JMIR Publications

ABSTRACT

Background:

Rising rates of youth mental health difficulties have led to an increased focus on initiatives for improving the mental wellbeing of young people. Digital mental health interventions (DMHIs), including serious games and the use of extended reality interventions, show promise, offering novel opportunities for delivering effective, evidence-based support. However, the factors that influence engagement and mechanisms of change remain underexplored, particularly for augmented reality (AR) games.

Objective:

This study aimed to explore processes of engagement and identify mechanisms of change in Dragons of Afterlands, a co-designed AR multiplayer serious game for adolescent wellbeing. A secondary aim was to generate a theoretical model to highlight psychological mechanisms of change that can inform future development of similar interventions.

Methods:

A qualitative study using constructivist Grounded Theory was conducted within a mixed-methods intervention trial. Thirty-one young people aged 11–14 years from two UK secondary schools participated in focus groups, live gameplay audio recordings, field observations, and written feedback regarding the four-week intervention. Data were analysed iteratively using line-by-line, focused and theoretical coding to identify engagement factors and change mechanisms, and how these factors interplayed to promote wellbeing.

Results:

Engagement was driven by the interaction between individual factors, social processes, digital features and game design factors, and the environmental context. The novelty of AR gameplay, narrative immersion, interactive opportunities and progression, supported sustained motivation, although technological glitches and limited relatability of content were considered barriers to engagement. Social interactions emerged as a central engagement driver and mechanism of change. The multiplayer format fostered social development, including connection with others, communication and confidence, and the combined digital and physical environment created a psychologically safe space for disclosure, shared problem-solving and rehearsal of coping strategies, with some evidence of skill transfer beyond sessions. Cognitive-emotional development was facilitated through challenges embedded in the game, storytelling, and structured choices that promoted reflection, perspective-taking, emotional awareness and problem-solving. Positive affect arose from enjoyment from playing, and spending time with others in a calm and supportive environment. This functioned both as reinforcement for engagement and a psychological mechanism of change. Together, social, cognitive-emotional, and affective processes cited, may contribute to hedonic and eudaimonic aspects of wellbeing.

Conclusions:

This study provides the first qualitative model integrating engagement processes and psychological mechanisms within an AR serious game for adolescent wellbeing. Findings suggest that combining immersive digital features with real-world social interaction may enhance both sustained engagement and therapeutic impact. Robust technology, personalisation and relatable content appear important for optimising change processes. The proposed model offers a framework to guide refinement and future evaluation of AR-based wellbeing interventions.