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

Gamified formative assessment has emerged as a promising learner-centered educational strategy to enhance student engagement and learning in higher education. Although Kahoot-based formative assessment has been associated with favorable educational outcomes across health professions education, evidence regarding its influence on students’ psychological outcomes, particularly anxiety and coping strategy utilization, remains limited in undergraduate physiotherapy education. This study investigated the effects of repeated Kahoot-based formative assessment on anxiety, changes in total Coping with Stress Inventory (CSI) scores, motivation, satisfaction, and perceived knowledge retention compared with traditional paper-based quizzes. In this randomized controlled trial, 131 undergraduate physiotherapy students were randomly allocated to either a Kahoot group ( n = 65) or a paper-based group ( n = 66) within their respective courses. Within each course, both groups completed identical formative quizzes over four consecutive weeks. Test anxiety, state anxiety, trait anxiety, and total CSI scores were assessed before and after the intervention, while motivation toward the instructional material, satisfaction with the instructional method, and perceived knowledge retention were evaluated post-intervention. For outcomes assessed at baseline and post-intervention, between-group inferences were based on baseline-adjusted ANCOVA models, with within-group and change-score analyses used as supportive analyses. Baseline-adjusted analysis demonstrated a significant between-group difference in the primary outcome of test anxiety, with lower adjusted post-intervention scores in the Kahoot group than in the paper-based group. Secondary/exploratory analyses also showed nominally significant between-group differences in state anxiety and total CSI scores. For trait anxiety, the homogeneity of regression slopes assumption was not met; therefore, the conventional baseline-adjusted group effect was not interpreted. Secondary/exploratory post-intervention comparisons also showed nominally significant differences in motivation toward the instructional material, satisfaction with the instructional method, and perceived knowledge retention. Repeated Kahoot-based formative assessment was associated with differences in psychological and student-reported educational outcomes compared with traditional paper-based quizzes. The findings suggest that Kahoot-based formative assessment may be associated with lower test anxiety. Secondary/exploratory findings also indicated differences in state anxiety, total CSI scores, motivation, satisfaction, and perceived knowledge retention; however, these findings should be interpreted cautiously. Perceived knowledge retention was assessed using a single self-report item and should not be interpreted as evidence of objectively improved knowledge retention or learning effectiveness. ClinicalTrials.gov, NCT07554534. Retrospectively registered on April 21, 2026.