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Children’s ability to call 911 can save lives.1  An estimated 80% of emergency calls in the United States are placed from mobile phones.2  Although nearly 80% of children use devices for media (eg, gaming, applications, videos) by 2 to 4 years of age,3  their ability to use mobile devices to respond to an emergency, including bypassing a passcode to access the emergency call function, remains unknown. Mobile phones are rapidly replacing landlines,4  yet many school-based emergency education programs focus on use of landlines without simulation practice or assessment of learning5  and, therefore, may inadequately prepare children for emergencies in the digital era. We aimed to assess this digital divide by evaluating primary school–aged children’s ability to recognize an emergency, dial 9-1-1, and report an emergency on a smartphone.

Participants were typically developing primary school–aged children from an urban school. Participants were recruited by using research information letters, and an in-person information session was held to answer parents’ questions. Ethical approval was obtained from St. Michael’s Hospital Research Ethics Board, and informed consent and assent were obtained. A parent questionnaire to collect participant demographic information including age, sex, previous emergency education, and experience with mobile devices was administered. Caregiver sociodemographic data were also collected, including education level and annual household income.

The study was explained to each child individually and each child assented to participating in a practice emergency simulation. The simulated scenario required them to recognize an emergency, dial 9-1-1, and report the emergency using a simulated 9-1-1 smartphone application designed for this study. During the simulation, an actor playing the role of a school helper engaged the child in an educational activity (ie, reading a book) in a school library. The actor received a call on his smartphone and then placed it on the table in front of the child, so it was visible and accessible. Subsequently, the actor, who was eating a snack, started to choke on his food and cough while clutching his neck (ie, universal choking sign) and then collapsed to the floor: a situation that requires calling 9-1-1. If the child dialed 9-1-1 correctly on the smartphone, a simulated 9-1-1 dispatcher answered the call from another room and asked for emergency information. Simulations were videoed by using a camera hidden from view. Using a 13-item task analysis checklist, 2 raters independently assessed each child’s ability to recognize the emergency and respond using the smartphone. Interrater reliability was excellent (κ = 0.975), disagreements were adjudicated by a third rater. A debrief followed each simulation to review the scenario with the child and reassure them it was simulated. Sociodemographic data and information on mobile phone use were gathered by using a parent survey.

Fifty children participated (mean age: 6.22 ± 1.63 years; range: 4–9 years; girls: n = 18 [36.0%]). Eighty percent (n = 40 of 50) of children in this study had regular mobile phone access; none had their own device. Twenty-four percent (n = 12 of 50) of households reported having no landline phone. Although half of parents (n = 25 of 50, 95% confidence interval [CI]: 35.5%–64.5%) reported to have spoken to their child about what to do in an emergency and how to dial 9-1-1, only 34% (n = 17 of 50, 95% CI: 21.2%–48.8%) had demonstrated using a smartphone. Sociodemographic and mobile phone usage data are outlined in Table 1.

TABLE 1

Sociodemographic Characteristics and Mobile Phone Usage Data From Parent Survey

Survey questionFrequency, n (%), Total n = 50 Responses
Annual household income CAD$ (USD$)  
 <24 000 (<18 000) 2 (4.0) 
 25 000–49 999 (18 000–37 999) 3 (6.0) 
 50 000–74 999 (38 000–56 999) 7 (14.0) 
 75 000–99 999 (57 000–75 999) 10 (20.0) 
 >100 000 (>76 000) 21 (42.0) 
 N/A 7 (14.0) 
Caregiver education level  
 Elementary school 1 (2.0) 
 High school 1 (2.0) 
 College education 4 (8.0) 
 University education 21 (42.0) 
 Graduate education 22 (44.0) 
 Other 1 (2.0) 
Immigration status  
 Landed immigrant 9 (18.0) 
 Canadian citizen 37 (82.0) 
Family primary phone usagea  
 Landline 19 (38.0) 
 Smartphone 40 (80.0) 
 Nonsmartphone 2 (4.0) 
Child mobile phone usage per week  
 Never uses 2 (4.0) 
 Does not use every week 8 (16.0) 
 >1 h 16 (32.0) 
 1–2 h 13 (26.0) 
 2–4 h 8 (16.0) 
 4–7 h 2 (4.0) 
 N/A 1 (2.0) 
Child type of mobile phone usagea  
 Playing games 38 (76.0) 
 Taking pictures 33 (66.0) 
 YouTube 31 (62.0) 
 Using educational apps 23 (46.0) 
 Searching information 20 (40.0) 
 Playing music 16 (32.0) 
 Recording video 14 (28.0) 
 Sending text messages 9 (18.0) 
 Browsing the Internet 7 (14.0) 
 Other 10 (20.0) 
Survey questionFrequency, n (%), Total n = 50 Responses
Annual household income CAD$ (USD$)  
 <24 000 (<18 000) 2 (4.0) 
 25 000–49 999 (18 000–37 999) 3 (6.0) 
 50 000–74 999 (38 000–56 999) 7 (14.0) 
 75 000–99 999 (57 000–75 999) 10 (20.0) 
 >100 000 (>76 000) 21 (42.0) 
 N/A 7 (14.0) 
Caregiver education level  
 Elementary school 1 (2.0) 
 High school 1 (2.0) 
 College education 4 (8.0) 
 University education 21 (42.0) 
 Graduate education 22 (44.0) 
 Other 1 (2.0) 
Immigration status  
 Landed immigrant 9 (18.0) 
 Canadian citizen 37 (82.0) 
Family primary phone usagea  
 Landline 19 (38.0) 
 Smartphone 40 (80.0) 
 Nonsmartphone 2 (4.0) 
Child mobile phone usage per week  
 Never uses 2 (4.0) 
 Does not use every week 8 (16.0) 
 >1 h 16 (32.0) 
 1–2 h 13 (26.0) 
 2–4 h 8 (16.0) 
 4–7 h 2 (4.0) 
 N/A 1 (2.0) 
Child type of mobile phone usagea  
 Playing games 38 (76.0) 
 Taking pictures 33 (66.0) 
 YouTube 31 (62.0) 
 Using educational apps 23 (46.0) 
 Searching information 20 (40.0) 
 Playing music 16 (32.0) 
 Recording video 14 (28.0) 
 Sending text messages 9 (18.0) 
 Browsing the Internet 7 (14.0) 
 Other 10 (20.0) 
a

Respondents could choose >1 option. N/A, not applicable.

Less than half of the children in kindergarten and grade 1 (n = 10 of 25, 95% CI: 21.1%–61.3%) recognized the simulation as an emergency. In contrast, 80.0% of children in grades 2 and 3 (n = 20 of 25, 95% CI: 59.3%–93.2%) recognized the emergency (Table 2). Of those who recognized the emergency compared with those who did not, there were no differences in the proportion of children having received 9-1-1 education from their parents (53.3% vs. 45.0%, P > .05). None of the children in kindergarten and grade 1 were able to complete the tasks of dialing 9-1-1 or reporting the emergency. Twenty percent of children in grades 2 and 3 (n = 5 of 25, 95% CI: 6.8%–40.7%) dialed 9-1-1 successfully; 2 had regular smartphone access, 2 were shown how to dial 9-1-1 on a smartphone, and 1 had both access and education. Only 16.0% of children in grades 2 and 3 (n = 4 of 25, 95% CI: 4.5%–36.1%) successfully reported the emergency to the simulated dispatcher.

TABLE 2

Number (Percentage) of Children Completing Each Step Outlined on the Task Analysis Checklist to Assess Children’s Ability to Recognize the Emergency, Dial 9-1-1 on a Smartphone, and Report the Emergency to a Dispatcher

Taskn (%) of Children Completing Each Step Outlined on the Emergency Response Task Analysis Checklista
Kindergarten, Age 4–5 (n = 17)Grade 1, Age 6 (n = 8)Grade 2, Age 7–8 (n = 13)Grade 3, Age 8–9 (n = 12)
Child recognized situation as an emergency 7 (41.2) 3 (37.5) 11 (84.6) 9 (75.0) 
Child locates phone 0 (0.0) 0 (0.0) 4 (30.8) 3 (25.0) 
Child picks up the phone 0 (0.0) 0 (0.0) 4 (30.8) 3 (25.0) 
Child presses “emergency call” (passcode bypass) button on phone 0 (0.0) 0 (0.0) 3 (23.1) 2 (16.7) 
Child dials “9” 0 (0.0) 0 (0.0) 3 (23.1) 2 (16.7) 
Child dials “1” 0 (0.0) 0 (0.0) 3 (23.1) 2 (16.7) 
Child dials “1” 0 (0.0) 0 (0.0) 3 (23.1) 2 (16.7) 
Child presses “call” button to activate phone call 0 (0.0) 0 (0.0) 3 (23.1) 2 (16.7) 
Child places the phone to their ear and/or activates the speaker function 0 (0.0) 0 (0.0) 2 (15.4) 2 (16.7) 
Child responds to question “Do you need fire, ambulance or police?” correctly 0 (0.0) 0 (0.0) 2 (15.4) 2 (16.7) 
Child responds to question “What is your name?” correctly 0 (0.0) 0 (0.0) 2 (15.4) 2 (16.7) 
Child responds to question “What is your address?” correctly 0 (0.0) 0 (0.0) 2 (15.4) 2 (16.7) 
Child responds to question “What is your emergency?” correctly 0 (0.0) 0 (0.0) 2 (15.4) 2 (16.7) 
Taskn (%) of Children Completing Each Step Outlined on the Emergency Response Task Analysis Checklista
Kindergarten, Age 4–5 (n = 17)Grade 1, Age 6 (n = 8)Grade 2, Age 7–8 (n = 13)Grade 3, Age 8–9 (n = 12)
Child recognized situation as an emergency 7 (41.2) 3 (37.5) 11 (84.6) 9 (75.0) 
Child locates phone 0 (0.0) 0 (0.0) 4 (30.8) 3 (25.0) 
Child picks up the phone 0 (0.0) 0 (0.0) 4 (30.8) 3 (25.0) 
Child presses “emergency call” (passcode bypass) button on phone 0 (0.0) 0 (0.0) 3 (23.1) 2 (16.7) 
Child dials “9” 0 (0.0) 0 (0.0) 3 (23.1) 2 (16.7) 
Child dials “1” 0 (0.0) 0 (0.0) 3 (23.1) 2 (16.7) 
Child dials “1” 0 (0.0) 0 (0.0) 3 (23.1) 2 (16.7) 
Child presses “call” button to activate phone call 0 (0.0) 0 (0.0) 3 (23.1) 2 (16.7) 
Child places the phone to their ear and/or activates the speaker function 0 (0.0) 0 (0.0) 2 (15.4) 2 (16.7) 
Child responds to question “Do you need fire, ambulance or police?” correctly 0 (0.0) 0 (0.0) 2 (15.4) 2 (16.7) 
Child responds to question “What is your name?” correctly 0 (0.0) 0 (0.0) 2 (15.4) 2 (16.7) 
Child responds to question “What is your address?” correctly 0 (0.0) 0 (0.0) 2 (15.4) 2 (16.7) 
Child responds to question “What is your emergency?” correctly 0 (0.0) 0 (0.0) 2 (15.4) 2 (16.7) 
a

Scored as “done” or “not done.”

Although mobile devices are ubiquitous in children’s lives today,6  in this study we found that most primary school–aged children, and particularly those in kindergarten and first grade, are not prepared to respond to an emergency using a smartphone to dial 9-1-1 and communicate the emergency to a dispatcher. Additionally, most children in kindergarten and first grade were unable to recognize an emergency. Elementary school emergency education is frequently offered through regional police school visits and typically involves didactic teaching without simulated practice or assessment,5  strategies known to enhance transfer of skills to real-life. Furthermore, instructional materials and curricula may not adequately reflect advancements in digital technology such as smartphones.5  In this study, we underscore the need to develop emergency skills education aimed at enhancing young children’s emergency preparedness in the digital era with a focus on developmentally appropriate strategies for building these skills in children as young as 4 to 6 years of age. We created a Canadian Institutes of Health Research award-winning knowledge translation education video outlining how to recognize an emergency and how and when to call 9-1-1, focusing on the steps required to call 9-1-1 on a smartphone.7,8  A potential limitation of this study is that the majority of participants (62%) had household incomes close to or above the median annual household income in the United States, and 94% of primary caregivers had at least a college education. Therefore, the study population may not represent the full breadth of children from all sociodemographic backgrounds.9  Future research evaluating educational strategies using simulated practice with smartphone applications would help inform best practices.

We thank the Allan Waters Family Simulation Program for their assistance with the simulation portion of this study.

Dr Huber conceptualized and designed the study, designed the data collection instruments, coordinated and supervised data collection, provided administrative, technical, and material support, conducted the initial analyses, and drafted the initial manuscript; Ms Davis, conceptualized and designed the study, designed the data collection instruments, and collected data; Ms Phan collected data, conducted the initial analyses, and drafted the initial manuscript; Ms Jegathesan designed the data collection instruments, collected data, contributed to the initial analysis, and drafted the initial manuscript; Dr Campbell supervised data collection and provided administrative, technical, and material support; Ms Chau conducted the initial analyses; Dr Walsh conceptualized and designed the study, designed the data collection instruments, coordinated and supervised data collection, provided administrative, technical, and material support, conducted the initial analyses, and drafted the initial manuscript; and all authors critically reviewed and revised the manuscript for important intellectual content and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Supported by an Innovation Fund grant, a Hospital for Sick Children Paediatric Consultants Education grant, a Hospital for Sick Children Department of Paediatrics Paediatric Research and Clinical Summer Program grant, and a St. Michael’s Hospital Department of Pediatrics grant. Dr Walsh holds a Career Development Award from the Canadian Child Health Clinician Scientist Program and an Early Researcher Award from the Ontario Ministry of Research and Innovation.

     
  • CI

    confidence interval

1
Rand
B
.
9-year-old boy calls 911, helps saves his grandfather's life. ABC News
.
2
National 911 Program
.
National 911 Progress Report
.
Washington, DC
:
911.gov
;
2019
:
7
.
3
Canadian Paediatric Society, Digital Health Task Force, Ottawa, Ontario
.
Screen time and young children: promoting health and development in a digital world
.
Paediatr Child Health
.
2017
;
22
(
8
):
461
477
4
Government of Canada: Canadian Radio-television and Telecommunications Commission
.
Communications Monitoring Report 2016: Canada’s Communication System: An Overview for Canadians
.
Ottawa, ON
:
Government of Canada
;
2016
:
4
5
Toronto Police Services
.
The 911 emergency call
.
Available at: www.torontopolice.on.ca/safetyzone/kids/911_emergency_call.pdf. Accessed November 20, 2020
6
Chassiakos
YLR
,
Radesky
J
,
Chistaskis
D
,
Moreno
MA
,
Cross
C
;
Council on Communications and Media
.
Children and adolescents and digital media
.
Pediatrics
.
2016
;
138
(
5
):
e20162591
7
Walsh
CM
,
Chau
R
,
Huber
JF
.
Specially commended, IHDCYH talks 2019: when & how to call 911
.
February 6, 2020. Available at: https://youtu.be/qdI_kTGV2zU. Accessed November 20, 2020
8
Walsh
CM
,
Chau
R
,
Huber
JF
.
When & how to call 911. Teaching children how to call 911 using various phones
.
February 6, 2020. Available at: https://youtu.be/JdKG_L5YuB8. Accessed November 20, 2020
9
Livingstone
S
,
Mascheroni
G
,
Dreier
M
,
Chaudron
S
,
Lagae
K
.
How Parents of Young Children Manage Digital Devices at Home: The Role of Income, Education and Parental Style
.
London, United Kingdom
:
EU Kids Online
;
2015
.
Available at: http://eprints.lse.ac.uk/id/eprint/63378. Accessed November 20, 2020

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.