Background GBD data estimate about 75 000 children die worldwide annually in crashes as pedestrians, equal to 9 deaths every hour of every day. Pedestrian behavior requires complex cognitive-perceptual skill to judge vehicle speeds and distances, process multiple stimuli quickly, and efficiently make decisions. Previous research suggests children can learn these skills through repeated practice, either in vivo or through simulation in virtual reality (VR). Delivering such repeated practice efficiently and globally represents a significant public health challenge.

Objective In a pre-post design, we evaluated whether classroom-based training in a VR pedestrian environment delivered by smartphone can teach children to cross streets more safely. We also examined changes in children’s self-efficacy to cross streets.

Methods 56 children ages 8–10 participated in a primary school in Changsha, China. Baseline pedestrian safety assessment occurred in the VR environment and through unobtrusive observation (11 days) of a subsample street-crossing outside the school. Self-efficacy was assessed through both self-report and observation. Following baseline assessment, children engaged in the smartphone VR for 12 days in their classrooms. Follow-up assessment replicated baseline measurements.

Findings Probability of crash in the VR evaluation decreased post-training (0.40 vs 0.09). Observational data showed that the odds of looking at oncoming traffic while crossing increased (OR=2.4; first traffic lane). Self-efficacy increases occurred both in self-report (proportional OR=4.7 crossing busy streets) and observation of children following crossing-guard signals (OR=0.2; first lane).

Conclusion Children can learn pedestrian safety skills through training in VR environments delivered by smartphone. Training also increases children’s self-efficacy to cross streets.

Policy implications Given rapid motorization and global smartphone penetration, smartphone-based VR offers a strategy to supplement existing policy and prevention efforts to improve global child pedestrian safety. Broad dissemination is feasible.