David C. Schwebel, Ph.D. - US grants

DESCRIPTION (provided by applicant): Pedestrian injuries are among the leading causes of pediatric injury and mortality in American children ages 7-8, but existing behavior-oriented interventions achieve only modest success. One limitation to existing interventions is that they fail to provide children with the repeated practice needed to develop the complex perceptual and cognitive skills required for safe pedestrian activity. Virtual reality (VR) offers a highly promising technique to train children in pedestrian safety skills. VR permits repeated unsupervised practice without risk of injury;automated feedback to children on success or failure in crossings;adjustment of traffic density and speed to match children's skill level;and an appealing and fun environment for training. The proposed research is designed to test the efficacy of virtual reality as a tool to train child pedestrians in safe street-crossing behavior. A randomized controlled trial will be conducted with four equal-sized groups of children ages 7-8 (total N = 240). One group will receive training in an interactive and immersive virtual pedestrian environment. The virtual environment, already developed, has been demonstrated to have face, construct, and convergent validity. The second group will receive pedestrian safety training via video and computer strategies that are most widely used in American schools today. The third group will receive what is judged to be the most efficacious treatment currently available, individualized behavioral training at street side locations. The fourth and final group will serve as a no-contact control group. All participants in all groups will be exposed to a range of field- and laboratory-based measures of pedestrian skill during baseline and post-intervention visits, as well as during a six-month follow-up assessment. Primary analyses will be conducted through linear mixed models designed to test change over time in the four intervention groups. PUBLIC HEALTH RELEVANCE: Pedestrian injuries are among the leading cause of pediatric mortality for American children ages 7-8. This project will study the efficacy of virtual reality as a means to train children in safe pedestrian behavior. Results will have significant implications for child pedestrian injury prevention.

DESCRIPTION (provided by applicant): Approximately 223,000 emergency room visits a year are attributable to child playground injury. To address this significant public health problem, this project aims to develop and evaluate a multimedia, user friendly, Internet-based behavior modification program to improve child safety on childcare center playgrounds. This program, Stamp-in-Safety, is designed to lower the number of playground injuries by reducing child risk-taking and improving adult supervision on playgrounds at childcare centers and preschools. Briefly, the Stamp-in-Safety program involves adult supervisors offering an appealing ink-stamp to children who are demonstrating safe behavior on the playground. As well as rewarding children for this desired behavior, the program accomplishes a second, equally important objective: it encourages adult supervisors to develop the habits of watching children carefully, engaging with children on the playground, and ultimately noticing and intervening to prevent risky behaviors. In consultation with expert panelists, we will develop Stamp-in-Safety, an interactive, user-friendly, Internet-based training program for staff members at childcare centers. The functionality and usability of the Stamp-in-Safety program will be evaluated according to a three-step process. First, we will conduct internal and then external reviews of the content of the program. Second, preschool playground supervisors will review the material and provide feedback concerning the appeal, usability, and functionality of the program. Third, we will conduct a small study using a quasi-experimental pre-post design to evaluate the program with 50 preschool employees. This study will address the following research questions: (1) Does the Stamp-in-Safety training via remote and unmediated (i.e., online) delivery provide sufficient promise of efficacy to warrant full development? (2) Were supervisors satisfactorily able to access and complete the training? (3) Did the program achieve a sufficiently high degree of user acceptance so as to contribute to program adoption? and (4) Were supervisors able to implement the program as described in Stamp-in-Safety training materials? The 50 employees will implement the program at their centers and will complete pre- and post-intervention surveys addressing knowledge (about the program and supervision principles), perceptions (about the program, child playground safety, and adult supervision of children), and beliefs (about the efficacy, usability, and functionality of the Stamp-in-Safety program). Engagement in and acceptance of the program will be assessed post-intervention by gathering website usage data (e.g., time spent on website, number of exercises completed) from participants. Finally, supervisors will self-report several behaviors on a daily checklist to evaluate the fidelity of intervention delivery. PUBLIC HEALTH RELEVANCE: Approximately 223,000 emergency room visits a year are attributable to child playground injury. To address this significant public health problem, the Stamp-in-Safety program is designed to lower the number of playground injuries by reducing child risk-taking and improving adult supervision on playgrounds at childcare centers and preschools. We will evaluate the feasibility and usability of the Stamp-in-Safety program with preschool playground supervisors.

A Website to Teach Children Safety with Dogs: Development and Evaluation Dog bites result in over 800,000 doctor/ER visits, 6000 hospitalizations, and a dozen deaths each year in the United States. By a large margin, children suffer the highest risk - and children typically are bitten by familiar dogs in familiar places. Several programs exist to reduce pediatric dog bite risk, but few are empirically- supported or theoretically-motivated. None are widely disseminated. This study builds from existing child dog bite prevention programs to develop and then evaluate a website to teach children safe interactions with dogs. The website will be interactive, entertaining, and engaging, allowing children (target ages 4-6) to learn in a technologically-sophisticated and interactive environment. It will be developed based in behavioral theory. Hearkening child development theory, it will teach and permit practice of cognitive skills that develop in early childhood and are critical to safety with dogs: impulse control, perspective taking, and attention to details. Hearkening health behavior change theory, the website will help children and their parents perceive personal vulnerability to bites, recognize normative behavior to protect themselves, and have personal motivation to change previous habits. Overarching the website design will be goals to create an engaging and entertaining environment, and to facilitate cognitive and behavioral change on the part of both child and parent via multiple mechanisms. Besides teaching children, the website will educate parents via an innovative messaging system triggered by child attainment of points and skill levels. Following website development, an evaluation study will investigate usability and efficacy of the website using a repeated measures pre-test, post-test experimental design. 68 children ages 4-6 will be recruited, complete a pre-intervention assessment evaluating knowledge and behavior relevant to dog safety via multiple methods, and then be randomly assigned to use either the newly-developed dog safety website or a control pedestrian safety website at home over the subsequent 2 weeks. Frequent reminders will encourage website use. Following the 2-week period, all children will return for a post-intervention assessment battery to evaluate knowledge and behavior change. Data will be analyzed using descriptive and inferential statistics, with primary hypotheses tested using linear mixed models.

? DESCRIPTION (provided by applicant): Child pedestrian injury represents a significant public health problem in China and many other LMICs. Although automatic for most adults, safe street-crossing requires complex cognitive-perceptual skills that children must develop. Research in developed nations suggests children can learn those skills through repeated practice, including within interactive virtual reality (VR) pedestrian environments. Therefore, we propose development of an interactive VR pedestrian environment that simulates the Chinese traffic/street environment and can be delivered via the internet to the tablet platform for wide us in China and beyond. The system will be built using Unity 3D software and will run over a standard internet connection to tablets, phones, and computers. This work builds on our development of VR to train US children in pedestrian safety and our investigations of other child injury risks (drowning, dog bites) among Chinese children. Along with development of the VR system, we propose an evaluation study. We will implement a pre- post research design and use multiple behavioral and observational assessments of pedestrian skill prior to and after training a sample of about 300 Chinese schoolchildren in pedestrian safety with the newly-developed tablet-based VR system. Assessment strategies pre- and post-training will include self-report, individualized behavioral observation of pedestrian safety in the VR and at street side locations, and observation of children's street-crossing after school dismissal. Primary data analyses will assess changes within individual from pre- to post-training. Attention will be paid to development of research capacity and ensuring further evaluation and sustainability of the program if it proves successful in the efficacy trial.

DESCRIPTION (provided by applicant): Distracted Pedestrian Behavior: Using Virtual Reality to Increase Safety An average of over 4700 American pedestrians die annually, 10% of whom are young adults ages 17- 25. Of concern, the pedestrian injury rate in the United States shows an increasing trend the past decade, perhaps partly due to the skyrocketing rate of distracting mobile device use by pedestrians and drivers. We propose a repeated measures experimental research trial to evaluate an experiential intervention to reduce distracted pedestrian behavior on an urban college campus. The intervention has two primary goals: (a) to increase individual's perceived vulnerability/susceptibility to injury when crossing streets while distracted and (b) to change community norms such that it becomes normative to put one's phone aside while crossing streets. We will accomplish these goals through an intervention hallmarked by the innovative experiential strategy of allowing individuals to engage in the target risk behavior, street-crossing while distracted by text- messaging, within the safety of a virtual pedestrian environment. We expect individuals who experience the risk of distracted versus undistracted pedestrian behavior in simulation will self-examine and alter their behavior in the real world. The intervention will take place during a weeklong campaign based in classroom buildings. We expect to create a buzz on campus that alters normative behavior and accomplishes health- related behavior change via social contagion efficiently and effectively. Two data collection strategies will evaluate outcomes: (a) unobtrusive observation of pedestrian behavior both pre-intervention and on three occasions post-intervention (immediate, 3 month follow-up, 6 month follow-up) on the target intervention campus and also at a control campus not exposed to the intervention, and (b) self-report concerning perceived vulnerability/susceptibility of distracted pedestrian injury and typical pedestrian behaviors from a randomly selected sub-sample of 300 individuals assessed on three occasions (pre-intervention, post-intervention, 3 month follow-up) at the campus where the intervention is implemented. Primary analyses will be conducted using linear mixed models to assess trends over time.

Virtual Reality by Mobile Phone: Improving Child Pedestrian Safety Pedestrian injuries are a leading cause of pediatric injury. Effective, practical, and cost-efficient empirically- based and theoretically-driven behavioral interventions to teach young children street-crossing skills are needed. Our laboratory has explored virtual reality (VR) as a means to teach child pedestrian safety skills for several reasons, including: (a) it offers children repeated unsupervised practice in pedestrian crossings without risk of injury, (b) it provides automated feedback to children on crossing success or failure, (c) it can be tailored to child skill levels: (d) it offers an appealing and fun training environment, and (e) most recently given technological advances, it offers potential for broad dissemination using mobile phone technology. Previous work indicated VR was an effective pedestrian safety training tool. The present proposal extends previous findings in two critical ways. First, it will evaluate delivery of a pedestrian VR using a mobile phone and the Google Cardboard platform, technology released in 2014 that enables a standard mobile phone to be used as an immersive virtual reality delivery system. Second, it will overcome the limitation of previous research suggesting children learned some pedestrian skills after six 30-minute training sessions in a VR but did not yet master adult-level pedestrian skills. We will implement a randomized non-inferiority trial with two equal-sized groups of children ages 7-8 (total N = 498). All participants will complete baseline, post-intervention, and 6- month follow-up assessments of pedestrian safety and up to twenty-five 30-minute pedestrian safety training trials until they reach adult levels of functioning. Half the children will be randomly assigned to train in Google Cardboard and the other half in an existing semi-immersive laboratory VR. Primary outcomes will be assessed using ANCOVA models.

Preventing Youth Soccer Injury: A Randomized Cross-Over Trial By most accounts, soccer is the most popular sport in the world. An estimated 270 million people play or officiate organized soccer worldwide each year (Kunz, 2007), including over 3 million youth in the United States (US; http://www.usyouthsoccer.org/media_kit/keystatistics/). Almost half of participating children in the US are girls. Soccer is the 3rd most common cause of youth sports injury requiring emergency department visits in the US, the leading cause of sports concussion for girls, and among the top five leading causes of sports concussion for boys (Buzas et al., 2014; MMWR, 2011; Schwebel & Brezausek, 2014). We propose a simple but innovative strategy to reduce illegal and aggressive youth soccer play that may lead to injury: increase the number of referees regulating youth soccer matches from one to three. Our laboratory has conducted a series of studies that demonstrate children are more cautious in potentially dangerous situations when they recognize they are being watched more intensely and/or proximally by an adult authority figure. We believe this discovery, which has been repeatedly replicated in both laboratory and ecologically-valid field settings, would extend to the soccer field and that the presence of extra referees would reduce illegal and aggressive soccer play that leads to injuries, including concussions. To test this hypothesis, we propose a randomized cross-over trial. We will record approximately 300 recreational youth soccer games among teams of boys and girls ages 10 to 11, randomly assigning each game to have either one referee (current practice) or three referees (experimental intervention). We will use objective behavioral coding strategies to review recordings and tally multiple outcomes including six primary outcomes: injury incidents, injuries to the head, injuries requiring professional medical attention, player-to- player collisions, falls to the ground, and fouls. Primary data analysis will be conducted via linear mixed models examining difference in outcomes across games with 3 vs. 1 referee and accounting for potential game-related, referee-related, and temporal variables.

Using Bluetooth Beacon Technology to Reduce Distracted Pedestrian Behavior Over 4,800 American pedestrians die annually (CDC, 2017), a figure that is current increasing. One hypothesized reason for the increasing trend in pedestrian injuries and deaths is the role of mobile technology in distracting both pedestrians and drivers. Existing behavioral interventions to reduce distracted pedestrian behavior are few. We propose to develop and then evaluate Bluetooth beacon technology as a means to alert and warn pedestrians when they are approaching dangerous intersections, reminding them to attend to the traffic environment and cross the street safely rather than engaging with mobile technology. Our proposed research will be conducted in three phases: (a) technology development, (b) internal testing, and (c) crossover research trial to evaluate efficacy of the program. Bluetooth beacons are very small (about the size of a dime) and inexpensive (~$20 range) devices that broadcast information unidirectionally (beacon to smartphone) within a closed proximal network. We propose placing beacons at intersection corners (e.g., on signposts) frequently trafficked by urban college students. The beacons will transmit to an app installed on users? smartphones, signaling users to attend to their environment and cross the street safely. The app will be developed to be flexible based on user preferences (e.g., visual warnings, aural warnings, vibrations, phone screen frozen); for research purposes, the app also will download data concerning the users? behavior while crossing the street (e.g., user stops using phone, puts phone in pocket, text-messages, leaves music playing, etc.). Iterative internal pilot-testing will improve the app, and then we will conduct a small pilot study (N=30) to gather further data for refinement. Following this, a crossover trial will evaluate the app with a sample of 411 young adults whose behavior is monitored for: (a) 3 weeks without the app being activated, (b) 3 weeks with the app activated, and then (c) 6 weeks without the app activated to assess retention of behavior. Throughout the 12 week period, we will monitor user behavior at multiple intersections around campus, along with gathering self-report questionnaire perceptions and behavior at baseline and 12-week post-intervention assessments.

Using Interactive Virtual Presence to Remotely Assist Parents with Child Restraint Installations Motor vehicle crashes cause the death of an American child every 3 hours. When installed correctly, car seats (also called ?child restraints?) reduce risk of serious injury and death to infants and young children in a crash roughly threefold. Unfortunately, a very large portion of child restraints traveling on American roadways is installed incorrectly. A network of trained technicians, many affiliated with Safe Kids Worldwide, work across the country to assist parents in achieving correct use of child restraints through scheduled ?car seat checks,? where technicians cooperate with parents to install restraints in their vehicles. Car seat checks are effective in reducing errors in child restraint installations. However, the services are highly underutilized due to barriers in access, scheduling complications, and resources to staff the car seat checks sufficiently to meet demand. The present study evaluates use of interactive virtual presence technology (also called interactive merged reality) ? joint and simultaneous remote verbal and visual interaction and exposure to the same 3D stimuli ? to remotely assist parents to install child restraints correctly into their vehicles. If effective, this technology could supplement or replace car seat checks, significantly reduce the number of errors made in car seat installations nationwide, and revolutionize how government, industry, and non-profit agencies help parents install restraints. Building from small preliminary studies on the topic, we propose a large randomized non-inferiority trial to evaluate whether parents, including especially underserved parents in rural areas and/or of underrepresented racial or ethnic minority background, who install child restraints while communicating with a remote expert technician via interactive virtual presence achieve installations and learning that are not inferior in their safety to parents who install restraints live with a remote technician on-site. Non-inferiority trials are a type of randomized trial whereby a novel treatment (in this case, interactive virtual presence to install child restraints) is compared to an existing treatment known to be effective (in this case, live one-on-one installation of restraints) to demonstrate the novel treatment does not perform inferiorly to the existing treatment known to be effective. To accomplish our goals, we will recruit 1476 parents at 7 Safe Kids locations nationwide and randomly assign consenting parents to install their child restraint either via interactive virtual presence or with a live technician. The correctness of installation safety will be assessed using objective checklists, both following installation and again 4 months later. We aim to demonstrate that child restraint installation is accurate (>90% correct) when conducted remotely via interactive virtual presence, that such installations are not inferior to the accuracy of installation with a live on-site expert, and that parents learn and retain information about correct child restraint installation.

ShootSafe: An Interactive Website to Teach Children Firearms Safety Firearms injuries present a major pediatric public health challenge to our country, killing over 800 children ages 0-15 annually and leading to lifelong disability among over 1000 survivors. About ? of firearms injuries to children under age 15 are due to unintentional causes rather than suicide or homicide. We propose development and evaluation of ShootSafe, an innovative, engaging, and educational website accessible by smartphone, tablet or computer that engages children to learn firearms safety. ShootSafe extends a smattering of existing basic programs to achieve three primary educational goals: (a) teach children the knowledge and skills they need to hunt, shoot, and use firearms safely; (b) help children learn and hone the 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 and activities plus powerful podcast videos delivered by peer actors (impactful testimonials about firearms injuries and deaths they experienced) and experts (wisdom and experience from trusted role models). The website will deliver messages through the internet, a technological medium today's children prefer learning in. It also will incorporate brief messaging to parents, who will absorb key lessons and reinforce them with their children. The project has two specific aims: (a) develop an innovative and engaging website to train children in firearms safety and (b) evaluate the website through a randomized controlled trial with 162 children ages 10- 12, randomly assigning the children to engage in the ShootSafe website or an active control website on child nutrition. The second aim will incorporate sub-aims to evaluate changes in children's (a) knowledge, (b) cognitive skills in impulse control and hypothetical thinking, (c) perceptions about firearms safety, and (d) simulated behavior when handling, storing and transporting firearms. All outcome measures will be assessed through multiple methods and measures at baseline, immediately post-intervention, and at a 4-month follow-up assessment to evaluate retention. Training will comprise two 30-minute sessions. In summary, we propose a program that addresses a critical pediatric public health problem through an electronic platform that appeals to today's children and innovative programming to deliver basic knowledge about firearms safety, hone relevant cognitive skills, and alter perceptions about safety. If the study hypotheses prove true, translation into practice through broad dissemination is highly feasible. Note that this project falls under Objective Two in the RFA (to rigorously evaluate effectiveness of an innovative and promising strategy to keep individuals safe from firearm-related injuries and death). It also falls under Funding Option B, as it will support new data collection activities.