Currently submitted to: Journal of Medical Internet Research
Date Submitted: Nov 20, 2025
Open Peer Review Period: Nov 20, 2025 - Jan 15, 2026
(closed for review but you can still tweet)
NOTE: This is an unreviewed Preprint
Warning: This is a unreviewed preprint (What is a preprint?). Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn (a note "no longer under consideration" will appear above).
Peer review me: Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period (in this case, a "Peer Review Me" button to sign up as reviewer is displayed above). All preprints currently open for review are listed here. Outside of the formal open peer-review period we encourage you to tweet about the preprint.
Citation: Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author).
Final version: If our system detects a final peer-reviewed "version of record" (VoR) published in any journal, a link to that VoR will appear below. Readers are then encourage to cite the VoR instead of this preprint.
Settings: If you are the author, you can login and change the preprint display settings, but the preprint URL/DOI is supposed to be stable and citable, so it should not be removed once posted.
Submit: To post your own preprint, simply submit to any JMIR journal, and choose the appropriate settings to expose your submitted version as preprint.
Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.
Serious Gaming for Adolescent Mental Health in South Africa: A Quasi Experimental Pilot Study of the StepWell Saga
ABSTRACT
Background:
Adolescents in low- and middle-income countries face a growing mental health burden, with African pooled estimates of “mental health distress” approaching one in four. Adolescent mental health disorders are highly prevalent in South Africa, with treatment gaps exceeding 75% in public sector settings. Digital serious games show promise for delivering psychoeducation and cognitive behavioral skills at scale, though effect sizes and engagement vary across trials.[1,6]
Objective:
To evaluate the feasibility, reach, and preliminary effectiveness of StepWell Saga, a mobile serious game designed to educate South African adolescents and young adults about mental health and to build emotional resilience.
Methods:
We conducted a quasi-experimental, non-equivalent group study with a waitlisted control design. Participants aged 18–24 years were recruited nationally via digital platforms and randomized to either the (1) intervention (game access + pre- and post- mental health assessments) or (2) control (pre- and post- mental health assessments only) groups. Outcome measures included depressive symptoms (PHQ9), anxiety (GAD7), a brief mental wellness score, mental health knowledge, and user satisfaction. Qualitative feedback was collected from a subset of participants. Ethics approval was granted by the FPD Research Ethics Committee (10 Oct 2023).
Results:
Of 1186 expressions of interest, 400 were enrolled; 24 intervention and 35 control participants completed post assessments. The public launch resulted in 2598 store downloads and 5982 APK downloads were recorded (though offline play limited telemetry). No statistically significant pre to post group differences were observed for PHQ9 or GAD7. Mental wellness improved within the intervention (mean +0.74; p=0.032) and was borderline significant in controls (p=0.049). None of the intervention participants progressed beyond level 15 (mental health content begins at level 4), indicating low dosage exposure. Qualitative themes included enhanced coping, perseverance, and feeling seen/supported. In routine screening, 64% (53/83) flagged for suicidal ideation and were referred (with consent) to crisis counselling.
Conclusions:
StepWell Saga demonstrated broad potential reach but limited in-study exposure and no group level symptom changes. Design and implementation refinements—shorter progression, improved art/gameplay, offline data caching, and embedded stealth/formative assessment—are warranted. Findings align with mixed evidence for youth mental health games and underscore the need for adequately powered, exposure assured trials.[6,5,8]
Citation
Request queued. Please wait while the file is being generated. It may take some time.
Copyright
© The authors. All rights reserved. This is a privileged document currently under peer-review/community review (or an accepted/rejected manuscript). Authors have provided JMIR Publications with an exclusive license to publish this preprint on it's website for review and ahead-of-print citation purposes only. While the final peer-reviewed paper may be licensed under a cc-by license on publication, at this stage authors and publisher expressively prohibit redistribution of this draft paper other than for review purposes.