Comparing Game-Based and Virtual Objective Structured Clinical Examination Formats: Perceived Fairness and Achievement Emotions in Clinical Competency Examinations for Low- and Middle-Income Countries

Assessment formats shape not only what is measured, but also how examinees experience high-stakes evaluation. While Objective Structured Clinical Examinations (OSCEs) remain a cornerstone of clinical competency assessment, they can induce anxiety and raise concerns about fairness. Digital game-based assessment (DGBA) offers an alternative interaction paradigm in which assessment is embedded within a standardized digital environment. Focusing on perceived fairness and test-related achievement emotions, we conducted a mixed-methods study comparing a DGBA platform (ENTRUST) and virtual OSCEs during a high-stakes surgical certification examination involving trainees across sub-Saharan Africa. Quantitative findings showed that ENTRUST was associated with lower test-related anxiety, higher enjoyment, and stronger perceptions of fairness, objectivity, and absence of bias than virtual OSCEs. Qualitative findings helped explain these differences by showing how assessment interaction characteristics such as evaluator presence, pacing, structured autonomy, feedback visibility, and interaction structure shaped examinees’ perceptions of control and consistency. Together, these findings highlight assessment as an interaction design problem, suggesting that differences in emotions and perceived fairness arise not simply from assessment content or game elements but from the broader interaction design of assessments. We conclude with implications for designing DGBAs for professional training and certification.