The qualitative analysis of the interview transcripts revealed several main themes. The abbreviation ES is used for educational staff and the abbreviation S is used for student. Table 2 presents the main themes and a description of the main themes.
Table 2
Main themes and subthemes and main findings
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Theme
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Subthemes
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Main findings
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Non-Acquaintance with the term
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-Unfamiliar term
-Abstract term
-Literally translating or analyzing the term
-Association with role of health advocate by the CanMEDS
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General definition
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Social aspects of healthcare
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-The responsibility towards society to contribute to solving societal problems
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Responsibility of the institution
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-Responsibility of educational institution towards students
-Student population representation of serving population
-Putting individual student at the center
-Reciprocal relationship between society and educational institution
-Commitment to and connection with the society
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Reflection on our definition
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The role of context
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-Dependent on context
-Multifactorial construct
-Logical and complete definition
-Definition especially focused on education
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Aspects of social accountability
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Sustainability
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-Efficiency
-Preventive medicine
-Planetary health
-Ecological footprint
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Interprofessional collaboration
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-Collaboration between professionals/students of different disciplines
-Treating others equally
-Having respect for others
-Way to achieve social accountability
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Moral issues
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-Ethical issues
-Dilemmas
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Diversity
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-Sensitivity and respect for differences
-Acquiring knowledge about relationship social-economic-status and diseases
-Having a broad view
-Being aware of bias
-Creating an inclusive environment
-Counteracting colonization in education
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Person-centeredness
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-Patient-centeredness
-Dealing with more assertive patients
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Community-based learning
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-Using knowledge and skills to benefit the community
-Involving the community in education and research
-Teaching societal issues
-Using education and research to improve healthcare policies
-Volunteering
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Non-Acquaintance with the term. When asked to define social accountability, most of the educational actors and students explicitly stated that they experienced difficulties explaining the meaning of the term social accountability. They mentioned several reasons for this difficulty. Firstly, the term was unfamiliar to most of the educational actors and to all students. When we asked participants to provide a definition, one responded: “That must be a joke, because I wanted to ask you first” (ES40). This quote is indicative of the participants’ unfamiliarity with the term. Furthermore, several educational actors and students provided a definition by literally translating or analyzing the term. They mentioned that the term social accountability consists of two parts: social and accountability. Social relates to the relationship between a physician, student, educational institution or hospital and the society and accountability relates to the obligation the aforementioned entity has towards society. Other participants stated that they consider the term as abstract. An educational actor said: “I think you need to try to make it concrete by using several main aspects” (ES1). Several educational actors associated social accountability with the role of health advocate, as described by the CanMEDS. This role includes the understanding of societal needs, improving health by means of preventive medicine, increasing health equity, and creating change in the medical system. They seem to be more familiar with this term than with the term social accountability.
General definition
Despite the experienced difficulties, participants described what they considered as key features of social accountability.
Social aspects of health care. Both the educational actors and students described social accountability in terms of the social aspects of healthcare. A student mentioned: “According to me, the central thing you learn with social accountability is to better interact with colleagues and with the patient” (S31). The educational actors and students consider social accountability as the responsibility of a doctor, an organization, or an educational institution towards society to contribute to the solutions of societal problems. They mentioned for example homeliness and health problems that are caused by living circumstances as examples of social problems that should be addressed.
Responsibility of the institution. Some participants also see social accountability as the responsibility an educational institution has towards the student. According to them, this responsibility includes ensuring that the medical student population represents the population they will serve. An educational actor mentioned: “Because the extent in which we as an educational institution take our responsibility to take account of diversity or other social issues like using our resources in an environment-friendly way is different from educating our students about these issues” (ES10). Furthermore, the participants considered taking social accountability as putting the individual student at the centre. A student reflected on the study program: “You are an individual instead of a number” (S28). Several educational actors thought that social accountability is reciprocal. The educational institution is funded by society and in return, the educational institution and hospital provide education to future health professionals and contribute to society by providing good healthcare and making sure everyone has access to medical care. According to the participants, social accountability involves a commitment to and connection with society.
Reflection on our definition
The role of context. As a reaction to the definition we proposed, the educational actors and students mentioned that the term can be interpreted in many ways. According to them, the definition is dependent on the context and the term is multifactorial. The participants mentioned that social accountability is of importance in different contexts: the context of research, education, organization, student, society, individual and collective. In the context of research, social accountability means, according to them, involving the community in research. In education it means, for instance, teaching about topics that are related to social accountability and creating equal changes for everyone in the selection procedure. On an individual level, it means paying respect to patients and colleagues of different backgrounds, while on a collective level it means reducing the emissions of the hospital. Most of the educational actors and students stated that they thought the constructs we considered as social accountability were logical and complete. Some of them mentioned an additional aspect such as moral issues. As a student mentioned: “There is not really anything missing” (S4). According to the participants, our definition, especially the constructs of community-based learning and interprofessional learning, was specifically focused on education, rather than the context of research or organization. A participant stated: “And then you mention several constructs which are all very educational related” (ES9).
Aspects of social accountability. The participants reflected upon the aspects of social accountability we distinguished based on the aspects of the ASPIRE award. The distinguished aspects of social accountability are visually presented in Figure 1.
Sustainability. Most of the educational actors and students considered sustainability as an essential part of social accountability. They distinguished several aspects of sustainability. First of all, some participants stated that efficiency is part of sustainability. An educational actor stated: “Efficiency is for me also (a part of) social accountability because we have a system with restricted human resources and funding in which we have to make sure that everyone has access to a minimum of healthcare. What we consider as the minimum and what we can afford to provide” (ES7). Another aspect of sustainability that is distinguished by the participants is preventive medicine. According to the participants, preventive medicine is about creating a society in which there are as minimal diseases as a result of environmental circumstances as possible and remaining of sustainable use to the patients and the employer.
Several participants mentioned that students need to be educated about their own ecological footprint as a student and a professional and the footprint of the healthcare sector. They need to learn what the impact is on the environment and ways to minimize this impact. A participant stated: “This way they can get perspectives for action to reduce their own impact” (ES12). Furthermore, participants consider planetary health as part of sustainability. To improve sustainability it is of great importance to recognize the connection between ecosystems, sustainability, and health.
Interprofessional collaboration. Another aspect of social accountability acknowledged by some educational actors and students is interprofessional collaboration. According to the participants, interprofessional collaboration is the collaboration between professionals or students of different disciplines. They consider this as treating other professionals equally and respecting their competencies and professionalism. However, some participants did not consider interprofessional collaboration as part of social accountability, but rather as a way to achieve social accountability. This is because they see interprofessional collaboration as the development of communication and collaboration skills. These skills help to solve the social issues addressed by social accountability. A participant said: “I see social accountability like a mission, a purpose. If you make it big, your own life purpose, you can fulfil this mission in several ways. Interprofessional education is one of the ways in which you can operationalize it” (ES10).
Moral issues. Another aspect of social accountability mentioned by the participants is the aspect of moral issues when considering societal problems. The dilemma of whether or not to work in a private clinic is proposed by a participant as an example of a moral issue. An educational actor stated: “Students have to think about whether or not they want to work in a private clinic. We have our main point of focus on educating doctors who treat all patients equally. That means that we educate doctors who generally consider working in a private clinic, where only the richest people can be treated, morally disapproving” (ES10). Participants consider ethical issues as an essential part of social accountability. A student asked himself the following question: “Is it ethical that we send a patient back into a society that causes diseases, after their treatment in the hospital?” (S35). They stressed that a lot of diseases can be prevented by taking societal factors into account.
Diversity. According to the participants, diversity of patients and students is about sensitivity and respect for differences in culture, ethnicity, gender, age, living circumstances, migration background, sexual preference, living environment, and educational level. Participants consider it important that students acquire knowledge about the socio-economic background in relation to diseases. Another important competence to deal with diversity is having a broad view and being aware of bias. An educational actor said: “They (the students) think that they know how everything in the world works, but actually they are looking at their own prejudices” (EA8). One student mentioned that she thinks social accountability is not only about broadening your own view within the medical field, but also in different fields. She thinks a second bachelor or master program in another field can supplement medical education. According to some participants, diversity is also about creating a diverse and inclusive learning-and working environment. An example of counteraction of colonization in medical education mentioned by the participants is the avoidance of stereotypes in casuistry. Students should learn, for instance, not only about the white skin but also about the coloured skin. An educational actor stated: “But I think it is the responsibility as a medical institution to be aware of the fact that we base our casuistry often too much on stereotypes” (ES10). An example mentioned by one of the participants of a stereotype often used in casuistry is an HIV patient who is drug-addicted or a truck driver who snacks a lot and has diabetes as a result of obesity.
Person-centeredness. According to the participants, person-centeredness is about teaching students to take social aspects of the patient into account and aligning the knowledge and course of action with the needs of the patient. They also consider as part of social accountability to deal with patients who are now more assertive than patients used to be in the past and, for instance, google for information about diseases. A student said: “To learn to deal with patients who take matters in their own hands with regard to diagnosing” (S26).
Community-based learning. Another aspect of social accountability mentioned by the participants is community-based learning. According to the participants, social accountability is also about using knowledge and skills in a way that benefits the local community and involving the community in the development of educational material or the formulation of research questions. Furthermore, participants consider community-based learning as teaching students about the issues that are considered important by society. A participant mentioned: “The worst thing you can do is to build your educational institution like an ivory tower with only a service entrance for employees” (ES11).
Furthermore, participants state that community-based learning is using education and research to improve healthcare policies. Students need to learn about healthcare policies in relation to societal needs and demographics to adjust policies and societal needs. The educational actors think that students need to learn about the aspects in which healthcare and society do not fit each other, knowledge about how the society is built up, the social problems that are behind the demand for care and several paths of solution. Paths of solution are for example having conversations with the community and co-constructing policies, research, and education with society.
Students also associate social accountability with volunteering and providing help in developing regions or countries. An example of volunteering is the Kruispost, a Dutch health care centre that provides free medical and psychosocial care to people who cannot find help in the regular healthcare system: e.g. uninsured, homeless, or asylum-seeking people. An example of providing help in developing regions or countries is Doctors without Borders. A student said about Doctors without Borders: “You get a feeling about what can be improved in society as a beginning doctor or student” (S33).