Many higher education institutions have experienced a significant expansion in the use of standardized, centralized assessments based on multiple-choice questions (MCQs) to assess a large numbers of students, often prioritizing scalability over depth of evaluation. This type of assessment offers organizational efficiency and standardization of evaluation criteria. However, educational literature indicates that the nature of the assessment system can directly influence students' learning strategies. In some educational settings, the heavy reliance on multiple-choice questions may lead students to focus on memorizing past exam questions or relying on online question banks rather than developing a deep conceptual understanding of the subject matter.

Moreover, current research has largely relied on self-reported study strategies, with limited focus on objective assessment of how students learn and apply knowledge in MCQ-dominated assessments. This work proposes a conceptual framework to examine potential misalignment between performance on MCQ-based assessments and conceptual understanding. The framework aims to examine the relationship between the structure of multiple-choice assessments and the learning approaches of undergraduate students in health science programs.

The proposed approach integrates analysis of students’ test preparation patterns and further examines their ability to apply scientific concepts to novel conceptual questions outside the traditional multiple-choice format. The approach aims to provide a more robust understanding of how assessment structures influence learning behaviors. This may support the development of more balanced assessment strategies that promote conceptual understanding and analytical thinking in higher education while preserving the practical efficiency needed in large-enrollment courses.