5/73) to 18% (9/51) of countries and territories. Conclusion: Nonspecific codes led to inaccurate mortality estimates in many countries. We recommend that injury researchers and policy-makers acknowledge the potential pitfalls of relying on raw or uncorrected road traffic mortality data and instead use corrected data to ensure more accurate estimates when improving road traffic safety programmes.

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

OBJECTIVE: Over 7,000 American children die from pedestrian injuries annually, and pedestrian injury ranks among the top 5 causes of unintentional child death. Prevention efforts are multifaceted. One strategy, use of virtual reality (VR) to teach children to cross streets, is of growing interest to public health practitioners. The present study is a systematic review and meta-analysis that examined the efficacy of using VR to teach children pedestrian safety. METHODS: Following PRISMA guidelines, searches among 7 databases were completed, followed by abstract/full-text screening and data extraction. Hedge's g was computed for the effect sizes of 3 outcomes: pedestrian knowledge, pedestrian-relevant cognition (attention to traffic, time to contact, start delay), and pedestrian behaviors (safe crossings, unsafe crossings). Risk of bias was assessed using Cochrane guidelines. Meta-regression analyses and subgroup analyses were conducted including 3 moderators: age, sex, and immersion level. RESULTS: A total of 20 studies, reported in 24 articles, were included in the qualitative analysis. Meta-analysis of the 12 studies with sufficient quantitative data available showed a statistically significant medium effect of VR safety interventions on child pedestrian knowledge and behavior. Mixed results emerged for the effect of VR safety interventions on children's pedestrian-relevant cognition. Age and sex moderated the effect of VR training on pedestrian knowledge. CONCLUSIONS: This synthesis of the literature on pediatric VR pedestrian safety interventions suggests an overall beneficial impact of VR interventions to teach children how to cross streets safely. Efforts should continue to develop and disseminate effective VR interventions. REGISTRATION ID: CRD42022309352.

Cost-benefit analysis of a distracted pedestrian intervention.

OBJECTIVE: Cellphone ubiquity has increased distracted pedestrian behaviour and contributed to growing pedestrian injury rates. A major barrier to large-scale implementation of prevention programmes is unavailable information on potential monetary benefits. We evaluated net economic societal benefits of StreetBit, a programme that reduces distracted pedestrian behaviour by sending warnings from intersection-installed Bluetooth beacons to distracted pedestrians' smartphones. METHODS: Three data sources were used as follows: (1) fatal, severe, non-severe pedestrian injury rates from Alabama's electronic crash reporting system; (2) expected costs per fatal, severe, non-severe pedestrian injury-including medical cost, value of statistical life, work-loss cost, quality-of-life cost-from CDC and (3) prevalence of distracted walking from extant literature. We computed and compared estimated monetary costs of distracted walking in Alabama and monetary benefits from implementing StreetBit to reduce pedestrian injuries at intersections. RESULTS: Over 2019-2021, Alabama recorded an annual average of 31 fatal, 83 severe and 115 non-severe pedestrian injuries in intersections. Expected costs/injury were US$11 million, US$339 535 and US$93 877, respectively. The estimated distracted walking prevalence is 25%-40%, and StreetBit demonstrates 19.1% (95% CI 1.6% to 36.0%) reduction. These figures demonstrate potential annual cost savings from using interventions like StreetBit statewide ranging from US$18.1 to US$29 million. Potential costs range from US$3 208 600 (beacons at every-fourth urban intersection) to US$6 359 200 (every other intersection). CONCLUSIONS: Even under the most parsimonious scenario (25% distracted pedestrians; densest beacon placement), StreetBit yields US$11.8 million estimated net annual benefit to society. Existing data sources can be leveraged to predict net monetary benefits of distracted pedestrian interventions like StreetBit and facilitate large-scale intervention adoption.

Value of the short physical performance battery (SPPB) in predicting fall and fall-induced injury among old Chinese adults.

BACKGROUND: The short physical performance battery (SPPB) is an easy-to-use tool for fall risk prediction, but its predictive value for falls and fall-induced injuries among community dwellers has not been examined through a large-sample longitudinal study. METHODS: We analyzed five-round follow-up data (2, 3, 4, 5, 7 years) of the China Health and Retirement Longitudinal Study (CHARLS) (2011-2018). Data concerning falls and fall-induced injuries during multi-round follow-ups were collected through participant self-report. The Cochran-Armitage trend test examined trends in fall incidence rate across SPPB performance levels. Multivariable logistic regression and negative binomial regression models examined associations between SPPB performance and subsequent fall and fall-induced injury. The goodness-of-fit and area under the receiver operating curve (AUC) were used together to quantify the value of the SPPB in predicting fall and fall-induced injury among community-dwelling older adults. RESULTS: The CHARLS study included 9279, 6153, 4142, 4148, and 3583 eligible adults aged 60 years and older in the five included follow-up time periods. SPPB performance was associated with fall and fall-induced injury in two and three of the five follow-up time periods, respectively (P < 0.05). The goodness-of-fit for all predictive models was poor, with both Cox-Snell R2 and Nagelkerke R2 under 0.10 and AUCs of 0.53-0.57 when using only SPPB as a predictor and with both Cox-Snell R2 and Nagelkerke R2 lower than 0.12 and AUCs of 0.61-0.67 when using SPPB, demographic variables, and self-reported health conditions as predictors together. Sex and age-specific analyses displayed highly similar results. CONCLUSIONS: Neither use of SPPB alone nor SPPB together with demographic variables and self-reported health conditions appears to offer good predictive performance for falls or fall-induced injuries among community-dwelling older Chinese adults.

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

BACKGROUND: Interactive and experiential learning programs have proven effective to teach children safety and prevent child unintentional injury. However, previously-published programs were designed primarily to address safety concerns of children living in urban, well-resourced areas, and therefore might be less effective or economically infeasible to distribute to children in resource-limited areas, such as those living in rural areas or underdeveloped regions. This proposed study will evaluate the effectiveness of teaching children safety lessons to rural preschoolers in China through the preschool-based Safety Experience Room intervention that was developed based on relevant theories, the lessons of previous intervention research, the characteristics of child injuries in underdeveloped rural areas, and the needs and circumstances of rural families and preschools in China. The study will also evaluate the cost-effectiveness of delivering the program. METHODS AND ANALYSIS: A single-blinded, 12-month follow-up, parallel-group cluster randomized controlled trial with a 1:1 allocation ratio will be implemented in two selected counties. In total, at least 2378 rural preschoolers aged 3-6 years old will be recruited from 12 preschools, 6 in Yang County and 6 in Shicheng County. Clusters will be randomized at the preschool level and allocated to the control group (routine school-based education) or the intervention group (routine school-based education plus the Safety Experience Room education). External support strategies will be implemented by local partners to minimize attrition. Data collection will be conducted at baseline and then every 3 months during a 12-month follow-up time period. Intention-to-treat (ITT) data analysis will be used. Generalized estimation equations (GEE) will evaluate the effectiveness of the program and generalized cost-effectiveness analysis (GCEA) will evaluate the cost-effectiveness of it. A per-protocol (PP) sensitivity analysis will assess the robustness of ITT results. Subgroup analyses will be performed to evaluate the impact of socio-demographic factors on the intervention effect, following the same strategies as the primary analyses. DISCUSSION: The newly-designed Safety Experience Room program is expected to be feasible, effective, and financially beneficial. If these hypotheses prove true, we will take steps to disseminate the program to rural preschools across China. TRIAL REGISTRATION: Chinese Clinical Trial Registry ( http://www.chictr.org.cn ), CHiCTR2000038025, registered on 8 September 2020.

Content Quality of Web-Based Short-Form Videos for Fire and Burn Prevention in China: Content Analysis.

BACKGROUND: Web-based short-form videos are increasingly popular for disseminating fire and burn prevention information, but their content quality is unknown. OBJECTIVE: We aimed to systematically assess the characteristics, content quality, and public impact of web-based short-form videos offering primary and secondary (first aid) prevention recommendations for fires and burns in China between 2018 and 2021. METHODS: We retrieved short-form videos offering both primary and secondary (first aid) information to prevent fire and burn injuries published on the 3 most popular web-based short-form video platforms in China: TikTok, Kwai, and Bilibili. To assess video content quality, we calculated the proportion of short-form videos that included information on each of the 15 recommendations for burn prevention education from the World Health Organization (WHO; P1) and that correctly disseminated each recommendation (P2). High P1 and P2 indicated better content quality. To assess their public impact, we calculated the median (IQR) of 3 indicators: the number of comments, likes, and saves as a favorite by viewers. Chi-square test, trend chi-square test, and Kruskal-Wallis H test examined differences in indicators across the 3 platforms, years, content, and time duration of videos and between videos disseminating correct versus incorrect information. RESULTS: Overall, 1459 eligible short-form videos were included. The number of short-form videos increased by 16 times between 2018 and 2021. Of them, 93.97% (n=1371) were about secondary prevention (first aid) and 86.02% (n=1255) lasted <2 minutes. The proportion of short-form videos including each of the 15 WHO recommendations ranged from 0% to 77.86% (n=1136). Recommendations 8, 13, and 11 had the highest proportions (n=1136, 77.86%; n=827, 56.68%; and n=801, 54.9%, respectively), whereas recommendations 3 and 5 were never mentioned. Among the short-form videos that included the WHO recommendations, recommendations 1, 2, 4, 6, 9, and 12 were always disseminated correctly, but the other 9 recommendations were correctly disseminated in 59.11% (120/203) to 98.68% (1121/1136) of videos. The proportion of short-form videos including and correctly disseminating the WHO recommendations varied across platforms and years. The public impact of short videos varied greatly across videos, with a median (IQR) of 5 (0-34) comments, 62 (7-841) likes, and 4 (0-27) saves as a favorite. Short-form videos disseminating correct recommendations had larger public impact than those disseminating either partially correct or incorrect knowledge (median 5 vs 4 comments, 68 vs 51 likes, and 5 vs 3 saves as a favorite, respectively; all P<.05). CONCLUSIONS: Despite the rapid increase in the number of web-based short-form videos about fire and burn prevention available in China, their content quality and public impact were generally low. Systematic efforts are recommended to improve the content quality and public impact of short-form videos on injury prevention topics such as fire and burn prevention.

Effectiveness of a helmet promotion campaign, China.

Objective: To evaluate the effectiveness of a 2020 nationwide helmet promotion campaign, in terms of helmet wearing and correct helmet wearing, aimed at electric bike riders and motorcyclists in China. Methods: We obtained 192 hours of film of traffic before (2019) and after (2021) implementation of the campaign at eight road intersections in Changsha, recording cyclist (traditional and electric) and motorcyclist helmet-wearing behaviour during both weekdays and the weekend, and peak and off-peak traffic. We extracted data on rider characteristics and helmet-wearing behaviour. We applied a logistic regression to obtain estimates of helmet wearing and correct helmet wearing, and calculated odds ratios adjusted for rider variables. Findings: We filmed 11 525 cyclists and motorcyclists, 5256 (45.6%) before and 6269 (54.4%) after the campaign. We estimated a substantial increase in the overall percentage of helmet wearing from 8.8% (95% confidence interval, CI: 8.0-9.6) to 62.0% (95% CI: 60.8-63.2). After controlling for covariates, we noted that helmet wearing increased in all groups. However, we observed a decrease in the overall percentage of correct helmet wearing from 91.9% (95% CI: 89.4-94.3) to 83.5% (95% CI: 82.3-84.7). Post-campaign, we estimated the highest percentage of helmet wearing for delivery riders (88.8%) and lowest for traditional cyclists (3.8%); we estimated the lowest percentage of correct helmet wearing for three-wheeled motorcyclists (58.8%). Conclusion: To increase helmet wearing and correct helmet wearing, we recommend amending the campaign to include traditional cyclists as well as education and legislation on the correct fastening of helmet chinstraps.

Coding quality of deaths and its impact on elderly unintentional fall mortality data from 1990 to 2019: a retrospective analysis of the WHO Mortality Database.

BACKGROUND: Several studies have assessed the reporting quality of all-cause mortality data from the WHO Mortality Database, but little is known about coding quality and its impact on elderly unintentional fall mortality data worldwide. We aimed to assess the coding quality of deaths and its impact on elderly unintentional fall mortality. METHODS: Using data from the WHO Mortality Database, 1990-2019, we calculated the number of countries/territories that had mortality data in the database, and the proportion of deaths with five types of problematic codes based on the 10th International Classification of Disease (unspecified deaths, injury deaths with undetermined intent, unspecified unintentional injury, unintentional falls with unspecified mechanism, unintentional falls with unknown occurrence place). We estimated age-adjusted unintentional fall mortality before and after correcting problematic codes. RESULTS: Only 64% (124/194) of WHO member states had at least 1 year of mortality data in the database during 1990-2019, and data unavailability was more common for underdeveloped countries/territories than for developed countries/territories. Coding quality was poor for many countries/territories. Among the study years when countries/territories possessed mortality data, 80, 53, 51, and 63% had a proportion of unintentional fall deaths with unspecified mechanism over 50% in low-income, lower middle-income, upper middle-income, and high-income countries/territories, respectively; comparable proportions for unintentional fall deaths with unknown occurrence place were 100, 42, 71, and 62%. Among the 94 countries/territories having mortality data, problematic codes caused a relative mortality difference ≥ 50% in 59 countries/territories (63%). After correcting problematic codes, 5 of 55 countries/territories with data witnessed a reverse in mortality changes between 2005 and 2015. Among the 82 countries/territories with mortality data for 5 or more years, 18 countries/territories (22%) experienced a directional reverse in linear regression coefficient. CONCLUSIONS: The availability and coding quality of global data related to elderly unintentional fall mortality was poor between 1990 and 2019. When data are available, varying coding quality across countries/territories and over time have a substantial impact on mortality estimates and mortality comparisons. Global agencies plus each individual government should be aware of the importance of collecting and sharing high-quality mortality data, and take action to improve data quality for inclusion in the WHO Mortality Database.

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

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

Short- and Long-Term Effects of Superhero Media on Young Children's Risk-Taking Behaviors.

OBJECTIVE: Unintentional injuries, the leading cause of death for American children, are caused by a range of psychosocial factors, including risk behavior. One factor that may impact child risk-taking is modeling of superhuman risk-taking from superhero media, both immediately following superhero exposure and based on lifetime exposure and engagement. METHODS: Fifty-nine 5-year-olds were randomly assigned to view either a 13-min age-appropriate superhero television show or a comparable nonsuperhero show. After the viewing, children engaged in three risk-taking measures: (a) activity room, unsupervised play for 5 min with assortment of apparently dangerous items that might encourage child risk-taking; (b) picture sort, 10 illustrations of children in risk situations, with participant response concerning intended risk-taking in that situation; and (c) vignettes, 10 stories presenting situations with varying degrees of risk, with participant response on intended choice. Parents completed questionnaires concerning children's long-term superhero media exposure and individual superhero engagement (e.g., if child's most recent Halloween costume was of a superhero). Correlations and regressions evaluated effects of immediate superhero exposure, lifetime superhero exposure, and lifetime superhero engagement on children's risk-taking. RESULTS: Mixed results emerged. Lifetime superhero exposure was significantly related to children's risk-taking outcomes in two bivariate (vignettes and picture sort) and one multivariate (picture sort) model. Neither immediate superhero exposure nor lifetime superhero engagement was strongly related to risk-taking. CONCLUSIONS: Children's lifetime superhero exposure may influence children's risk-taking. Given American children's substantial media exposure, research should continue to unpack the role of superhero media on children's unintentional injury and other health risk behaviors.

Sex-specific and age-specific suicide mortality by method in 58 countries between 2000 and 2015.

OBJECTIVE: To examine recent changes in sex-specific and age-specific suicide mortality by method across countries. METHODS: Using mortality data from the WHO mortality database, we compared sex-specific, age-specific and country-specific suicide mortality by method between 2000 and 2015. We considered seven major suicide methods: poisoning by pesticides, all other poisoning, firearms and explosives, hanging, jumping from height, drowning and other methods. Changes in suicide mortality were quantified using negative binomial models among three age groups (15-44 years, 45-64 years, and 65 years and above) for males and females separately. RESULTS: Suicide mortality declined substantially for both sexes and all three age groups studied in 37 of the 58 included countries between 2000 and 2015. Males consistently had much higher suicide mortality rates than females in all 58 countries. Hanging was the most common suicide method in the majority of 58 countries. Sex-specific suicide mortality varied across 58 countries significantly for all three age groups. The spectrum of suicide method generally remained stable for 28 of 58 included countries; notable changes occurred in the other 30 countries, including especially Colombia, Finland and Trinidad and Tobago. CONCLUSION: Likely as a result of prevention efforts as well as sociodemographic changes, suicide mortality decreased substantially in 37 of the included 58 countries between 2000 and 2015. Further actions are needed to explore specific drivers of the recent changes (particularly for increases in eight countries), to understand substantial disparities in suicide rates across countries, and to develop interventions to reduce suicide rates globally.

Disability-adjusted life years associated with population ageing in China, 1990-2017.

BACKGROUND: The Chinese population has aged significantly in the last few decades. Comprehensive health losses including both fatal and non-fatal health outcomes associated with ageing in China have not been detailed. METHODS: Based on freely accessible disability adjusted life years (DALYs) estimated by the Global Burden of Diseases (GBD) 2017, we adopted a robust decomposition method that ascribes changes in DALYs in any given country across two time points to changes resulting from three sources: population size, age structure, and age-specific DALYs rate per 100,000 population. Using the method, we calculated DALYs associated with population ageing in China from 1990 to 2017 and examined the counteraction between the effects of DALYs rate change and population ageing. This method extends previous work through attributing the change in DALYs to the three sources. RESULTS: Population ageing was associated with 92.8 million DALYs between 1990 and 2017 in China, of which 65.8% (61.1 million) were years of life lost (YLLs). Males had comparatively more DALYs associated with population ageing than females in the study period. The five leading causes of DALYs associated with population ageing between 1990 and 2017 were stroke (23.6 million), chronic obstructive pulmonary disease (COPD) (18.3 million), ischemic heart disease (13.0 million), tracheal, bronchus, and lung cancer (6.1 million) and liver cancer (5.0 million). Between 1990 and 2017, changes in DALYs associated with age-specific DALY rate reductions far exceeded those related to population ageing (- 196.2 million versus 92.8 million); 57.5% (- 112.8 million) of DALYs were caused by decreases in rates attributed to 84 modifiable risk factors. CONCLUSION: Population ageing was associated with growing health loss in China from 1990 to 2017. Despite the recent progress in alleviating health loss associated with population ageing, the government should encourage scientific research on effective and affordable prevention and control strategies and should consider investment in resources to implement strategies nationwide to address the future challenge of population ageing.

Study protocol: developing and evaluating an interactive web platform to teach children hunting, shooting and firearms safety: a randomized controlled trial.

BACKGROUND: Firearms injuries present a major pediatric public health challenge in the United States. This study protocol describes research to develop and then conduct a randomized clinical trial to evaluate ShootSafe, an interactive, engaging, educational website to teach children firearms safety. ShootSafe has three primary goals: (a) teach children basic knowledge and skills needed to hunt, shoot, and use firearms safely; (b) help children learn and hone critical cognitive skills of impulse control and hypothetical thinking needed to use firearms safely; and (c) alter children's perceptions about their own vulnerability and susceptibility to firearms-related injuries, the severity of those injuries, and their perceived norms about peer behavior surrounding firearms use. ShootSafe will accomplish these goals through a combination of interactive games plus short, impactful testimonial videos and short expert-led educational videos. METHODS: Following website development, ShootSafe will be evaluated through a randomized controlled trial with 162 children ages 10-12, randomly assigning children to engage in ShootSafe or an active control website. Multiple self-report, computer-based, and behavioral measures will assess functioning at baseline, immediately following training, and at 4-month follow-up. Four sets of outcomes will be considered: firearms safety knowledge; cognitive skills in impulse control and hypothetical thinking; perceptions about firearms safety; and simulated behavior when handling, storing and transporting firearms. Training in both conditions will comprise two 45-min sessions. DISCUSSION: If results are as hypothesized, ShootSafe offers potential as a theory-based program to teach children firearms safety in an accessible, engaging and educational manner. Translation into practice is highly feasible. TRIAL REGISTRATION: The study protocol was registered on 11/10/20 at clinicaltrials.gov ( NCT04622943 ).

Assessing the effectiveness of an app-based child unintentional injury prevention intervention for caregivers of rural Chinese preschoolers: protocol for a cluster randomized controlled trial.

BACKGROUND: Compared to urban children, children living in rural areas of most countries, including China, are at higher risk of suffering unintentional injuries. Most proven injury prevention interventions, however, are rarely implemented in rural China due to lack of resources. Mobile health interventions are low-cost and easy-to-implement, facilitating implementing injury prevention in resource-limited areas (e.g., rural areas). This study is designed and implemented to examine the effectiveness of an app-based intervention for unintentional injury prevention among rural preschoolers in China. METHODS: A single-blind, 18-month, parallel-group cluster randomized controlled trial with 1:1 allocation ratio will be implemented in 2 rural areas of China (Yang County, Shaanxi Province, and Shicheng County, Jiangxi Province). In total, at least 3508 rural caregivers of preschoolers aged 3-6 years old who own a smartphone will be recruited from 24 preschools. Clusters will be randomized at the preschool level and allocated to the control group (receiving routine school-based education plus app-based parenting education excluding unintentional injury prevention) or the intervention group (receiving routine school-based education plus app-based parenting education including unintentional injury prevention). External support strategies will be adopted by local partners to minimize user fatigue, non-compliance, and attrition. Data collection will be conducted at baseline and then every 3 months during the 18-month follow-up time period. Intention-to-treat data analysis will be implemented. Missing values will be imputed by using the Expectation Maximization algorithm. Generalized estimating equation will test the overall effectiveness of the app-based intervention. A per-protocol sensitivity analysis will be conducted to test the robustness of results. Subgroup analyses will follow the strategies for primary analyses. The primary outcome measure is the incidence rate of unintentional injury among preschoolers during the study period. Secondary outcome measures comprise longitudinal changes in caregiver's attitudes, caregiver-reported supervision behaviors, and caregiver-assessed home environment safety surrounding child unintentional injury prevention in the last week using a standardized audit instrument. DISCUSSION: The app-based intervention is expected to be feasible and effective over the 18-month intervention period. If the app is demonstrated effective as hypothesized, we will initiate processes to generalize and popularize it broadly to rural child caregivers across China. TRIAL REGISTRATION: ChiCTR2000037606 , registered on August 29, 2020.