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2007; 29: 833–835
SHORT COMMUNICATION
Survey of attitudes towards curriculumreforms among medical teachers indifferent socio-economic and culturalenvironments
VLADIMIR J. SIMUNOVIC1, DARKO HREN2, ANA IVANIS2, JENS DØRUP3, ZDENKA KRIVOKUCA4,SINISA RISTIC5, HENRI VERHAAREN6, HANS-GUNTHER SONNTAG7, SAMO RIBARIC8,SNJEZANA TOMIC9, BENJAMIN VOJNIKOVIC10, HAJRIJA SELESKOVIC11, MADS DAHL3, ANA MARUSIC2
& MATKO MARUSIC2
1Mostar University School of Medicine, Bosnia and Herzegovina, 2Zagreb University School of Medicine, Croatia, 3AarhusUniversity School of Medicine, Denmark, 4Banja Luka University School of Medicine, Bosnia and Herzegovina, 5FocaUniversity School of Medicine, Bosnia and Herzegovina, 6Ghent University School of Medicine, Belgium, 7HeidelbergUniversity School of Medicine, Germany, 8Ljubljana University School of Medicine, Slovenia, 9Split University School ofMedicine, Croatia, 10Sarajevo University School of Medicine, Bosnia and Herzegovina, 11Tuzla University School of Medicine,Bosnia & Herzegovina
Abstract
Background: Curriculum reforms in medical schools require cultural and conceptual changes from the faculty.
Aims and Methods: We assessed attitudes towards curriculum reforms in different academic, economic, and social environments
among 776 teachers from 2 Western European medical schools (Belgium and Denmark) and 7 medical schools in 3 countries
in post-communist transition (Croatia, Slovenia, Bosnia and Herzegovina). The survey included a 5-point Likert-type scale on
attitudes towards reforms in general and towards reforms of medical curriculum (10 items each).
Results: Teaching staff from medical schools in Bosnia and Herzegovina had a more positive attitude towards reforms of medical
curriculum (mean score 36.8 out of maximum 50 [95% CI 36.1 to 37.3]) than those from medical schools in Croatia or Slovenia
(30.7 [29.8 to 31.6]) or Western Europe (27.7 [27.1 to 28.3]) (P < 0.001, ANOVA). Significant predictors of positive attitudes towards
medical curriculum reform in post-communist transition countries, but not in Western European schools, was younger age,
as well as female gender in Bosnia and Herzegovina.
Conclusions: Factors influencing faculty attitudes may not be easy to identify and may be specific for different settings.
Their identification and management is necessary for producing sustainable curriculum reform.
Introduction
Curricular reform is the main feature of medical education in
the new millennium, as an answer to expanding knowledge
base and professional competencies in medicine (Leinster
2002). This change is global but local reforms have to take
into consideration the particularities of specific national,
organizational, cultural and socio-economic issues (Institute
for International Medical Education 2002). Many central and
eastern European countries in post-communist socio-
economic transition, which have just joined or are striving
to join the European Union (EU), have specific problems
related to the political and socioeconomic framework in
which their medical curricula have been shaped in the past
(Dusek & Bates 2003). In war-thorn countries that emerged
from the former Yugoslavia, medical schools joined with
partners from Western Europe in restructuring medical
curricula within the framework of the Trans-European
Programme for Co-operation in Higher Education in
Central and Eastern Europe (Tempus) (Simunovic et al.
2006). As the first step towards the curriculum reform, we
assessed the attitudes towards curriculum reform among
medical teachers in a cross-sectional survey at 9 medical
schools from 5 European countries.
Methods
The survey questionnaire was developed and psychometri-
cally validated; it contained Likert-type statements about
curriculum reform (10 items) and reform of medical curriculum
(10 items), with scores from 1 – strongly disagree to 5 –
strongly agree. Cronbach’s alpha of the whole scale was 0.917.
The questionnaire was distributed to the members of the
faculty present at a regular faculty meeting or sent by e-mail to
faculty members. No attempts were made to recruit additional
responders. As the faculty sizes and response rates differed
among the schools (Belgium – Gent, n¼ 31, response rate
Correspondence: Professor Marusic, Croatian Medical Journal Zagreb University School of Medicine, Salata 3b, Zagreb 10000, Croatia.
Email: ana.marusic@agram.mef.hr
ISSN 0142–159X print/ISSN 1466–187X online/07/080833–3 � 2007 Informa UK Ltd. 833DOI: 10.1080/01421590701589201
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31%; Denmark – Aarhus, n¼ 201, 15%; Croatia – Split, n¼ 63,
30%; Slovenia – Ljubljana, n¼ 84, 30%; Bosnia and
Herzegovina – Banja Luka, n¼ 41, 14%; Foca, n¼ 61, 46%;
Mostar, n¼ 106, 48%; Sarajevo, n¼ 151, 64%; and Tuzla,
n¼ 38, 36%), statistical analysis was performed for three
groups of schools: EU countries (Belgium and Denmark), new
or candidate EU countries (Slovenia and Croatia) and Bosnia
and Herzegovina (Table 1).
Results
The scores on the total scale and subscales significantly
differed among the three groups of medical schools
(F1,836¼ 176.94, P < 0.001, partial �2¼ 0.31, Sheffe post hoc).
The total score on the attitudes towards reforms in general
for EU medical schools was around the neutral value and
significantly lower that the scores in schools either from the
new EU member (Slovenia), candidate member country
(Croatia), or from Bosnia and Herzegovina (Table 1). The
faculty from schools from Bosnia and Herzegovina had the
most positive attitudes among all respondents (Table 1).
We performed linear regression analysis for each group of
schools to examine the relationship between age, sex,
academic position, field of teaching, previous participation in
reforms, and attitudes towards reforms in general as predictors
for the score on the scale of attitudes towards medical reforms.
In Western European schools, only the attitude toward reforms
in general (�¼ 0.440, P < 0.001) was identified as a significant
predictor, explaining 18% of the variance. In Slovenia and
Croatia, the predictors were attitude toward reforms in general
(�¼ 0.596, P < 0.001) and younger age (�¼�0,216,
P¼ 0.037), explaining 42% of the variance. For schools from
Bosnia and Herzegovina, attitudes towards reforms in general
(�¼ 0.662, P < 0.01) younger age (�¼�0.146, P < 0.001), and
female gender (�¼ 0.095, P¼ 0.011) were significant predic-
tors, explaining 52% of the variance.
Discussion and conclusion
Our study showed that teachers in medical schools from
different socio-economic, political, cultural and historical
backgrounds differed in their attitudes towards medical
curriculum reforms and that common academic descriptors
of teaching staff, such as their age, gender, academic position,
teaching subjects, or experience in reforms were poor
predictors of their attitude towards curriculum reforms.
Although limited by its design, sampling procedure and
response rate, as well as self-reporting nature of the survey,
uniform assessment at multiple study sites in several countries
and large sample size increase the external validity of our
results. Whereas medical teachers from high-income Western
European countries had an indifferent attitude towards reforms
of medical curriculum, their colleagues from either a new high
income EU member country (Slovenia) or EU candidate
country with upper middle income economy (Croatia) had
moderately positive attitudes. In contrast, teachers from Bosnia
and Herzegovina, country with lower middle income economy
and a heavy burden or war destruction and political and ethnic
divisions (Simunovic et al. 2006), had very positive attitudes
towards reforms. Medical teachers from developed countries,
who have been engaged in curriculum reform from the 1990s,
now leave an impression that they are either tired of the
reforms or satisfied with current educational system in their
country. Rapid restructuring at all levels of the society in post-
communist countries after many years of a repressive regime
may have had a positive effect also on the sector of medical
education in Slovenia, Croatia and Bosnia and Herzegovina, all
members of the former Yugoslavia, which dissolved in a brutal
war in 1990s (Andelinovic et al. 2005). This may be particularly
relevant for Bosnia and Herzegovina, where the attitudes
towards reforms were most positive, and where the possible
reform would be welcomed primarily by young, female
clinical teachers. As in developed countries, women physi-
cians in post-communist lag even more behind their male
colleagues in academic advancement and retention, although
they have been a significant majority among graduating
physicians since the early 1970s (Danic et al. 2003).
These results are important for curriculum reform efforts at
the global level (Institute for International Medical Education
2002) because they show that approaches to any reform must
address local specificities. In order to understand how to
change attitudes for curriculum reform, we obviously have to
adopt approaches outside of medical sciences and look for
theories and evidence from social, behavioural and business
Table 1. Attitudes of medical teachers towards reforms and subscales on reforms in general and reforms in medical curriculum in medicalschools from different socio-economic and cultural settings in Europe.
Attitude score (mean, 95% confidence interval)*
Medical school settingTotal
(range 20–100)Reform in general
(range 10–50)Reform of medical curriculum
(range 10–50)
European Union (EU) countries(2 schools, n¼232) 57.9 30.2 27.7
(56.9 to 58.9) (29.6 to 30.8) (27.1 to 28.3)
New EU members or candidates(2 schools, n¼ 147) 65.2 34.3 30.7
(63.5 to 66.9) (33.3 to 35.3) (29.8 to 31.6)
Bosnia and Herzegovina(5 schools, n¼ 397) 76.1 39.2 36.8
(74.9 to 77.3) (38.5 to 39.8) (36.1 to 37.3)
*Scores on all scales significantly differed among all three groups of medical schools (P < 0.001, mixed within-between subjects ANOVA).
V. J. Simunovic et al.
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sciences (Hofstede et al. 2002; Bowe et al. 2003). The situation
with global efforts in medical curriculum reform is
perhaps most similar to international business strategic
alliances – operations that depend on interaction with local
environments, which may hold different expectations, goals,
and value systems (Hofstede et al. 2002). Similarly, factors
influencing faculty attitudes towards medical reforms may not
be easy to identify and may be specific for different settings,
but their identification and management at local level and
harmonization with globally agreed goals are necessary for
producing sustainable curriculum reforms.
Notes on contributors
VLADIMIR J. SIMUNOVIC, MD, PhD, is the Professor of Neurosurgery at the
School of Medicine and Vice-dean for Science at the College of Nursing of
the University of Mostar, Bosnia and Herzegovina. He was the coordinator
for the TEMPUS project DICTUM, which addressed curriculum reform at
medical schools in Bosnia and Herzegovina.
DARKO HREN, BS, is a psychologist, working on his doctoral thesis on
moral reasoning at the Zagreb University School of Medicine, Zagreb,
Croatia. He is also senior statistical editor for the Croatian Medical Journal,
and teaches principles of research.
ANA IVANIS, MD, is a doctoral fellow at the Zagreb University School of
Medicine, Zagreb, Croatia. The topic of her thesis is authorship issues in
scientific journals. She is also manuscript editor in the Croatian Medical
Journal.
JENS DØRUP, MD, PhD, was the Associate Professor of Medical Informatics
and Head of the E-learning Unit of the University of Aarhus. Prof. Dørup
died in 2006, after this manuscript was submitted to the Medical Teacher.
ZDENKA KRIVOKUCA, MD, PhD, is the Professor of Anatomy at the Banja
Luka University School of Medicine, Banja Luka, Bosnia and Herzegovina.
SINISA RISTIC, MD, PhD, is the Assistant Professor at the Department
of Physiology, Foca University School of Medicine, Foca, Bosnia and
Herzegovina.
HENRI VERHAAREN, MD, PhD, is the Professor of Pediatric Cardiology and
Documentary Information, as well as the Director of the Biomedical
Library, University and University Hospital Ghent, Ghent, Belgium.
HANS-GUNTHER SONNTAG, MD, PhD, is the Professor of Hygiene and
Dean Emeritus, Heidelberg University School of Medicine, Heidelberg,
Germany. Prof. Sonntag introduced a novel and highly successful
HEICUMED curriculum at the Heidelberg School of Medicine and has
been the contractor of several TEMPUS grants for curriculum reform in
Bosnia and Herzegovina, including the DICTUM, under which this research
was performed.
SAMO RIBARIC, MD, PhD, is the Assistant Professor of Pathophysiology at
the Institute of Pathophysiology, Ljubljana University School of Medicine,
Ljubljana, Slovenia. Prof. Ribaric was the member Curriculum Reform
Commission at the Ljubljana School of Medicine.
SNJEZANA TOMIC, MD, PhD, is the Assistant Professor of Pathology,
Department of Pathology, Split, University School of Medicine, Split,
Croatia.
BENJAMIN VOJNIKOVIC is Secretary General of the Sarajevo University
School of Medicine, Sarajevo, Bosnia and Herzegovina.
HAJRIJA SELESKOVIC, MD, PhD is the Professor of Internal Medicine and
former dean of the Tuzla University School of Medicine, Tuzla, Bosnia and
Herzegovina.
MADS DAHL, MSc, PhD, is the Assistant Professor at the Section for Health
Informatics, Aarhus University School of Medicine, Aarhus.
ANA MARUSIC, MD, PhD, is the Professor of Anatomy at the Zagreb
University School of Medicine, Zagreb, Croatia. She also teaches scientific
communication to medical students and is the co-editor in Chief of the
Croatian Medical Journal.
MATKO MARUSIC, MD, PhD, is the Professor of Physiology and
Immunology at the Zagreb University School of Medicine, Zagreb,
Croatia. He is the founder of the Croatian Medical Journal and its
Co-editor in Chief. Prof. Marusic introduced a mandatory course on
principles of research into the medical curriculum in Croatia.
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Curriculum reforms among medical teachers
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