Effect of a Novel Video Game on Stroke Knowledge of
9- to 10-Year-Old, Low-Income Children
Olajide Williams, MD, MS; Mindy F. Hecht, MPH; Alexandra L. DeSorbo, MPH;
Saima Huq, MPH; James M. Noble, MD, MS, CPH
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Background and Purpose—Improving actionable stroke knowledge of a witness or bystander, which in some cases are
children, may improve response to an acute stroke event.
Methods—We used a quasiexperimental pre-test post-test design to evaluate actionable stroke knowledge of 210 children
aged 9 to 10 years in response to a single, 15-minute exposure to a stroke education video game conducted in the school
computer laboratory. After immediate post-test, we provided remote password-protected online video game access and
encouraged children to play at their leisure from home. An unannounced delayed post-test occurred 7 weeks later.
Results—Two hundred ten children completed pretest, 205 completed immediate post-test, whereas 198 completed delayed
post-test. One hundred fifty-six (74%) children had Internet access at home, and 41 (26%), mostly girls, played the video
game remotely. There was significant improvement in stroke symptom composite scores, calling 911, and all individual
stroke knowledge items, including a distractor across the testing sequence (P<0.05). Children who played the video game
remotely demonstrated significant improvement in knowledge of 1 symptom (sudden imbalance) compared with children
who did not (P<0.05), although overall composite scores showed no difference.
Conclusions—Stroke education video games may represent novel means for improving and sustaining actionable stroke
knowledge of children. (Stroke. 2014;45:889-892.)
Key Words: healthcare disparities ◼ health education ◼ stroke
B
ecause the average 8- to 12-year-old child plays ≈13
hours of video games every week,1 supplementing the
content of these media with stroke education may represent a
powerful way to improve stroke knowledge.
Stroke treatment is time-dependent, and activation of the
emergency medical service plays a critical role.2 Knowledge
of stroke symptoms and the importance of calling 911 (collectively termed actionable stroke knowledge) is low among
adults and children living in high stroke-risk communities.3,4
Although stroke knowledge does not necessarily imply rapid
action in all lay public,5 there may be a sex-specific impact
among women.6 Moreover, bystanders and family members
may play an important role in calling 911 for suspected stroke,
and some of these individuals may include young children.4,7
We previously showed that increasing stroke knowledge
of children may lead to increased knowledge in their parents
(most of whom were women).8 As part of that program, we
developed a clotbuster stroke video game for the purpose of
improving actionable stroke knowledge of children, which
we explored as an independent tool in this study. We hypothesized that: (1) the stroke video game will improve stroke
knowledge of children after a single, 15-minute game round;
(2) children will access an online version of the game as a
leisurely activity; and (3) children who access the online game
will demonstrate greater stroke knowledge during delayed
testing compared with those who do not.
Methods
Setting and Study Population
We enrolled a convenience sample of 210 fourth- and fifth-grade
children from 1 elementary school in Bronx, New York, located in a
low-income, high stroke-risk community. Student ages ranged from
9 to 12 years (mean age, 10 years), and 52% were girls. School-level
demographic data revealed a student body comprising 65% Hispanic,
18% Asian, 13% black, 2% white, and 2% Native American/Alaska
Native. The Columbia University Institutional Review Board approved this study.
Design
We used a quasiexperimental pre-test post-test design in which we
compared individual’s scores between pre-test, immediate post-test
(IP), and an unannounced and unanticipated delayed post-test of
gamers using instruments that assess actionable stroke knowledge.
Intervention
Development of the stroke video game (Figure 1) was influenced by
social cognitive theory.9 The video game involves navigating a clotbusting spaceship intra-arterially, shooting down clots that occlude
the passage of blood to the brain, while avoiding large atherosclerotic
plaques on the arterial wall. When clotbuster medicine runs out, the
Received July 22, 2013; accepted November 27, 2013.
From the Department of Neurology, The Neurological Institute of New York, Columbia University Medical Center, New York, NY.
Correspondence to Olajide Williams, MD, MS, Department of Neurology, The Neurological Institute of New York, Columbia University Medical Center,
710 W 168th St, New York, NY 10032-3784. E-mail [email protected]
© 2014 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.113.002906
889
890 Stroke March 2014
gamer must answer stroke knowledge questions in order to refill it
and continue playing. Correct answers are provided for incorrect responses, and the game is synced to a hip-hop song with educational
lyrics around stroke that also contain the correct answers. This incentive reward circuit is designed to motivate gamers to learn, creating
a loop that increases the gamers’ confidence in his or her mastery or
self-efficacy of the stroke information being taught.
Gaming Protocol
Children were assembled in a school computer laboratory and were
informed that test scores will not affect their class grades. After a
baseline survey (pre-test), all children played the video game for a
prespecified 15-minute duration (a single game round), immediately
after which they were given an IP. After IP, each child was given a
Hip Hop Stroke Hero card, which contained a unique identifier access code for logging onto our website to play the stroke video game
at home as a leisurely activity. The children were then encouraged
to play the game for fun at home. An unannounced delayed post-test
was administered 7 weeks later.
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Assessments
Stroke action (calling 911) was assessed using hypothetical stroke
scenarios in which the diagnosis is not revealed such as: “You are eating lunch with a friend and suddenly pieces of his sandwich start falling out of the right side of his mouth and you notice that the right side
of his face is drooping down. What should you do?”10 Knowledge of
symptoms was assessed using a multiple choice format, which included the 5 suddens stroke symptoms (except that facial droop was
taught in the context of unilateral face, arm, and leg weakness; facial
droop was selected on the basis that it is a specific component of
the face-arm-speech test, and slurred speech was used as a surrogate
for speech disturbance in general, which includes incomprehensible
speech), and a distracter (chest pain). A composite score was created
by counting the number of correct multiple choice responses to the 5
suddens stroke symptoms, and the distracter was included to make the
test consistent with the Behavioral Risk Factor Surveillance System
survey.11 The maximum score that could be achieved was 6. A second
composite score was computed using all of the elements of the first
composite score with the addition of calling 911. The maximum score
that could be achieved was 7. We also assessed knowledge of stroke
localization in the brain and the term brain attack (a stroke alias).
Statistical Analysis
χ2 analyses were used for group-wise comparisons for each stroke
knowledge question relative to test sequence. Wilcoxon signed-rank
tests were used to compare improvement among individual subjects
across the testing sequence for overall composite scores of stroke
symptom knowledge. Multinomial logistic regression was used to
study the effect of website access on composite knowledge scores.
All tests were 2-sided, with P<0.05 considered statistically significant. All analyses were conducted using IBM SPSS version 20.
Results
Two hundred ten children completed pre-test, 205 completed
IP, and 198 completed delayed post-test (94% retention).
Twenty-five percent of children had a personal experience
with stroke victims. Ninety percent of children reported liking the game, whereas 6% did not like the game (4% did not
respond). There was significant improvement of stroke symptom composite scores, calling 911, and all individual stroke
knowledge items across the testing sequence (all P values
<0.05; Figures 2 and 3). Interestingly, we observed further
increases in knowledge of 3 of 5 stroke symptoms from IP to
delayed post-test (sudden imbalance, sudden facial droop, and
sudden headache). There were no significant sex differences
in post-test stroke knowledge composite scores (P=0.98).
Post hoc we explored the possibility of whether accessing our
game online after initial exposure improved stroke knowledge
scores. Of 156 children (74%) who reported having Internet
access at home, 67% reported they were confident or very
confident that they would play the game at home. However,
only 41 children (26%; of which 25 were girls) played the
game remotely between IP and delayed post-test. Composite
stroke knowledge scores were not significantly different
between children who played remotely and those who did not
(P=0.71), although we found a significant increase in knowledge of 1 symptom (sudden imbalance), favoring children
who were exposed at home (P=0.03), whereas most other
stroke symptoms showed nonsignificant trends that favored
increased knowledge among remote players.
Discussion
Our results show that playing a stroke video game for 15 minutes may improve actionable stroke knowledge of children,
which may be retained for ≈7 weeks. In addition, we found
that one quarter of children (mostly girls) accessed the video
game from home as a leisurely activity and that these children demonstrated some additional improvement in stroke
Figure 1. Screenshots from Clot Buster stroke video game. The video game can be played at http://hiphoppublichealth.org/#!/check-this/
(registration required).
Williams et al Effect of a Video Game on Children’s Stroke Knowledge 891
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Figure 2. Frequency of correct stroke knowledge responses. Pre-test (PT) vs immediate post-test (IP): a, P<0.001; b, P<0.01; c, P<0.05;
PT vs delayed post-test (DP, 7 weeks): d, P<0.001; e, P<0.05; PT vs IP and PT vs DP: P values are based on χ2 tests. Localization, stroke
alias, and calling 911 were all multiple choice questions with 4 possible answers (expected correct=25% if subjects had no knowledge),
whereas all others were Yes/No (expected correct=50% if subjects had no knowledge). The localization question regarded in which organ
in the body a stroke occurs, the stroke alias question targeted the term brain attack, and the calling 911 question offered 4 options for
stroke action.
knowledge compared with those who did not access the video
game from home.
Although novel to stroke information, incorporating health
information into video games is in itself not new. Indeed,
educational video games have led to increased nutritional
knowledge and eating behaviors,12,13 reduced diabetes mellitus–related emergency department visits by children and
adolescents with type 1 diabetes mellitus,14 and improved
adherence to chemotherapy and treatment plans by adolescent
patients with cancer.15
Our study has several limitations. We used a quasiexperimental pre-test post-test design with a relatively small convenience sample size, and our study did not have a control
group. We instead compared test performance with baseline
measures to minimize disruption of classroom activity by a
control program without anticipated educational gain as evidenced by the eighth-grade control subjects in another study16
where only slight improvement or worse performance was
found for stroke education outcome measures. We used identical measures at each assessment, which is vulnerable to
priming effects. Despite 67% of children reporting confidence
that they would play the video game at home, only 26% actually did. We did not quantify the frequency and duration of
each remote video game encounter in our analysis, nor did
we explore reasons for the discrepancy between children who
said they would play remotely and those who actually did. In
addition, we did not account for possible contamination of our
sample by other local stroke programs and campaigns during
our study period, although we were not aware of any. Finally,
we did not perform a cost–benefit analysis of the stroke video
game.
Overall, our findings demonstrate that a stroke video game
may be an innovative method for improving and sustaining
actionable stroke knowledge among young children.
Figure 3. Stroke knowledge
before and 7 weeks after video
game exposure.
892 Stroke March 2014
Acknowledgments
We thank our Hip Hop Public Health team, and New York City Council.
Sources of Funding
Supported by National Institutes of Health/National Institute of
Neurological Disorders and Stroke 1 R01 NS067443-01A1 (to O.W.,
Principal Investigator).
Disclosures
None.
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Effect of a Novel Video Game on Stroke Knowledge of 9- to 10-Year-Old, Low-Income
Children
Olajide Williams, Mindy F. Hecht, Alexandra L. DeSorbo, Saima Huq and James M. Noble
Downloaded from http://stroke.ahajournals.org/ by guest on June 18, 2017
Stroke. 2014;45:889-892; originally published online January 30, 2014;
doi: 10.1161/STROKEAHA.113.002906
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2014 American Heart Association, Inc. All rights reserved.
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