Development, feasibility and acceptability of a gamified cognitive DEvelopmental assessment on an E-Platform (DEEP) in rural Indian pre-schoolers – a pilot study

Figures & data

Table 1. Demographic and prior smartphone exposure details of participants in the three sets of household visits that were conducted in this study.

Demographic details	Formative visit 1 (N = 10)	Formative visit 2 (N = 10)	Pre-pilot visit (N = 100)
	% or Mean (SD)
Mean age, months	37.4 (1.6)	37.1 (2.3)	37.2 (1.0)
Gender, male	50%	40%	50%
Mean height, cm	88.8 (4.8)	91.4 (3.3)	90.2 (3.9)
Stunted (HAZ< – 2SD)	50%	11%	31.3%
Mean weight, kg	11.9 (1.7)	11.5 (1.1)	11.8 (1.4)
Underweight (WAZ< – 2SD)	44%	22%	29%
Mean head circumference, cm	–	48.7 (1.3)	47.6 (1.9)
Exposure to schooling
Attending private preschool	50%	30%	11%
Attending Anganwadi Centre	70%	10%	12%
Prior smartphone exposure
Previously used smartphones	40%	80%	86%
Frequent user (within last 24 hrs)	–	62.5%	62%
Reasons for using smartphone
Listening to music	–	70%	57%
Watching videos	–	20%	29%
Playing games	–	70%	59%
Seeing photos	–	20%	23%
Browsing internet	–	0%	2%

Table 2. Summary of the iterative process of game development.

Phase	Approach	Games	Learnings	Impact on game development
Phase 1 – Game conceptualization	Expert consultation and rapid review of cognitive and gaming literature	N/A	Identified memory, reasoning, response inhibition, divided attention, visual form perception and visual integration as domains of cognition integral to learning Numerous games testing individual cognitive domains are available off-the-shelf and have a wide range of front-end graphics, music and user interfaces	Identified off-the-shelf games that primarily assess each of these domains. Multiple games testing the same cognitive domain were identified to enable characterization of front end features that are attractive/distracting to children
Phase 2 – Formative visits	Household visits stage 1 (N = 10)	Off-the-shelf games targeting the domains identified during conceptualization	Children were easily engaged by tablet-based games for 20–30 minutes Tapping on tablets came naturally, drag-and-drop is a tougher gesture Identified elements of game interface that were conducive or distracting for gameplay Identified the importance of use of narrative, music and positive reinforcement	Designed game to be 20–30 minutes long Administered tapping games first followed by drag-and-drop games Used elements of game design that were conducive for game play Integrated an upbeat musical soundtrack and confetti/applause as positive feedback; brainstormed potential narratives that would engage children
	Household visits stage 2 (N = 10)	Alpha versions of game being developed in this study	Some games showed saturation of child performance while others were too difficult Children enjoyed the preliminary narrative tested	Number and order of difficulty levels in each game and their timers determined Independent games integrated into a first-person narrative
Phase 3 – Pilot study	Household visits (N = 100)	Beta version of game being developed in this study	Number of children playing game levels decreases as difficulty increases Accuracy decreases as difficulty increases Completion time increases as difficulty increases	DEvelopmental Assessment on an E-Platform (DEEP) ready for validation against a gold standard measure of development

Figure 1. Cognitive domains tested by each game.

Table 3. The games used in the assessment.

Game name (abbreviation) and description	Snapshot	Primary domain tested	Instruction for play	Start rules	Difficulty levels (no. of levels)	Backend data metrics
Single Tap (ST) Single balloon presented which released stars when tapped.		Manual processing speed	Pop this balloon as fast as you can	Child pops the balloon 5 times	NA	Correct and incorrect taps with time stamps
Alternate Tap (AT) Two balloons presented. Each faded into a shadow when tapped while the alternate balloon retained its colour.		Manual processing speed and coordination	Pop these balloons alternately as fast as you can	Child pops the balloons alternately 3 times	NA	Correct, incorrect and background taps with time stamps
Popping Bubbles (PB) Balloons spawned from bottom to top.		Manual processing speed and coordination	Pop as many balloons as you can	Child pops 5 balloons	Increased speed of spawning balloons (2)	Correct and background taps with time stamps
Grow Your Garden (GYG) Water buckets and bugs presented randomly which, when tapped, resulted in a flower appearing and disappearing respectively.		Response inhibition	Touch the bucket, do not tough the bug	Child touches 3 buckets and avoids 2 bugs	Stimuli presentation changed from distinct to overlapping and time reduced from 3–1 second (4)	Correct, incorrect and background taps with time stamps
Hidden Objects (HO) Multiple monsters simultaneously hide in different locations		Divided attention	Touch the hiding place of the characters	Child taps correct locations and no incorrect ones	Increased number of characters with ratio of potential hiding places fixed at 1:2 (5)	Correct, incorrect and background taps with time stamps
Odd One Out (OOO) Four objects presented amongst which three were identical and one distinct.		Reasoning	Touch the object which is different from the other 3	Child taps correct object and no incorrect one	Objects differed on either colour, size, shape or category (4)	Correct, incorrect and background taps with time stamps
Matching Shapes (MS) Objects presented on the left with their outlines on the right. Each object had to be moved to its outline.		Visual form perception	Drag the objects to their matching shadows	Child is able to match 2 objects to their shadow	Increased similarity between objects presented together (5)	Correct and incorrect drags with time stamps
Jigsaw (JIG) Animal parts presented on the left with the outline of the complete animal on the right. Each part had to be moved to its outline to create the whole animal.		Visual integration	Drag the parts of the animal to its shadow to make a whole	Child is able to complete a 2-piece jigsaw	Increased number of pieces of jigsaw and similarity between them (6)	Correct and incorrect drags with time stamps
Location recall (LR) The moon hid behind one of multiple hiding places on a planet. The child had to recall the moon’s hiding location after completing each game listed above.		Memory	Touch the hiding place of the moon	Child taps correct location and no incorrect one	Increased number of possible hiding places (8)	Correct, incorrect and background taps with time stamps

Figure 2. Performance of children on beta version the games during pilot study (n = 100); L1-L6 represent increasing difficulty levels within each game. (a) Number of children reaching game levels for all games. LR is not represented since it was integrated within the narrative and thus all children played all levels; (b) Mean accuracy as percentage correct taps/drags across game levels (error bars are standard error means); (c) Mean completion time for HO, OOO, MS and JIG (error bars are standard error means). Data for ST, AT, PB and GYG is not represented (see results for reasons). (d) Histograms of accuracy and completion time in LR.

Table 4. Qualitative interview results.

Category	Theme	Quote
Before the visit	Understanding of assessment during consenting	‘They [assessors] will tell me about my child’s mental development and I will also find out how smart he [the child] is’ Mother of 912#06#008#NA#01
	Family’s anticipation of visit	‘I got to know that you would come and that made me happy.’ Mother of 922#01#016#DX#01 ‘I felt kind of nervous as to how he will perform. I also wondered that if he won’t be able to do these things then what if they find a weakness in him.’ Mother of 922#01#091#BY#01
During the visit	Children’s interest in DEEP	‘[Child’s name] was happy and she was clapping and she was telling me that when madam will come again I will play again and burst balloons.’ Mother of 916#05#233#KU#01 ‘Even after two days of them leaving, [child’s name] asked me when they [assessors] were going to come back and if they would come back with the tablet.’ Mother of 912#06#008#NA#01
	Reasons for lack of instant engagement	‘When a stranger from outside comes to the house, then the child gets a little scared on seeing them’ Mother of 912#06#008#NA#01 ‘It so happened [lack of instant engagement] because she [child] saw you all [assessors] for the first time and children do get a little nervous on seeing strangers.’ Mother of 916#05#391#RA#01