Quiz Game Showed Lower Test Anxiety in Physiotherapy Students, Trial Finds

A gamified quiz platform that turns classroom testing into a fast-paced competition may do more than entertain students: it appears to ease the anxiety that exams routinely produce. A randomized controlled trial conducted with undergraduate physiotherapy students in Türkiye found that those who took repeated formative quizzes through Kahoot reported significantly lower test anxiety than peers who completed identical quizzes on paper. The study, published in BMC Medical Education by Elif Durgut and Sefa Yildirim of Bezmialem Vakif University in Istanbul, is among the first to rigorously compare the psychological consequences of gamified and traditional formative assessment in physiotherapy curricula, an area where the evidence on students’ emotional responses has been notably thin.

The trial enrolled 131 undergraduate physiotherapy students, randomly assigning 65 to a Kahoot group and 66 to a paper-based group within their respective courses. Over four consecutive weeks, both groups answered exactly the same formative quizzes; the only difference was the delivery format. Randomization is the trial’s critical strength, because it distributes confounding factors such as baseline ability, prior exam history, and personality evenly between the arms, allowing any post-intervention differences to be attributed with reasonable confidence to the assessment method itself rather than to who happened to be in each group.

The researchers measured a broad psychological battery before and after the four-week intervention. Their primary outcome was test anxiety, complemented by state anxiety, trait anxiety, and total scores on the Coping with Stress Inventory, a validated instrument that captures how people respond to stressors. Because baseline levels of anxiety vary considerably between individuals, the team used baseline-adjusted analysis of covariance, or ANCOVA, as the main statistical approach. ANCOVA statistically controls for each participant’s pre-intervention score, which increases precision and reduces the influence of chance imbalances at baseline, while within-group and change-score analyses were reported as supportive rather than decisive evidence.

On the primary outcome, the adjusted analysis showed a significant between-group difference: the Kahoot group ended the intervention with lower adjusted post-intervention test anxiety scores than the paper-based group. This finding carries particular weight because test anxiety is not merely an unpleasant feeling. Decades of educational psychology research link elevated test anxiety to impaired working memory function during examinations, avoidance of assessment situations, and, ultimately, underperformance that may not reflect a student’s actual competence. If a low-cost digital format reliably reduces that burden, the implications reach well beyond a single course.

The secondary and exploratory analyses added a broader picture, though the authors are careful to flag their provisional status. Nominally significant between-group differences emerged in state anxiety, the transient, situational form of anxiety measured by the state subscale of the State-Trait Anxiety Inventory, and in total Coping with Stress Inventory scores. Post-intervention comparisons also suggested differences in motivation toward the instructional material, satisfaction with the instructional method, and perceived knowledge retention, all favoring the gamified format. Motivation was assessed with a single-use version of the Instructional Material Motivation Scale, an instrument grounded in self-determination theory, which frames autonomy, competence, and relatedness as engines of intrinsic drive.

One measure refused to fit the statistical mold. For trait anxiety, the stable dispositional component of the anxiety construct, the homogeneity of regression slopes assumption underlying ANCOVA was not met. That assumption requires the relationship between the baseline score and the outcome to be similar in both groups; when it fails, the conventional baseline-adjusted group effect becomes misleading. The authors appropriately declined to interpret that comparison, a methodological restraint that strengthens the credibility of the findings they did report. In an era when statistical shortcuts are common in education research, such transparent handling of a violated assumption is worth noting.

The study’s authors are equally candid about the limits of the perceived knowledge retention result. That outcome rested on a single self-report item, and they explicitly caution that it should not be read as evidence of objectively improved knowledge retention or learning effectiveness. Students in the Kahoot group felt they remembered more, but feeling is not measuring. Genuine learning gains would require objective testing of knowledge at delayed time points, and the trial did not include such an assessment. This distinction between perceived and actual learning is one of the most common pitfalls in gamification research, where engaging formats can inflate subjective impressions without necessarily changing what students know.

Why might a game-show-style quiz calm exam nerves? Several mechanisms are plausible within existing theory. Gamified quizzes are typically low-stakes, with points and leaderboards replacing grades, which reframes the event as play rather than judgment. Immediate feedback after each question turns errors into information rather than failure, potentially reducing the fear of being wrong that drives test anxiety. The social, competitive energy of a shared game may also foster relatedness and positive arousal, and repeated exposure to quiz conditions over four weeks could function as a form of exposure, gradually habituating students to the testing situation itself. The coping inventory difference suggests the format may even shift how students appraise and manage academic stress more broadly.

Formative assessment, the practice of testing to support learning rather than to certify it, has long been recognized as one of the most powerful interventions in higher education, and health professions programs have been actively seeking learner-centered ways to deliver it. Kahoot and similar platforms are already ubiquitous in classrooms worldwide, often adopted on intuition rather than evidence. Trials like this one matter because they test that intuition. The trial was retrospectively registered on ClinicalTrials.gov as NCT07554534 on April 21, 2026, received ethics approval from the Bezmialem Vakif University Non-Interventional Research Ethics Committee under approval number 2024/345, and proceeded with written informed consent from all participants in accordance with the Declaration of Helsinki. The authors declared no funding and no competing interests.

The practical message for educators is cautiously encouraging. Repeated Kahoot-based formative assessment was associated with lower test anxiety, lower state anxiety, different stress coping scores, higher motivation, greater satisfaction, and higher perceived retention compared with paper quizzes over four weeks of identical content. The primary test anxiety result carries the strongest statistical footing, while the remaining outcomes are secondary or exploratory and demand replication with objective learning measures before firm conclusions are drawn. For physiotherapy programs, and for any discipline weighing whether to trade paper quizzes for a smartphone-based game, the study offers a reasonable, evidence-backed nudge toward the gamified format, provided instructors remember that a student’s confidence in their memory is not the same as the memory itself.

Subject of Research: Effects of gamified Kahoot-based formative assessment on anxiety, stress coping, and motivation in undergraduate physiotherapy students

Article Title: Effects of repeated Kahoot-based formative assessment on anxiety, stress coping, and motivation in undergraduate physiotherapy education: a randomized controlled trial

Article References: Effects of repeated Kahoot-based formative assessment on anxiety, stress coping, and motivation in undergraduate physiotherapy education: a randomized controlled trial. (n.d.). https://doi.org/10.1186/s12909-026-10603-1

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10603-1

Keywords: Kahoot, formative assessment, test anxiety, gamification, physiotherapy education, randomized controlled trial, motivation, stress coping, medical education, state anxiety, self-determination theory, ANCOVA