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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