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Abstract

Background

Social accountability aligns the health demands and priorities of the community and the commitment of medical schools. Existing literature has proposed contextually distinctive interventions encompassing geographical initiatives, institutions and communities, and systematic categorizations for the implementation of social accountability in a rural setting. Research concerning social accountability implementation strategies has been insufficient. This study provides an overview of the existing literature surrounding the social accountability practice of physicians and medical schools, in rural settings, through evidence of the barriers and facilitators inherent to these communities.

Methods

This scoping review of 53 studies was conducted to determine challenges and facilitators associated with promoting social accountability in rural settings that are faced by physicians and medical schools. The review was consistent with the Arksey and O’Malley framework and included a search of Web of Science, MEDLINE, CINAHL, Scopus, and Embase to identify peer-reviewed articles on the topic from inception until April 1, 2024. Articles were screened against eligibility criteria, and important study characteristics and findings were extracted. A thematic analysis and narrative synthesis approach was used to analyze the data and report the results.

Results

A total of 2698 abstracts were identified, 180 full-text articles were reviewed, and 53 articles were identified as eligible for inclusion in the review. Strategies used and problems inherent in promoting social accountability across physician practice and medical education are reported.

Conclusions

This scoping review synthesizes existing evidence on the barriers and facilitators of social accountability practices in rural settings globally. The identified literature captures recurring themes of medical infrastructure inadequacy, community immersion curriculum design, targeted admission, geographical isolation, and institutional or peer support.

Keywords

social accountability healthcare inequality medical education medical schools rural medicine

Introduction

About 45% of the world's population, amounting to over 3 billion people, live in rural and remote areas where they experience a number of challenges in accessing quality healthcare.^1–4 These include a lack of proper healthcare facilities, geographical inaccessibility of clinics and hospitals, poor infrastructure, transportation difficulties, and financial constraints.^5–8 In addition, most of the people residing in these areas belong to vulnerable and socioeconomically disadvantaged groups.⁹ Rural communities generally have poorer health compared to urban communities.^9,10 Individuals are more likely to experience chronic diseases and are less likely to have medical insurance.^11–13 Similarly, rural populations have high rates of smoking, heavy drinking and obesity.^14–16 Moreover, rurality has been found to be associated with shorter life expectancy.¹⁷ For years, rural and remote populations have also struggled to recruit and retain physicians, leading to a shortage of healthcare professionals from primary care physicians to specialists and in turn exacerbating existing disparities in health status and access.^11,18

In recent years, there has been an emphasis on addressing the lack of physicians in rural and remote areas through promoting social accountability in medical education. Social accountability is the “obligation [of medical schools] to direct their education, research and service activities towards addressing the priority health concerns of the community, the region, and/or nation they have a mandate to serve.”¹⁹ It is a paradigm shift that requires stakeholders such as physicians and medical educators to reassess their personal and collective responsibilities in addition to implementing interventions to reduce the maldistribution of physicians across rural and urban areas and meet the needs of rural populations.²⁰ Efforts to incorporate social accountability into medical education have focused on recruiting students who are representative of the local population, teaching social accountability-related material in lectures, increasing community engagement, offering service-learning placements within rural settings, and providing opportunities for international electives.²¹ In contrast, physicians seeking to promote social accountability on a personal level often turn to medical ethics commitments and professional values.

The importance of social accountability in facilitating equitable access to medical care, empowering marginalized communities and vulnerable groups, and improving public health and quality of care is beginning to receive recognition. Although several studies have examined initiatives to promote social accountability in physicians and medical schools, there have been no attempts to scope and synthesize the literature, recognizing factors that might ease or hinder their implementation. This scoping review was conducted with the aim of providing an overview of the literature on the promotion of social accountability in rural and remote areas, specifically identifying challenges and facilitators encountered by physicians and medical schools in the process.

Methods

Framework

This scoping review was conducted to identify barriers and facilitators faced by physicians and medical schools while attempting to promote social accountability within rural communities. An initial review of gaps in the literature surrounding the factors influencing social accountability efforts in rural communities informed the objectives of this review. Drawing on these findings, the research questions were generated and refined through preliminary team meetings. Scoping reviews are a type of evidence synthesis that provides a comprehensive landscape of the body of literature on a particular topic.²² The aim was to provide a broad overview and identify any knowledge gaps, pertaining well to this specific methodology. This review was conducted using the Arksey and O’Malley framework²³ which consists of six steps: (1) identifying the research question; (2) searching the literature for relevant studies; (3) screening studies for eligibility; (4) data extraction; (5) data analysis; and (6) an optional stakeholder consultation. A stakeholder consultation was not performed. This scoping review was reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR),²⁴ which can be located in the Supplementary Appendix.

Search Strategy and Study Selection

A comprehensive search was conducted on April 1, 2024 using keywords related to all concepts examined in this review such as “social accountability”, “physicians,” and “medical school” and tailored to each database including Web of Science, MEDLINE, CINAHL, Scopus, and Embase (Supplemental File 1). Title and abstract and full-text screening were conducted on Covidence.²⁵ For both stages of screening, each record was independently assessed for eligibility using the predetermined inclusion criteria by at least two reviewers and any conflicts were resolved by consensus. Primary articles of any study design that addressed social accountability among physicians and medical schools in the context of rural and remote communities were included. Articles were only included if they were written in English. On the other hand, articles that did not discuss social accountability from the perspective of physicians or medical schools were excluded. Studies were also removed if they were based in non-rural settings. Moreover, non-research articles (eg, errata, commentaries, book chapters, letters to the editor, protocols, editorials, perspectives, and opinion pieces), thesis dissertations, conference proceedings, and reviews were excluded.

Data Extraction and Analysis

A standardized data extraction template was created on Covidence. The extraction form for each study was independently populated by two reviewers with information on the methodological and participant characteristics along with the main findings. A third reviewer collated the abstracted data through consensus. Study characteristics extracted included (1) the title of the article; (2) name of the lead author; (3) the country in which the study was conducted; (4) date of print publication; (5) study design (eg, cross-sectional, qualitative, mixed-methods, case report etc.); (6) setting (eg, rural village, medical institution); (7) participant population (eg, medical educators, physicians, medical students); (8) population size; (9) participant demographics and age; and (10) study objectives. Furthermore, the following information pertaining to social accountability was abstracted from each study: (1) its definition; (2) importance (eg, impact on patient outcomes or community wellbeing); (3) measures (eg, interviews, perspectives, surveys etc); (4) social accountability challenges experienced by physicians and medical schools; (5) the impact of these barriers on social accountability; (6) proposed solutions; (7) key roles to be taken up by physicians, medical schools and educators; (8) facilitators of social accountability for physicians and medical schools; (9) impact of the intervention; and (10) translation of social accountability in other communities (eg, similar medical education, training frameworks, physician workshops). Information regarding the article's conclusion, authors’ suggestions, directions for future research and study limitations were also reported in the extraction form. The data was subsequently reviewed to identify salient concepts and overarching patterns pertaining to the implementation of social accountability. Data was categorized on the basis of whether it pertained to physician practices or medical education. A thematic analysis approach was used to further analyze the data and identify relationships between the findings of included studies. This involved reviewing the key challenges and facilitators reported, and generating overarching themes that encompass the factors that influence social accountability practices in rural settings. The final themes presented in this review were refined through regular discussion among the review authors. A descriptive, narrative synthesis approach was used to report the results of this review. An a priori protocol was not registered as the objective of this scoping review is to be explorative and descriptive rather than evaluative or definitive. Scoping reviews are inherently flexible in methodology, thus, in the absence of a universally required registry for this type of evidence synthesis, protocol registration was not pursued. We do not assess the risk of bias or produce pooled effect estimates.

Results

Search Results

The database search yielded 2698 hits from which 692 records were removed due to duplication. The remaining 2006 records were screened for eligibility based on their title and abstracts and another 1826 articles were excluded. 180 full-text records were assessed against the inclusion criteria and a total of 53 articles were deemed eligible for inclusion in the final scoping review (Figure 1).

Figure 1.

Scoping review study selection flow diagram.

Descriptive Summary

All articles were published after 2005 with six (11.3%) articles being published between 2005 and 2010, 35 (66.0%) articles between 2011 and 2020 and 12 (22.7%) articles between 2021 and 2024 (Table 1). A majority (45.3%) of the included articles were qualitative studies. 13 (24.6%) studies followed a cross-sectional design, eight (15.1%) articles used prospective cohorts while four (7.5%) studies employed a mixed-methods approach. Descriptive analysis was used in two (3.7%) studies while retrospective cohort and retrospective case study approaches were taken in one (1.9%) study each (Table 2).

Table 1.

Original articles (n = 53) included in the scoping review.

Author	Title	Year of print publication	Study aim(s)	Study design	Country	Key challenges	Key facilitators
Cheek et al²⁶	Building a medical workforce in Tasmania: A profile of medical student intake	2019	Compared a medical program's admission process with a social accountability criteria and investigates the implications of widening participation and widening access	Descriptive analysis	Australia	Medical program fails to target applicants outside the designated rural area	Rural placement opportunities, expanded selection criteria
Chen et al²⁷	The redistribution of graduate medical education positions in 2005 failed to boost primary care or rural training	2013	Aimed to determine the effects of the 1997 graduate medical education cap and 2005 redistribution on medical education positions	Descriptive analysis	United States	Redistribution Of graduate medical education positions did not meet rural workforce needs
Cleland et al²⁸	A qualitative study of social accountability translation: From mission to living it	2024	Explored perceptions of socially accountable medical school practices	Qualitative	India		Communal living to promote community engagement, formal training aligned with community needs
Cleland et al²⁹	Attracting healthcare professionals to remote and rural medicine: Learning from doctors in training in the north of Scotland	2012	Utilized the social cognitive career theory to note the experiences of physician training through the Foundation Programme	Qualitative	Scotland	Isolated rural placements are viewed unfavorably, attitudes like perceived workload and expenses are unappealing	Providing trainees with a sense of responsibility but also reassurance of available aids and supervision
Clithero-Eridon et al³⁰	Contribution of the Nelson R. Mandela School of Medicine to a socially accountable health workforce	2019	Explored the social accountability of ‘fit-for-purpose’ medical graduates	Cross-sectional	South Africa	Specialization and skills development are indicators of one's willingness to stay	Recruitment of physicians with similar demographic characteristics to the community, leadership training in medical school curriculum
Clithero-Eridon et al³¹	Future medical student practice intentions: The South Africa experience	2020	Examined the career profiles and background of Nelson R. Mandela medical students	Cross-sectional	South Africa		Family medicine emphasis in the curriculum, fostering a sense of attachment to the community, community immersion
Crandall et al³²	Patients: A longitudinal comparison of problem-based and traditional medical curricula	2007	Explored the effects of gender and learning environment towards attitude factors such as willingness to practice in underserved areas	Prospective cohort	United States	Progressively negative attitudes	Promote professionalism through opportunities with vulnerable patients
Cristobal & Worley³³]	Can medical education in poor rural areas be cost- effective and sustainable: The case of the Ateneo de Zamboanga University School of Medicine	2012	Investigated the sustainability and medical workforce of a low-resource medical school with volunteer faculty	Retrospective case study	Philippines	Funding issues, unstable regional conflict	Recruiting locally and implementing a problem-based curriculum in coordination with community members
de Leeuw et al³⁴	Educating medical students’ “hearts and minds”: A humanities-informed cultural immersion program in Indigenous experiential community learning	2021	How participation in a cultural immersion program influenced students’ attitudes towards rural First Nations communities	Qualitative	Canada	Persistent fear of the unknown, lack of familiarity with the local culture	Experiential and immersive experiences to learn from local community leaders
Eggleton et al³⁵	Development of a rural strategy for an urban-based medical program: A pragmatic reality	2024	Determine how urban-based institutions can improve the rural workforce	Qualitative	New Zealand	Poor understanding of rural needs	Rural-oriented education programs
Florence et al³⁶	Rural health professions education at East Tennessee State University: Survey of graduates from the first decade of the community partnership program	2007	Determine the practice and career intentions and attitudes of The Community Partnerships Program	Cross-sectional	United States	Require a great deal of effort and resources	Community partnership program with service-based learning
Gladman et al³⁷	Measuring organisational-level Aboriginal cultural climate to tailor cultural safety strategies	2015	Determine how to promote cultural safety.	Cross-sectional	Australia	A lack of information on the differences between Aboriginal and non-Aboriginal groups	Promoting culturally safe care
Green-Thompson et al³⁸	The social accountability of doctors: A relationship based framework for understanding emergent community concepts of caring	2017	Examined the perceptions of community members on physician's social accountability	Qualitative	South Africa		Sufficient training for students, building knowledge and understanding of the people served
Griffin et al³⁹	Who do you think you are? Medical student socioeconomic status and intention to work in underserved areas	2017	Investigated the connection between medical student backgrounds and practice intentions	Prospective cohort	Australia	Very low SES students were less likely to desire to work in underserved regions, student attitudes in relation to family social factors	Curriculum changes to alter students subjective perspective with regard to their willingness to serve vulnerable communities
Guignona et al⁴⁰	A curriculum for achieving universal health care: A case study of Ateneo de Zamboanga University School of Medicine	2021	Determined the impact of Ateneo de Zamboanga University School of Medicine students on local communities and determined factors linked to social accountability	Qualitative	Philippines	Resistance to curriculum changes from governing bodies and medical schools	Faculty commitment to a community-centred vision, experiential learning curriculum, student engagement in local workforce
Halili et al⁴¹	Addressing health workforce inequities in the Mindanao regions of the Philippines: Tracer study of graduates from a socially-accountable, community-engaged medical school and graduates from a conventional medical school	2017	Determined community outcomes of graduates of the socially accountable Ateneo de Zamboanga University School of Medicine and a Philippines medical school	Cross-sectional	Philippines	No local medical school and lack of infrastructure	Medical school selection of local individuals with lower SES status
Hay et al⁴²	Selecting for a sustainable workforce to meet the future healthcare needs of rural communities in Australia	2017	Described the link between intent to practice, selection scores, and student place of origin	Prospective cohort	Australia	Training of individuals unmotivated to serve in rural areas	Selection reforms of applicants of rural origin and incorporating rural involvement during training
Hedrick & McHenry-Sorber⁴³	Negotiating the Gemeinschaft/ Gesellschaft dichotomy: Appalachian medical student perceptions of practice	2023	Explored the factors implicating intent to practice for Appalachian medical students	Qualitative	United States	Prevailing sentiments of rural care, limitations of rural practice such as a lack of amenities, finances	Personal connection during rural rotation, faculty role models to influence desirability of rural practice
Heller et al⁴⁴	Exploring medical students’ perceptions of family medicine in Kyrgyzstan: A mixed method study	2023	Explored influences of medical student specialty choice and perceptions on family medicine	Mixed methods	Kyrgyzstan	Attitudes towards Family Medicine specialty	Parents practicing Family Medicine, developing a sense of responsibility and understanding of local healthcare needs
Hogenbirk et al⁴⁵	Milestones on the social accountability journey: Family medicine practice locations of Northern Ontario School of Medicine graduates	2016	Evaluated how exposure to NOSM University's medical program affected practice location	Cross-sectional	Canada		Rural Canadian background was indicative of rural practice location, Programs like NOSM University's Postgraduate education forecasted rural practice
Hulme-Chambers et al⁴⁶	Medical termination of pregnancy service delivery in the context of decentralization: Social and structural influences	2018	Assessed barriers and facilitators of a decentralization initiative with the aim of improving accessibility to pregnancy medical termination services in rural areas	Qualitative	Australia	Concerns regarding quality of care that can be provided with barriers such as wait times and accessibility	Supportive colleagues, partnering with rural-based organizations
Johnston et al⁴⁷	Training a fit-for-purpose rural health workforce for low- and middle-income countries (LMICs): How do drivers and enablers of rural practice intention differ between learners from LMICs and high income countries?	2020	Examined how learner characteristics and country-specific contextual factors are linked with intention to practice in rural areas, practice field, emigration intention, and how these varies by a country's income status	Prospective cohort	Philippines, Sudan, South Africa and Nepal	Having an international background	Rural background students, underserved lower SES students
Larkins et al⁴⁸	Impact of selection strategies on representation of underserved populations and intention to practise: International findings	2015	Described how medical school selection strategies impacted underserved community representation and student practice intentions	Prospective cohort	Australia, South Africa, Sudan, Belgium and Philippines		Selection strategies beyond academics and more closely aligned with the local population
Larkins et al⁴⁹	Practice intentions at entry to and exit from medical schools aspiring to social accountability: Findings from the Training for Health Equity Network Graduate Outcome Study	2018	Identified characteristics linked with intention to work with underserved communities for students at Training for Health Equity Network medical schools	Prospective cohort	Australia, Philippines, Sudan, Belgium, Canada and South Africa	High income and urban background students, creating an aligned workforce, Cost dissuades more representative candidates	Local rural background students with lower parental income
Maar et al⁵⁰	Enhancing Indigenous health research capacity in northern Ontario through distributed community engaged medical education at NOSM: A qualitative evaluation of the community engagement through research pilot program	2018	Described the successes and challenges in the partnership between NOSM's medical education collaboration and Indigenous community sites	Qualitative	Canada	Past negative collaborative experiences among local Indigenous community members, Research Ethics Boards time and resource constraints	Building long-term relationships with local communities, Utilizing the Community Engagement Through Research program
Maclaren et al⁵¹	Understanding recruitment and retention of doctors in rural Scotland: Stakeholder perspectives	2022	Considered the perspective of stakeholders on issues within Scottish healthcare	Qualitative	Scotland	Family Preferences, Recruitment and retention difficulties	Rural exposure during childhood, Supportive tight-knit community, Family preferences, Rural placements
Malau-Aduli et al⁵²	Understanding medical students’ transformative experiences of early pre-clinical international rural placement over a 20-year period	2022	Utilized Transformational Learning Theory as a framework to describe the influence of international rural placement on participants’ development and learning	Qualitative	Australia		Immersive international rural placements
Mathews et al⁵³	Work locations in 2014 of medical graduates of Memorial University of Newfoundland: A cross-sectional study	2015	Identified the predictors of practice location for 2014 Memorial University medical graduates	Cross-sectional	Canada	Small community's inability to support diverse medical specialties	Rural background, local residency training
Matsumoto et al⁵⁴	Policy implications of a financial incentive programme to retain a physician workforce in underserved Japanese rural areas	2010	Described how a rural-oriented financial incentive approach affected medical student practice location	Retrospective cohort	Japan		Rural service exposure
McGrail & O'Sullivan⁵⁵	Increasing doctors working in specific rural regions through selection from and training in the same region: National evidence from Australia	2021	Investigated any correlation between entering medicine and/or training in a rural region and physicians current working area, along with the influence of rural training duration	Cross-sectional	Australia	Mismatch of skills, retention issues, enrollment costs, barriers in maintaining high quality rural training related in finances, sufficient infrastructure and working conditions, community engagement, and sufficiently experienced rural supervisors	Rural background students, General Practitioner specialty training
McGrail et al⁵⁶	Rural training pathways: The return rate of doctors to work in the same region as their basic medical training	2018	Determined how rural training impacts student practice location and the effects of longer rural exposure and having both training and schooling in the same remote area	Prospective cohort	Australia	Selection being unrelated to student's secondary school location	Preferential selection of rurally-based students, longer duration for local rural exposure
Meili et al⁵⁷	Teaching social accountability by making the links: Qualitative evaluation of student experiences in a service-learning project	2011	Investigated student experiences during the Making The Links program	Qualitative	Canada	A lack of meaningful clinical experience as a result of short rural training	Exposure to rural and low-income communities through making the links program
Mian et al⁵⁸	How underserved rural communities approach physician recruitment: Changes following the opening of a socially accountable medical school in northern Ontario	2017	Analyzed NOSM's impact on family physician recruitment in rural and underserved areas	Qualitative	Canada	Financial, language and cultural barriers	Recruiting local community members, rural and northern community exposure, improved communication between NOSM and the local community
Mikhail et al⁵⁹	Operation Remote Immunity: Exploring the impact of a service-learning elective in remote Indigenous communities	2023	Described how an elective in northern Indigenous communities based on service-learning influenced social accountability	Qualitative	Canada		Service-learning approach, personal exposure to inequities
Myhre et al⁶⁰	Specialty resident perceptions of the impact of a distributed education model on practice location intentions	2015	Examined how the University of Calgary's distributed education training model influenced residents’ practice intentions and how this differs based on speciality and program stage	Mixed methods	Canada		Engaging, supportive and passionate staff, cost-effective accommodations
Paul et al⁶¹	Making a difference: The early impact of an Aboriginal health undergraduate medical curriculum	2006	Outlined the effects of University of Western Australia's integration of a Aboriginal health curriculum	Cross-sectional	Australia		Involving local community members in curriculum development and teaching
Punzalan et al⁶²	The integration of primary care and public health in medical students’ training based on social accountability and community-engaged medical education	2023	Explored student and community perspectives regarding how socially accountable medical training incorporated primary care and public health	Qualitative	Philippines	Poor working conditions and lower salaries	Curriculum that emphasizes community immersion and hospital rotations
Roberts et al⁶³	A longitudinal integrated placement and medical students’ intentions to practise rurally	2012	Examined how an integrated placement affects medical students’ intentions to practice in rural areas	Qualitative	Australia	Limited employment opportunities, family concerns, geographic isolation, lack of support during rural student placements	Student support during placements such as professional role models
Ross et al⁶⁴	A qualitative investigation of the experiences of students and preceptors taking part in remote and rural community experiential placements during early medical training	2019	Described a medical program's rural community placements	Qualitative	Canada	Poor learning experiences and retention difficulties	Early remote and rural community experiential placements
Ross et al⁶⁵	The training for Health Equity Network evaluation framework: A pilot study at five health professional schools	2014	Assessed the evaluation framework with the goal of promoting social accountability across five Training for Health Equity Network schools	Mixed methods	Australia, Canada and Philippines		Implementing social accountability evaluation tools
Sen Gupta et al⁶⁶	Rural internships for final year students: Clinical experience, education and workforce	2008	Outlined the development and incorporation of a rural internship program	Qualitative	Australia	Poor quality rural placements	Well-developed rural internship model to better understand local communities
Shannon et al⁶⁷	Evaluation of a required statewide interdisciplinary rural health education program: Student attitudes, career intents and perceived quality	2005	Examined how student attitudes towards career intentions and rural health were impacted by a community-oriented rural education program	Prospective cohort	United States	Pre-existing student career intents	Community-based rural curriculum
Siega-Sur et al⁶⁸	The impact of socially-accountable, community- engaged medical education on graduates in the central Philippines: Implications for the global rural medical workforce	2017	Explored how socially accountable professional education influenced students’ career and practice intentions	Cross-sectional	Philippines		Tailored curriculum through community-centred programs
Smith & Weaver⁶⁹	Capturing medical students’ idealism	2006	Examined the impacts of a health elective at the University of Texas Medical Branch on students	Qualitative	United States with an international elective component in Nicaragua	Declining attitudes through training, financial issues and a lack of resources	Unique mentored student experiences
Strasser et al⁷⁰	Transforming health professional education through social accountability: Canada's Northern Ontario School of Medicine	2013	Outlined the effects of NOSM's social accountability mandate and described how it impacts health outcomes	Mixed methods	Canada		NOSM holistic curriculum involving community-partnerships
Strasser & Cheu⁷¹	Needs of many: Northern Ontario School of Medicine students’ experience of generalism and rural practice	2018	Examined student perceptions of generalism in rural practice at NOSM	Qualitative	Canada		Comprehensive community clerkship program
Tejativaddhana et al⁷²	Identifying challenges and barriers in the delivery of primary healthcare at the district level: A study in one Thai province	2013	Described the views of stakeholders on improving primary health services and examined difficulties in care delivery in Thailand	Qualitative	Thailand	Lack of recognition of the importance of equitable healthcare access, retaining issues, economic barriers, curative rather than preventative care focus
Thompson et al⁷³	Views from the field: Medical student experiences and perceptions of interprofessional learning and collaboration in rural settings	2018	Examined how interprofessional learning is viewed by medical students	Qualitative	Canada		Role flexibility, unstructured learning, positive learning environment, interprofessional learning
Vujcich et al⁷⁴	“[It's] more than just medicine”: The value and sustainability of mandatory, non-clinical, short- term rural placements in a Western Australian medical school	2020	Explored the rural placement program's impact on student career intentions and community rural health needs	Qualitative	Australia	Prevailing student attitudes,	Mandatory short-term rural placements
Wearne et al⁷⁵	Physical isolation with virtual support: Registrars’ learning via remote supervision	2015	Examined the influence of remote supervision on the educational experiences of general practitioner registrars	Qualitative	Australia and Canada	Difficulties in providing structured learning and proper supervision	Rural immersion and adequate remote supervision, giving learners a sense of responsibility
Wenghofer et al⁷⁶	Impact of the rural pipeline in medical education: Practice locations of recently graduated family physicians in Ontario	2017	Determined how NOSM education impacted students intention to practicein rural areas and compared this to other Canadian medical institutions	Cross-sectional	Canada	Lower diversity of healthcare specialties, financial limitations	Recruitment and training of rural and northern students
Woolley et al⁷⁷	Socially accountable medical education strengthens community health services	2018	Explored how those with socially accountable health professional education have influenced child and maternal health services	Cross-sectional	Philippines		Selective admission of representative students, service learning
Woolley et al⁷⁸	Does a socially-accountable curriculum transform health professional students into competent, work-ready graduates? A cross-sectional study of three medical schools across three countries	2019	Evaluated the impact of socially accountable medical schools on student competencies and job preparation	Cross-sectional	Australia, United States and Sudan		Community-based training and curriculum development

Table 2.

Characteristics of original articles included in the study.

Characteristic	No. (%)
Study type
Qualitative	24 (45.3%)
Cross-sectional	13 (24.6%)
Prospective cohort	8 (15.1%)
Mixed methods	4 (7.5%)
Descriptive analysis	2 (3.7%)
Retrospective cohort	1 (1.9%)
Retrospective case study	1 (1.9%)
Study country
Canada	13 (24.5%)
Australia	12 (22.6%)
Multi-national (including Belgium, Nepal, Nicaragua and Sudan)	7 (13.2%)
Philippines	6 (11.3%)
United States	5 (9.4%)
South Africa	3 (5.7%)
Scotland	2 (3.8%)
India	1 (1.9%)
Japan	1 (1.9%)
Kyrgyzstan	1 (1.9%)
New Zealand	1 (1.9%)
Thailand	1 (1.9%)

Studies included in this review were conducted across 15 countries: Australia, Belgium, Canada, India, Japan, Kyrgyzstan, Nepal, New Zealand, Nicaragua, Philippines, Scotland, South Africa, Sudan, Thailand, and the United States. A majority of the studies were from Canada (24.5%), followed by Australia (22.6%), Philippines (11.3%), and the United States (9.4%) with multi-national studies (including Belgium, Nepal, Nicaragua, and Sudan) accounting for 13.2% of the included articles. Three (5.7%) studies were conducted in South Africa (2.8%), two (3.8%) in Scotland, and one each (1.9%) in India, Japan, Kyrgyzstan, New Zealand, and Thailand (Table 2).

Thematic Analysis

Challenges for Physicians to Promote Social Accountability

A total of 21 (39.6%) studies reported on the challenges faced by physicians promoting social accountability.^{29,32,34,37,39,43,44,46,47,49–51,53,55,58,62,63,69,72,75,76} Professional limitations and poor working conditions were identified as a barrier in nine of these 21 studies, emerging as the most prevalent challenge.^{29,43,44,51,53,55,63,75,76} These included long working hours;²⁹ higher workloads;⁷⁶ low remuneration;^43,44,51,63 absence of appropriate medical equipment and facilities to support the community and physicians’ career aspirations;^43,44 unstructured learning environment;⁷⁵ inadequate supervision;⁷⁵ and a lack of opportunities for professional development.^32,44,53,76 Physicians who did not have a rural background were also faced with mismatches between their skills and the needs of the population they were serving, contributing to further issues within an already challenging work environment.⁵⁵

Negative, progressively worsening attitudes among medical students and physicians were listed as a challenge in seven studies^{32,34,37,44,46,63,69} These were characterized by a declining sense of idealism,^32,69 a lack of understanding and consideration for Indigenous communities,^34,37 and diminished interest in working with underserved populations.⁶⁹ Family medicine and primary care were poorly understood and viewed as unattractive fields that were perceived as neither valued by the public or other physicians.^44,72 Furthermore, physicians were reluctant to face stigma if they chose to live and work within rural communities.⁴⁶

In addition, medical students and physicians had their own preferences of where they would like to practice as mentioned in four studies.^39,47,49,62 The intention to emigrate was noted among individuals belonging to international, urban, and high-income backgrounds.^47,49,62 Higher pay, better working conditions, and the desire to gain experience in a foreign country were reported as the main reasons for wanting to leave.^47,62 One finding that particularly stood out was the lack of willingness among students from very low socioeconomic backgrounds to work in underserved communities, potentially attributed to aspirations of being upwardly mobile in society.³⁹

Deterrents of serving in rural and remote communities also included familial concerns, such as the scarcity of employment opportunities for partners and barriers hindering the success of their children, which were brought up in four articles.^43,51,58,63 Moreover, geographical isolation^29,58,63 and language barriers^29,44,58 were cited as challenges in three studies each. A lack of amenities in rural areas, such as poor accommodation, few restaurants, and limited social activities, were mentioned in two studies,^29,43 while one study reported on the reluctance of Indigenous people to engage in projects due to prior negative experiences with medical researchers.⁵⁰

Challenges for Medical Schools to Promote Social Accountability

Barriers to promote social accountability for medical schools and educational institutes were mentioned in 23 (43.4%) studies.^{26,27,30,33,35,36,40–42,44,49,50,55–58,62–65,68,69,72} Curriculum incompetency was the most frequently reported challenge and was listed in 14 articles.^{35,40,44,50,56–58,62–65,68,69,72} The curricula used within medical schools and clinical training were largely conventional with little focus on primary care.^62,72 Components incorporating rural immersion were often short and lacked appropriate support mechanisms for students and physicians.^50,63 In addition, options for medical school electives and residency track that incorporated community health were typically limited to individuals who were at least in their final year of medical school at which point they did not hold much utility in drawing physicians towards serving rural communities.⁶⁹ Demands such as the need for community collaboration, tailoring the program to local needs, and the absence of an appropriate evaluation tool made it difficult to establish effective, socially accountable curricula.^50,56,65,68 Furthermore, attempts at shifting towards a community-based approach to medical education were met with resistance from conventional medical institutions and government bodies, contributing to the current inadequacy of curricula.⁴⁰

Financial and resource constraints to establish socially accountable medical education and training programs were discussed in eight studies.^{33,36,40,44,49,50,56,69} A lack of diversity and inclusivity in admission and recruitment policies was referred to in four studies as a barrier that limited the selection of students from rural backgrounds and those that might be more inclined to practice in these communities.^26,42,49,56 Three studies each recognized poorly developed infrastructure^30,41,56 and training and availability of teaching staff^44,50,56 as a challenge for medical schools. Moreover, one study criticized the redistribution of graduate training positions for directing future primary care physicians to other specialties due to a relatively larger increase in non-primary versus primary care training.²⁷

Facilitators of Social Accountability for Physicians

Facilitators for physicians to promote social accountability were listed in 17 (32.1%) studies.^{30,31,38,42–47,49–53,55,58,75} Community immersion, the most discussed facilitator, was recognized in 16 studies.^{30,31,38,42–45,47,49–53,55,58,75} Exposure to rural communities during their medical education (eg, rotations) and through their own rural background and upbringing were both found to increase the willingness of physicians to serve these communities.^{30,31,38,42–45,47,49–53,55,58,75}

Positive attitudes towards rural health and primary care were identified as facilitators in four studies.^31,43,44,47 These included a sense of responsibility towards serving the needs of their country,^31,43,44,47 desire to stay close to their family,^31,43,47 attachment to their home community,^31,47 and finding the remoteness of rural areas to be appealing.⁴³

The importance of peer support and establishing meaningful relationships with colleagues was highlighted in four studies.^31,46,51,75 Similarly, the positive experience of their family members in rural areas encouraged physicians to remain and continue practicing in those communities.⁵¹

Facilitators of Social Accountability for Medical Schools and Medical Educators

Forty-five of the included articles (84.9%) discussed facilitators for medical schools and educators to promote social accountability.^{26,28,29,31,33–36,39–48,50–71,73,74,76–78} Using a community-centered curriculum was reported in 39 studies as an effective intervention.^{28,29,31,33–36,39,40,42–47,50–54,56–59,61–64,66–71,73,74,76–78} Such curricula were designed in collaboration with community members and local physicians and were specifically tailored to the needs of the area and its population.^{33,61,68,77,78} They typically entailed experiential or service-learning opportunities in a rural context, including clinical rotations and research projects.^{28,29,31,33,34,36,40,42,43,45–47,50–52,54,56–59,62–64,66,67,70,71,73,74,76–78} Service-learning activities were also offered with underserved, low-income, and international communities.^57,69,78 Other components of community-centered curricula included health equity,⁷⁸ family medicine,⁴⁴ primary care,^47,62 public health,⁶² and interprofessional education.^35,73

Targeted admission policies emerged as a facilitator in 11 studies.^{26,31,33,41,44,45,48,55,56,76,77} These were aimed at recruiting students that were regionally, ethnically, and socio-demographically diverse; and representative of the communities that the medical schools were serving.^45,48,77 Strategies focused on increasing recruitment from local, rural areas; non-traditional and indigenous backgrounds; and lower socioeconomic groups, considering non-academic abilities in their admissions criteria to select students with a higher likelihood of working in primary care, remote regions, and with underserved populations.^{26,31,33,41,45,48,55,56,76}

The role of medical educators, acting as good role models, in supporting medical school's social accountability mission was acknowledged in nine studies.^{40,43,44,47,60–63,70} These instructors encouraged students to consider rural practice by sharing their own passion for the field, relaying their experiences, and promoting family medicine.^{43,44,60,61,70} Government support for socially accountable programs was also reported to facilitate medical schools in their implementation of these initiatives in a single study.⁶² In addition, according to the findings in one study, having an evaluative tool helped medical schools gauge their progression towards attaining social accountability, allowing them to critically analyze enabling and impeding factors and thus, work towards their goal more effectively.⁶⁵

Discussion

This scoping review is the first to identify social accountability practices in a rural context on a global scale. Fifty-three publications from 15 countries documented the prevalence of rural social accountability practice, highlighting the integral significance of addressing this inequality. More understanding is needed regarding implementing social accountability in rural communities across other regions. Approximately 91% of the articles were published after the 2010 Delphi study toward a global consensus on the social accountability of medical schools (GCSA),⁷⁹ demonstrating a rising interest in the topic and increasing recognition of its importance.

Canadian medical schools demonstrated a heavy emphasis on social accountability practice, encompassing 24.5% of the overall literature, followed by Australia (22.6%), the Philippines (11.3%), the United States (9.4%), South Africa (5.7%), the UK (3.8%), India (1.9%), Japan (1.9%), Kyrgyzstan (1.9%), New Zealand (1.9%), and Thailand (1.9%), with multi-national studies comprising 13.2% of the included articles. Despite the inclusion of studies coming from diverse countries, this distribution demonstrated a lack of literature from regions of Latin America, the Middle East, and Northern and Central Africa.

The practice patterns of social accountability are regionally diversified. The Christian Medical College, Vellore, Tamil Nadu, India (CMCV), has a well-documented history of practicing social accountability for over 100 years, originally started as a not-for-profit entity for services across all socioeconomic backgrounds.⁵² Of the included studies, 12 pertained to NOSM University.^{45,47,49,50,58,64,65,70,71,73,76} NOSM University was established with an explicit social accountability mandate, which prioritizes the health needs of the local population and values community engagement. This mandate is guided by the belief that medical institutions bear an obligation to address the immediate health needs of the communities they serve. Key aspects of NOSM's model include community-based learning, rural placements, Indigenous health partnerships, and a tailored student recruitment strategy.¹⁷

Challenges for Physicians and Medical Schools to Promote Social Accountability

Thematic analysis indicated that barriers for physicians and medical school students to contribute towards rural social accountability practice include (a) inadequate working infrastructure as the most prevalent challenge, (b) a mismatch between physician skills and the population's needs, (c) unfavorable attitudes of medical students and physicians, (d) personal preferences attributed to socioeconomic backgrounds, (e) familial considerations for the development of subsequent generations due to geographical isolation, (f) cultural contrasts with the local population, and (g) negative inclination of Indigenous population towards medical researchers.

Barriers decelerating the spread of medical school rural practice of social accountability comprise of (a) inadequacies in curriculum design with insufficient consideration for the needs of rural settings and a focus on alleviating institutional or governmental objections, (b) monetary and resource constraints, (c) absence of admission diversity and equality considerations, (d) inadequate or nascent infrastructure development, and (e) human resource redistribution after graduation.

Facilitators of Social Accountability for Physicians and Medical Schools

Facilitators of physician efforts to promote social accountability were summarized as (a) exposure to rural communities, (b) rural familial background, (c) favorable attitudes towards rural regions during medical school studies, and (d) underpinning peer-to-peer mitigation.

Moreover, facilitators for mitigating social accountability challenges faced by medical schools encompass the following: (a) curriculum design centering on the community and assessing the demands of the population, (b) targeted admission policies emphasizing the recruitment of students who are inherently representative of the community or region they have the mandate to serve, (c) the provision of peer, mentor, and institutional support through establishing role models, and (d) evaluation of social accountability engagement using external tools.

Evaluating the barriers and facilitators of social accountability practice has demonstrated intrinsic challenges due to the multipolar nature of the construct on a global scale. This accentuates the need for a unified, region-dependent, and flexible framework, extending beyond the challenges of infrastructure, retention, socioeconomic status, and recruitment, encompassing the philosophical landscape and cultural differences inherent to the region. Overall, this scoping review serves to highlight the admission policies and educational responsibilities of medical schools, along with the individual ethical and community responsibilities of physicians.

Limitations

Limitations of this scoping review have been identified. The findings of this review were limited to published peer-reviewed primary studies and all gray literature was excluded, indicating a potential overrepresentation of significant results. The primary research studies that were included utilized small sample sizes. In addition, there was heterogeneity in the definitions of social accountability between included studies. This was considered when developing the inclusion criteria, which specified the definition of social accountability in accordance with the WHO guidelines.¹⁹

Conclusion

This scoping review synthesizes existing evidence from 53 articles on the barriers and facilitators of social accountability practices in rural settings across 15 countries. The identified literature captures recurring themes of medical infrastructure inadequacy, community immersion curriculum design, targeted admission, geographical isolation, and institutional or peer support. Prospective research could focus on expanding and refining current guidelines and frameworks to improve socially accountable benchmarks in rural areas.

Supplemental Material

sj-docx-1-mde-10.1177_23821205251348015 - Supplemental material for Challenges and Facilitators for Physicians and Medical Schools to Promote Social Accountability in Rural Communities: A Scoping Review and Thematic Analysis

Supplemental material, sj-docx-1-mde-10.1177_23821205251348015 for Challenges and Facilitators for Physicians and Medical Schools to Promote Social Accountability in Rural Communities: A Scoping Review and Thematic Analysis by Aghna Wasim, Ali Abud, Yihan Wang, Ehsan Tavakoli, Athena Moreno-Gris, Samar Joshi, Arthur Wang, Angela Neasadurai and Nikki Shaw in Journal of Medical Education and Curricular Development

Footnotes

Acknowledgement

We acknowledge all Evidentia Institute of Knowledge Synthesis volunteers and staff members for their support.

ORCID iDs

Aghna Wasim

Yihan Wang

Nikki Shaw

Ethical Considerations

This article does not contain any studies with human or animal participants. There are no human participants in this article and informed consent is not required.

Author Contributions

AW, AA, and YW contributed to conceptualization, data curation, formal analysis, investigation, methodology, project administration, visualization, writing (original draft), and writing (review & editing); ET, AMG, SJ, ALW, and AN contributed to data curation, formal analysis, writing (original draft), and writing (review & editing); NS contributed to conceptualization, formal analysis, investigation, methodology, supervision, visualization, writing (original draft), and writing (review & editing).

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data supporting the findings of this study are available from the Supplement Material.

Supplemental Material

Supplemental material for this article is available online.

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