Reconfiguration of Allied Health Education in Portugal: Perspectives from Professionals, Professors and Researchers

Abstract

In 2013, Portugal implemented a major restructuring of Allied Health (AH) education by merging multiple separate first-cycle degree programmes into a smaller number of broader qualifications. The reform was designed to streamline curricula, increase efficiency, boost graduate employability, and align national qualifications with international standards. This study examines how Portuguese AH professionals, academics, and researchers perceive these reforms ten years on. A cross-sectional web-based survey collected 495 responses from AH stakeholders. Perceptions were quantified with a validated 21-item scale organised into three domains through exploratory factor analysis: (A) curricular change and structural effects; (B) educational quality and international harmonization; and (C) Professional Consequences of the Mergers. Differences between groups were examined by Kruskal–Wallis and Mann–Whitney U tests. There were notable differences by age, educational background, experience, and academic qualifications. Younger practitioners and post-merger graduates indicated more favourable perceptions of the reforms (Domains A and B), whereas older, pre-merger-trained, and doctoral-level respondents were more critical, especially regarding autonomy and specialization (Domain C). Views on the reform are influenced by generational, experiential, and academic factors. Individualized communication and policy-focused approaches are needed to promote stakeholder engagement and maintain the legitimacy of subsequent health education reforms in Portugal.

1. Introduction

In 2013, Portugal implemented a major restructuring of Allied Health (AH) education by merging multiple separate first-cycle degree programmes into a smaller number of broader qualifications. The reform was designed to streamline curricula, increase efficiency, boost graduate employability, and align national qualifications with international standards. Despite the reform’s national relevance, its long-term impact on professional identity, curricular adequacy, and the perceived quality of AH education has remained insufficiently investigated. This study seeks to fill that gap. Similar concerns have been reported across Europe, where Allied Health curricula continue to show heterogeneity and uneven alignment despite Bologna-driven harmonisation efforts (Reis et al., 2018; Sousa et al., 2022).

The reform was embedded in the wider context of the Bologna Process (BP), the intergovernmental initiative that, since 1999, has harmonised European higher-education systems through the adoption of comparable degree structures, the European Credit Transfer and Accumulation System (ECTS), and quality-assurance mechanisms (European Commission, 2022). By aligning Portuguese AH education with these principles, policymakers expected to increase transparency, mobility, and international recognition. Yet, the reform also generated debate about potential loss of disciplinary depth and professional specificity—an issue echoed in broader analyses of health professional education, which emphasise the tension between harmonisation and professional identity (Frenk et al., 2010; Vikestad et al., 2025).

The problem motivating this study stems from the lack of empirical research assessing how the merger of AH programmes affected professionals, academics, and researchers a decade after its implementation. Understanding stakeholders’ perceptions is crucial to evaluate the legitimacy and sustainability of higher-education reforms, particularly in professionally regulated fields, as highlighted by Frenk et al. (2010), who argued that health professional education worldwide has lagged behind systemic transformations due to fragmented and outdated curricula, and called for reform models that integrate stakeholder perspectives and social accountability.

This study is guided by the research question: “How do individual differences, professional background, and academic trajectories influence stakeholders’ perceptions regarding the implementation of AH education reforms driven by the merger of degree programmes?”.

By addressing this question, the research seeks to analyse the extent to which these variables have shaped and impacted AH education reform in Portugal over the last decade. By doing so, the study will generate a nuanced understanding of how diverse professional and academic profiles mediate systemic reforms, thereby contributing to the analysis of the broader international debate on higher education policy, professional identity, within which the accreditation-driven change AH education reform in Portugal.

The article is organised into five main sections. Following the introduction, the context and the AH education reform in Portugal are outlined, after which the methodology and survey design are presented. The subsequent sections report the results, interpret them through a critical discussion, and conclude with the study’s contributions and implications for future reforms.

1.1. Definition, Scope and Evolution of AH Education in Portugal

The concept of AH (in Portuguese known by Health Technologies) encompasses a set of professions within the healthcare delivery sector, distinguished from one another by the knowledge professionals must possess, the methodologies and techniques they master, and the specific technologies they employ (Pacheco & Lopes, 2013). The field of AH is broad and represents a diverse range of health disciplines, apart from nursing and medical practitioners. Those practitioners possess a set of specific technical skills, specialized knowledge, and professional practices. This group comprises both nationally registered professions (under the National Registration and Accreditation Scheme) and non-registered or self-regulated AH professions (McAllister & Nagarajan, 2015). AH practitioners are autonomous members of the healthcare team, accountable for the provision of safe, high-quality services to clients and their families in different sectors, contexts, and settings (Leslie et al., 2023). Each AH area has its scope of practice, and established capability frameworks that outline the competencies and practice standards required for specific functions, processes, roles, and professional outcomes (Batt et al., 2020). The professions included or considered as AH Professions (AHPs) (or the Portuguese de-nomination of Diagnostic and Therapeutic Technologies (DTT)), vary internationally and, in some cases, even between national contexts In England, for example, AHPs comprise 14 professionally autonomous professional groups, trained to bachelor’s degree level or equivalent (Etty et al., 2024). In Portugal, legislative revisions redefined the career pathway and professional titles in the AH sector to reflect advances in scientific and professional development. The updated framework covers 18 professions, namely: Clinical and Public Health Laboratory Technician; Pathology, Cytology, and Thanatology Technician; Audiologist; Cardiopulmonary Technician; Dietitian; Pharmacy Technician; Physiotherapist; Oral Hygienist; Nuclear Medicine Technician; Neurophysiology Technician; Orthotist-Prosthetist; Orthoptist; Dental Prosthetics Technician; Radiology Technician; Radiotherapy Technician; Environmental Health Technician; Speech Therapist; and Occupational Therapist. There are other health professions that, even though they are regulated, are defined as activities of unconventional therapies (Diário da República, 1999a, 1999b). These professions have had a parallel evolution since 1980, with the same initial steps in both qualifying education and professional action (Lopes, 2004). State regulations have been homogeneously applied to these professions, covering access to education programs, curriculum design, professional action, professional careers, and collective labour agreements. The Portuguese higher education system now places AH training in the polytechnic higher education sector, with direct qualification for access to regulated professions (DGES, 2025).

During the first decade of the 2000s, the complexity of implementing the BP was evidenced by its continuous and adaptive nature (Veiga & Amaral, 2011). The changing environment in Portuguese higher education reflects the interaction between the implementation of the Bologna degree structure and the impact of evaluation practices promoted, since 2007, by the Portuguese Agency for Assessment and Accreditation of Higher Education (A3ES) (Veiga & Magalhães, 2019). In AH, during the Bologna implementation period, new challenges and opportunities surfaced, with emphasis on discourses on free movement and employability, legitimising the need for degree comparability, European-oriented training, programme accreditation, and regulation of training supply. The 2004 report by Lopes (2004) stated that “international comparability requires the adoption of curricular models aligned with European standards”, while the 2007 report by Lourtie and Pinto (2007) underlined that “the creation of clusters of degrees will promote professional mobility and enhance the employability of graduates”. This period was marked by an apparent consensus among actors. After the Bologna implementation, intense discursive interaction and contestation regarding the merits of ideas and policy implementation were witnessed.

1.2. AH Education Reform in Portugal

In 2013, the Working Group on the fields of Diagnostic and Therapeutic Technologies/Therapy and Rehabilitation, established under the initiative of the A3ES, prepared the “1st Report on proposals for ‘aggregation/merger’ of first-cycle degree programs” (A3ES, 2013). Driven by the need to respond to scientific and technological advancements, professional practice requirements, and international recognition, three new study programs in AH were introduced. These included: “Medical Imaging and Radiotherapy (MIR)” (integrating training in Nuclear Medicine, Radiology, and Radiotherapy); a study program in “Clinical Physiology (CP)” (integrating training in Cardiopulmonology and Neurophysiology); and a study program in “Biomedical Laboratory Sciences (BLS)” (integrating training in Clinical and Public Health Laboratory Sciences and in Pathology, Cytology, and Thanatology). The objective was to provide joint training for various professions sharing a common core of competencies (A3ES, 2013), while maintaining the existing scope of 18 regulated Diagnostic and Therapeutic Technologies (DTT) or AH professions.

The possibility of offering degrees granting access to two or three professional titles became a key factor, on one hand, in attracting students, increasing graduate employability and institutional competitiveness, on the other hand, generating tensions and disputes among stakeholders, often reflected in collective opposition to these reforms (Leite et al., 2017). Concerns were raised that the fusion of degrees might compromise the depth of professional training in favour of an artificial standardisation. The petition by APTMN claimed that “the newly proposed degree configurations jeopardise the historical and scientific specificity of the professions” (APTMN, 2014). The transition from former to newly restructured educational programmes was implemented differently across Higher Education Institutions (HEIs), varying both in terms of timing and in how enrolled students were integrated, or not, into the new model. HEIs that had specialized in training for one profession per program often saw in the aggregated programmes an opportunity to diversify their portfolio, expand their pool of applicants, and anticipate expected regulatory trends. This perspective was also empowered by the idea that if the Portuguese traditional model was indeed exemplary, one would expect other countries to converge toward it (CCISP, 2014). HEIs that had traditionally offered the associated professions through separate, specialized programs tended to resist aggregation. For such HEIs, the advantage of separate, profession-specific curricula laid in maintaining the depth, rigor, and identity of each profession, as well as in sustaining their long-standing reputations as centres of excellence in specialized training. They argued that grouping disciplines into a single cycle endangered mastery of profession-specific competencies, diluted the quality of clinical training, and relaxed ties with specialized practice environments. For them, the competitive advantage of their model laid not in breadth of qualification but in the continued production of highly specialized graduates whose profiles were closely aligned with the expectations of professional associations, regulatory authorities, and specialized healthcare employers. In line with this, some stakeholders argued that the excellence of existing AH education already ensured international recognition and mobility, positioning Portugal as “a reference within and beyond the European Area” (APTMN, 2014). The prestige of Portuguese AH degrees, they contended, had favoured employability abroad (Curado, 2014). Despite these diverse approaches, the training provision underwent substantial changes within a short timeframe.

The reform of AH degree programmes in Portugal, conducted by A3ES, demonstrates how institutional behaviour can be shaped by the evaluative state (Neave, 1998). Although the coexistence of traditional and aggregated programmes was formally allowed, most institutions strategically discontinued the former in anticipation of regulatory expectations—a dynamic consistent with the “law of anticipated outcomes” (Neave, 1998). Evaluation thus operated as an indirect governance mechanism, aligning institutions with agendas of efficiency, modernisation, and accountability, while raising concerns over academic autonomy and diversity. From Stephen Ball’s perspective (Ball, 1994), one can interpret this process as reflecting policy enactment: reforms are not neutral executions of central directives but situated translations, negotiated within institutional contexts under the influence of dominant evaluative discourses. Institutions, though formally autonomous, adapt strategically to the performative logic of the evaluative state. Schmidt’s discursive institutionalism adds that such transformations are sustained by institutionalised discourse (Schmidt, 2008, 2010). In this case, a shared narrative of quality, modernisation, and efficiency—coordinated by regulatory agencies—was progressively embedded into institutional practices. The reform thus exemplifies the convergence of evaluative governance, situated policy enactment, and the structuring power of discourse in contemporary higher education (Saúde et al., 2019). By adopting the new cycles proposed by the A3ES, institutions demonstrate alignment with the guidelines of the regulatory body, which can be interpreted as a proactive and strategic stance. Although A3ES guaranteed the coexistence of traditional and aggregated models, HEIs may have viewed this initiative as a sign of future mandatory reconfigurations, opting to anticipate potential regulatory restrictions (Saúde et al., 2019). Such practices reveal a strategic alignment with policy demands, rather than a full internalisation of Bologna principles. Quality assurance regimes and discourses began to shape institutional actions and identity. According to Veiga (2014), differing conceptions of “quality culture” across Portuguese HEIs influenced the interpretation and enactment of policy, including the implementation of reforms in AH education. These interpretations affect not only institutional legitimacy but also external perceptions regarding programme excellence and graduate readiness (Veiga, 2014). Brouwer et al. (2025), in their analysis of International Medical Programmes, identified three competing narratives—serving institutional interests, public interests, and individual aspirations. These coexisting discourses led to confusion, conflicting expectations, and curricular dilemmas for both staff and students. Such findings echo the discursive struggles identified in the Portuguese AH context, where reforms were legitimised through normative values (e.g., mobility, excellence) while generating contestation at the implementation level. These parallels reinforce the importance of clarifying discursive orientations in education policy to mitigate reform fatigue and institutional ambivalence (Saúde et al., 2019).

2. Materials and Methods

2.1. Study Type and Sample

We carried out an observational cross-sectional study on a sample of Portuguese AH professionals, AH academic staff, and researchers, noting that some respondents may simultaneously hold more than one of these roles. They were approached through researchers’ personal contacts in “snowball” mode with ad hoc questionnaires (Dragan & Isaic-Maniu, 2013).

A questionnaire survey was the instrument for data collection, applied to estimate the degree of agreement with some statements on education in AH overall and the process of integrating the first cycle of studies in particular fields of diagnostic and therapeutic technologies (AH). Specific topics included training quality, curricular alignment with labour market demands, and the use of evidence in health policy decision-making.

2.2. Study Disclosure and Ethics

The research was carried out following the Declaration of Helsinki and approved by the Institutional Ethics Committee of Faculty of Psychology and Educational Sciences of the University of Porto (FPCEUP) (Ref. 2025-01-02). For publicizing the study and recruiting participants, an invitation email was sent to AH professionals, faculty members, and researchers through professional networks and institutional mailing lists, ensuring national coverage, with details of the study’s subject and a link for accessing the electronic questionnaire developed on the Google Forms platform. Information on confidentiality and data protection was accessible to all participants in the explanation of the questionnaire. Informed consent and authorization to respond to the survey were requested from all the participants. This questionnaire was made available from December 2024 to March 2025.

2.3. Data Collection Instruments

Data were gathered with a structured, self-administered web-based questionnaire developed for use in this research. The instrument aimed to measure perceptions of the restructuring of AH education, its institutional ramifications, and its effects on professional practice in higher education and the healthcare field in Portugal. The research instrument, in its final form after a pilot test, included 26 questions (closed and open-ended), with some having sub-items, for a total of 33 items. The instrument has five sections, as follows:

(I)

Informed Consent: Participants were first provided with an information sheet detailing the study’s objectives, confidentiality assurances, voluntary participation, and data protection in compliance with the General Data Protection Regulation (GDPR). Consent was obtained digitally prior to participation.

(II)

Sociodemographic and Professional Background: This section gathered information on gender, age, academic qualifications, years of professional experience, main and secondary professional activities, employment sector (public or private), and geographical location.

(III)

Educational Offer and Quality Assurance in AH education: Respondents answered a battery of statements on the sufficiency of training programs, the equilibrium between the demand and supply of HT professionals, the relevance of accreditation processes, and the perceived necessity for HT education reform. Answering was recorded on a five-point Likert scale from “Strongly Disagree” to “Strongly Agree,” with the option “Don’t know/Prefer not to answer.”.

(IV)

Harmonization and International Recognition: This section covered views on the harmonization of Portuguese AH programs with international standards, the significance of international comparisons, and the quality and competitiveness of Portuguese AH qualifications as perceived.

(V)

Aggregation/Fusion of Undergraduate Programs (A3ES, 2013): The last part examined the views of participants regarding the 2013 proposal by A3ES for the aggregation/fusion of various AH undergraduate programs. Statements pertained to transparency, involvement of stakeholders, curriculum sufficiency, effects on professional autonomy, and job opportunities after fusion.

III, IV, and V sections questions were formulated in the form of a 5 point bipolar scale with a point of origin representing the lack of the effect (Neither Agree or Disagree) and 4 degrees to balance two opposing qualities, specifying the relative proportion of the qualities (Strongly Disagree, Disagree, Agree, Strongly Agree). The participants were also offered the possibility of making open-ended comments at the end of the pertinent sections, permitting qualitative inferences regarding opinions and experiences. The questionnaire was applied through Google Forms with guarantees of anonymity and confidentiality. The approximate completion time was 10 min.

2.4. Data Processing and Analysis

Data processing and analysis involved initially extracting data from the Google Forms platform to an Excel spreadsheet with separate sheets for questionnaire items. A database to hold the data collected was established using IBM SPSS Statistics 29 software. The data in the database are all anonymized and kept on a restricted-access desktop computer. The translated questions are presented in Appendix A.

3. Results

3.1. Socio-Demographic and Socio-Professional Characteristics of the Sample

The sample comprised 495 valid responses. Socio-demographic and socio-professional details of the sample are given in

Table 1. Socio-demographic characteristics.

Variables	n	%
Gender
Male	144	29.1
Female	349	70.5
Other	1	0.1
I prefer not to answer	2	0.2
Age
30 years old or less	71	14.3
31–40 years old	181	36.6
41–50 years old	120	24.2
51 years old or more	123	24.8
Academic Qualifications
BSc	313	63.2
MSc	132	26.7
PhD	50	10.1

and

Table 2. Socio-professional characteristics.

Variables	n	%
Academic Background
Pre-merger programs	355	71.7
Post-merger programs	64	12.9
Other AH programs	71	14.3
Non-AH programs	5	1.0
Professional Experience (years):
10 years or less	132	26.7
11–20 years	163	32.9
21–30 years	130	26.3
31 years or more	70	14.1
Main Professional Activity (professional role)
Lecturer in AH Programs	71	14.3
AH Professional	400	80.8
Lecturer in AH Programs and AH Professional	11	2.2
Other	13	2.6
Complementary professional activity
Lecturer in AH Programs	94	19.0
AH Professional	151	30.5
Internship monitor in AH Programs	138	27.9
Link to the teaching of Allied Health (Full or part-time lecturer or Internship monitor)	235	47.5

, respectively.

The gender breakdown was mainly female (70.5%), while 29.1% were male. Just two respondents (0.4%) ticked “other” or did not specify their gender. When it came to age, the most represented age group was 31 to 40 years (36.6%), followed by those in their 50s and above (24.8%) and those in the 41 to 50 years category (24.2%). Those in their 30s and below made up 14.3% of the sample.

Regarding academic qualifications, all participants reported holding higher education degrees, with no missing information for this question. Most participants had finished a bachelor’s degree (63.2%).

The data suggest a highly qualified group, consistent with the academic and professional profile of individuals engaged in the field of AH.

Concerning their academic background, 71.7% had completed their initial training in programmes prior to the national reform of AH curricula (pre-merger), while 12.9% were trained in post-merger programs. An additional 14.3% held degrees in other AH areas and 1.0% came from outside the AH field. As far as professional experience is concerned, 32.9% had 11 to 20 years of experience, 26.7% had 10 years or less, 26.3% had 21 to 30 years, and 14.1% indicated over 30 years of experience. Regarding primary professional roles, the majority of participants (80.8%) were practicing AH professionals, with 14.3% working solely in academic teaching roles. A minority combined both roles (2.2%), and 2.6% reported other professional roles. Other features are the existence of part-time teaching activities in AH programs (19.0%) and part-time clinical practice (30.5%). Also, 27.9% of respondents worked as internship course monitors. In total 47.5% reported direct participation in AH education. Geographically, the sample covered respondents from every region in the country, providing national coverage.

3.2. Validation of the Instrument

The survey tool was created to examine perceptions about the restructuring of academic education in AH. Its validation underwent a multi-phase process of data cleaning, exploratory factor analysis (EFA), and reliability testing. One of the original 496 complete responses was removed due to uniform response patterns (possible straight-lining), leaving a final sample of 495 respondents. We performed an exploratory factor analysis with maximum likelihood extraction and Oblimin rotation, appropriate for correlated factors. Initial criteria confirmed the sufficiency of the data for factor analysis: the Kaiser-Meyer-Olkin measure was 0.917, and Bartlett’s test of sphericity was significant (p < 0.001), indicating adequate item intercorrelations. Five factors were initially found to have eigenvalues in excess of 1. Yet, a three-factor solution was supported by examination of the scree plot and variance explained, accounting for 38.5% of the total variance.

Items with communalities below 0.30 (Q01, Q02, Q06) were removed from the model. One cross-loading item (Q07) was assigned to the factor where it showed higher communality. The resulting structure comprised:

Domain A (12 items): Curricular Reform and Impact of the Mergers

This domain gathers items related to the perceived legitimacy, rationale, and outcomes of the 2013 restructuring of AH degrees, including transparency of the process, alignment with Bologna principles, curricular adequacy, international competitiveness and employability (items: Q10, Q11, Q12, Q13 (recoded), Q14–Q20, Q22 and Q07).

Domain B (5 items): Educational Quality and International Alignment

This domain reflects the importance attributed to accreditation procedures, professional autonomy and alignment with international and European educational standards. It captures concerns with the external legitimacy and pedagogical robustness of training in AH (items: Q03, Q04, Q07, Q08, Q09).

Domain C (4 items): Professional Consequences of the Mergers

This domain aggregates critical perceptions concerning the mergers’ impacts on training specialization, professional autonomy, patient safety, and the perceived dominance of market-driven over pedagogical criteria (items: Q21, Q23, Q24, Q25 (all reverse-coded)).

The term domain was adopted to designate the three main areas of the questionnaire. Those domains are in accordance with the ideas that emerged in the post Bologna implementation period, such as international recognition, the free movement of students and professionals, the alignment of training with the demands of healthcare delivery emerge, as legitimising factors for the reconfiguration of AH education (Saúde et al., 2019).

3.3. Psychometric Properties

The internal consistency was assessed using Cronbach’s alpha (α). Domain A (12 items), Curricular Reform and Impact of the Mergers, demonstrated excellent reliability (α = 0.893). Sensitivity analysis showed that removing Q11 would slightly increase alpha to 0.902, but the item was retained based on theoretical relevance. Domain B (5 items), Educational Quality and International Alignment, yielded a lower alpha (0.602), indicating moderate consistency. However, no item deletion improved the alpha significantly. The individual item means ranged from 3.92 to 4.38, with standard deviations between 0.775 and 0.951, indicating that responses tended to cluster at the higher end of the Likert scale with relatively low dispersion. This may reflect a ceiling effect or high agreement among participants regarding the issues addressed in this dimension and it captures a theoretically relevant and multidimensional construct related Educational Quality and International Alignment. Following the interpretative thresholds suggested by George and Mallery (2003), who classify values between 0.6 and 0.7 as ‘questionable’ but still acceptable in exploratory research and for scales with few items. George and Mallery (2003) as well Maroco and Garcia-Marques (2006) further emphasize that the decision to retain or remove items or subscales should consider not only statistical criteria but also theoretical coherence and the intended purpose of the scale. This aligns with the methodological choice to retain Domain B for conceptual reasons, despite its moderate alpha value, as its inclusion contributes to the content and construct validity of the questionnaire as a whole. Domain C (4 items), Professional Consequences of the Mergers, was originally composed of five items, from which Q05 was deleted to enhance internal consistency. The 4-item revised version showed acceptable internal consistency (α = 0.811), with corrected item-total correlations favouring the unidimensionality of the construct.

After factor confirmation, domain scores were calculated by adding the items per domain. Distributional assumptions of these composite variables were examined using Kolmogorov–Smirnov tests, histograms, and skewness/kurtosis indices. Although normality tests were statistically significant (probably because of large sample size), data approached normality, in which case both parametric and non-parametric analyses could be conducted. Nevertheless, the study used non-parametric tests (Mann–Whitney U and Kruskal–Wallis) to maintain robustness under conservative assumptions. The tool exhibited good psychometric characteristics, presenting support for its utilization in research focused on stakeholder views of the reorganization of AH education in Portugal. The three-domain framework provides a logical and statistically valid basis for looking into the perceptions of curricular change and structural effect of the mergers, educational quality and international alignment and critique of the mergers and their professional implications.

3.4. Differences in Participants’ Responses Across the Domains

Non-parametric Kruskal–Wallis tests were conducted to examine differences in participants’ responses across demographic and professional variables for each of the three domains: Domain A—Curricular Reform and Impact of the Mergers; Domain B—Educational Quality and International Alignment; Domain C—Professional Consequences of the Mergers.

Table 3. Kruskal–Wallis Test Results by Domain.

Variables	H(df)	p
Curricular Reform and Structural Impact of the Mergers (A)
Age	40.653 (3)	<0.001
Academic background	74.333 (3)	<0.001
Professional Experience (years)	20.949 (3)	<0.001
Educational Quality and International Alignment (B)
Gender	8.303 (3)	0.040
Age	17.092 (3)	<0.001
Academic background	8.580(3)	0.035
Main Professional Activity (professional role)	18.009 (3)	<0.001
Linkage to the teaching of Allied Health	6.597 (1)	0.010
Academic qualifications	14.218 (2)	<0.001
Professional Consequences of the Mergers (C)
Age	27.898 (3)	<0.001
Academic background	43.413 (3)	<0.001
Main Professional Activity (professional role)	10.732 (3)	0.013
Professional Experience (years)	13.827 (3)	0.003
Academic qualifications	11.330 (2)	0.003

shows the results by domain.

Results indicate that attitudes within the areas of Curricular Reform and Impact of the Mergers (A), Educational Quality and International Alignment (B), and Professional Consequences of the Mergers (C) differ significantly in terms of gender, age, academic background, professional role, professional experience, teaching link, and academic qualifications.

Gender revealed statistically significant differences in Educational Quality and International Alignment (B) only. Bonferroni-adjusted post hoc tests indicated a considerable difference between male and female respondents (H = 8.303; p = 0.040), with males reporting greater mean ranks (274.17) than females (236.92). There were no differences that were significant in either Curricular Reform and Impact of the Mergers (A) or Professional Consequences of the Mergers (C).

Age was also related to responses, with significant differences observed in all three domains. The ≤30 years group consistently exhibited the highest mean ranks (328.11 in A; 281.46 in B; 287.69 in C), whereas the 31–40 years group displayed the lowest (216.35 in A; 223.68 in B; 204.22 in C). The most pronounced differences occurred between ≤30 years and 31–40 years, and between 31–40 years and 41–50 years, varying by domain.

For academic background, there were significant group differences in all domains. Respondents from pre-merger programs consistently had the lowest mean ranks (213.89 in Curricular Reform and Impact of the Mergers (A); 236.53 in Educational Quality and International Alignment (B); 222.03 in Professional Consequences of the Mergers (C)), whereas those from post-merger programs, other AH fields, and non-Allied Health fields had higher scores, with significant comparisons especially in Domains A and C (pre-merger and post-merger and pre-merger and other AH; p < 0.001).

No differences were recorded across professional roles in Curricular Reform and Impact of the Mergers (A); p = 0.284. In Educational Quality and International Alignment (B) and Professional Consequences of the Mergers (C), role differences were significant, however. TSDT professionals consistently had the lowest mean ranks (237.36 in B; 237.81 in C), while faculty members (exclusive and dual role) scored the highest (296.42 in B; 293.08 in C). Significant differences between TSDT and exclusive faculty, and between TSDT and dual-role faculty, were verified by post hoc tests (p < 0.05).

Professional experience-related differences were found in Curricular Reform and Impact of the Mergers (A) and in Professional Consequences of the Mergers (C), but not in Educational Quality and International Alignment (B); p = 0.367. Respondents with ≤10 years of experience had the highest mean ranks (293.58 in A; 263.59 in C) and those with 11–20 years of experience the lowest (224.92 and 214.03, respectively). Significant contrasts were detected between ≤10 years and 11–20 years (p < 0.05) and between ≤10 years and >30 years (p < 0.05). In Domains A and C, the group with less than 10 years of experience had significantly more positive attitudes in comparison with more experienced groups. In Domain C, the group with 11–20 years of working experience differed significantly from those with ≤10 years (p = 0.018) and from those with 21–30 years of experience (p = 0.013).

Statistically significant variation among participants’ association with teaching of AH was discovered only in Educational Quality and International Alignment (B), in which participants with teaching affiliation showed greater mean ranks (265.24) compared to those without teaching affiliation (232.41). Significant differences were not observed in the remaining domains.

For academic attainment, the disparities were notable in Domain B (p < 0.001) and Domain C (p = 0.003), but not in Domain A (p = 0.130). Bonferroni-corrected comparisons indicated that Doctorate holders had the highest mean ranks (290.41 in B; 311.88 in C), followed by Master’s degree holders (274.78 in B; 244.83 in C), while Bachelor’s degree holders had the lowest scores (229.93 in B; 239.13 in C).

4. Discussion

This study explored how sociodemographic and academic characteristics influenced stakeholders’ perceptions regarding Curricular Reform and Impact of the Mergers (Domain A), Educational Quality and International Alignment (Domain B), and Professional Consequences of the Mergers (Domain C). The results revealed a complex interplay of generational, institutional, and academic factors influencing the acceptance or resistance toward the ongoing implementation of the Portuguese AH education. Gender-related differences were limited to Domain B, where male participants reported higher mean ranks compared to females, suggesting a stronger endorsement of the quality and international alignment of the reformed curricula. These findings resonate with broader evidence on gendered pathways in higher education. Persistent structural and cultural barriers shape women’s opportunities and perceptions (European Parliament, 2020). Age emerged as a key differentiator across all domains, with younger participants (≤30 years) consistently reporting the highest mean ranks, while the 31–40 years group scored the lowest. This generational divide may reflect greater alignment of younger professionals with Bologna-aligned curricula and European mobility frameworks, whereas mid-career professionals (31–40 years)—likely educated before or during transitional phases—may experience greater dissonance with the structural and professional outcomes of the reforms. The findings echo literature describing educational path dependency, where earlier training shapes adaptation to institutional changes (Mahoney & Thelen, 2009). Graduates from pre-merger programs consistently scored lowest across domains, contrasting with post-merger graduates and participants from other or non-AH fields, who expressed more favourable views. These results highlight identity and recognition tensions faced by professionals trained before curricular harmonization, as documented in studies on professional acculturation during system-wide health reforms (Ağartan, 2019). Such divergences suggest that pre-merger professionals may perceive the reforms as devaluing their qualifications or altering professional hierarchies, a theme echoed in debates on credentialism and health workforce (Buchan & Aiken, 2008). Differences by role were evident in Domains B and C, where AH professionals recorded the lowest scores, while faculty (especially those combining teaching and practice) had the highest. This pattern underscores the dual perspective of faculty, who may perceive reforms as enhancing academic legitimacy and international competitiveness, while frontline AH professionals may prioritize the practical implications for workload, recognition, and career progression. This dynamic mirrors findings by Frenk et al. (2010), who noted that educational reforms in the health professions often emphasise academic alignment and systemic goals, while under-addressing the immediate concerns of frontline practitioners. Professionals with ≤10 years of experience expressed the most favourable perceptions in Domains A and C, while those with 11–20 years reported the lowest scores. These contrasts may reflect generational socialization, where recent entrants—trained under reformed curricula—benefit from alignment with European standards and professional mobility, while mid-career practitioners—educated in pre-merger contexts—may feel marginalized by shifting benchmarks (Westerheijden et al., 2010). Interestingly, those with >30 years of experience did not consistently express negative views, possibly due to established career security mitigating the perceived threats of reform. Linkage to the teaching of AH (full or part-time lecturer or internship monitor), influenced perceptions only in Domain B, where those engaged in education scored higher, endorsing the quality and international dimensions of the reformed programs. This finding aligns with studies showing that faculty members are often early adopters and advocates of internationalization and competency-based education, given their exposure to accreditation standards and cross-institutional collaborations (Marinoni & Pina Cardona, 2024). The absence of differences in Domains A and C suggests that teaching involvement is primarily linked to pedagogical, rather than structural or professional, assessments. Educational attainment exerted a clear gradient in Domains B and C, with Doctorate holders expressing the most favourable views, followed by Master’s graduates, while those with Bachelor’s/Licentiate or Post-Graduate qualifications scored lowest. Higher qualifications often correlate with greater involvement in academic networks, research activities, and policy discourse, factors linked to greater endorsement of reforms promoting international alignment and academic prestige (Harmsen, 2014). Conversely, lower-degree professionals may prioritize practical concerns over academic benchmarking, resulting in more critical stances toward reforms.

Overall, these findings reflect a multi-level dynamic in how reforms are perceived across AH education:

• Perceptions on Curricular Reform and Impact of the mergers is most strongly shaped by the formative trajectory and generational positioning, with younger and post-merger graduates expressing greater acceptance, while pre-merger and mid-career professionals show greater scepticism.
• Educational Quality and International Alignment reveals institutional and academic divides, with faculty, advanced-degree holders, and those connected to teaching roles favouring reforms, in contrast to AH professionals and lower-degree groups, who express reservations.
• Professional Consequences of the Mergers reflects academic hierarchy and generational optimism, as Doctorate holders and early-career professionals are more positive, while AH practitioners express greater concern over workplace implications.

These patterns echo theoretical frameworks on policy enactment (Schmidt, 2008) and discursive institutionalism (Schmidt, 2010), which posit that reforms are interpreted and contested through actors’ institutional positions, professional identities, and generational experiences. They suggest that successful implementation of educational reforms must balance the perspectives of experienced practitioners—whose expertise remains vital—with the alignment priorities and global outlook of younger, academically integrated professionals. Frenk et al. (2010) similarly stress that health professions education reforms should not focus exclusively on systemic alignment but must also attend to the realities and concerns of those working at the frontline. Individualized communication and policy-focused strategies are essential to foster stakeholder engagement during educational reforms (Petkovic et al., 2023).

5. Conclusions

This research illustrates that attitudes toward the curricular, pedagogical, and professional effects of the merger-driven reforms in Allied Health (AH) education are anything but monolithic. Rather, they are influenced by a set of generational, academic, and professional considerations, which together affect how various stakeholders assess the results of these systemic reforms. Across the three domains under consideration, unique patterns appear. Formative trajectories and generational location largely shape perceptions of Curricular Reform and Impact (Domain A), with younger practitioners and post-merger graduates showing more commitment to reformed curricula, and pre-merger and mid-career practitioners being more sceptical, echoing tensions surrounding educational path dependency and professional identity. Perceptions of Educational Quality and International Alignment (Domain B) are marked by institutional and academic divisions, with faculty members, holders of higher degrees, those affiliated with teaching, and male respondents supporting the reforms more vigorously, and AH professionals and those with lower academic degrees having more reservations. Lastly, perceptions of Professional Consequences (Domain C) are influenced by academic seniority and stage in career, with Doctoral degree holders and early-career professionals reporting more positive assessments, contrasting with the more critical views of active AH practitioners, who are immediately affected by the operational entailments of the reforms. This resonates with the tensions observed in the Portuguese AH context, where reform agendas were framed through normative ideals, yet often encountered resistance during implementation. Such dynamics underscore the need to make discursive orientations in education policy more transparent, in order to reduce reform fatigue and prevent institutional ambivalence. In light of this, our results emphasize that the effectiveness of upcoming educational and professional reforms in AH disciplines will rely on the extent to which they can respond to the disparate needs and interests of heterogeneous groups. Reform initiatives need to balance the practical experience and lived reality of experienced practitioners with the global outlook and reform readiness of younger, well-qualified professionals. Enhancing communication pathways, developing inclusive discourse, and making certain that reforms reinforce both academic competitiveness and labour force sustainability are essential to securing widespread acceptance and long-term effect. Finally, this research highlights the need for context-responsive and multi-stakeholder reform approaches, acknowledging that education and professional reconfiguration processes necessarily crosscut with identity, career paths, and institutional roles. Explicitly addressing such dimensions will be critical to promoting a unified and internationally competitive AH education system that also maintains professional equity and workforce stability.

These findings highlight that the implementation of reform processes is neither uniform nor purely technocratic; rather, it is mediated by professional identity, status, and institutional context. From a practical standpoint, several implications emerge. Policymakers and accreditation agencies should ensure transparent communication and systematic consultation with professional associations, thereby safeguarding legitimacy and coherence throughout reform processes. Within higher education institutions, it is essential to integrate stakeholder feedback mechanisms capable of anticipating unintended effects on professional identity and employability. Researchers are encouraged to conduct longitudinal and comparative studies to monitor the evolution of perceptions and outcomes across diverse European contexts. Likewise, programme directors should draw upon empirical evidence from stakeholder surveys to refine curricula and to strengthen the connection between academic and clinical training.

In terms of future directions, the findings of this study will be disseminated to programme directors, professional councils, and A3ES, with the aim of informing forthcoming accreditation cycles and continuous quality-improvement initiatives. Subsequent research will seek to expand this work through comparative analyses across European Union countries, examining how analogous reforms interact with national professional frameworks.