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Teaching and Learning in Medicine
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Groundwork

Global Perceptions on Social Accountability and Outcomes: A Survey of Medical Schools

Cassandra Barbera School of Health Professions Education, Faculty of Health, Medicine and Life Sciences. Maastricht University, Maastricht, The NetherlandsCorrespondence[email protected]
ORCID Iconhttps://orcid.org/0000-0003-3605-8485View further author information
ORCID Icon,
Saad Chahineb Associate professor, Faculty of Education, Queen’s University, Kingston, Ontario, CanadaORCID Iconhttps://orcid.org/0000-0003-0488-773XView further author information
ORCID Icon,
Jimmie Leppinkc Research director, Hospital virtual Valdecilla (HvV), Santander, Cantabria, SpainView further author information
&
Cees van der Vleutend Professor, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The NetherlandsORCID Iconhttps://orcid.org/0000-0001-6802-3119View further author information
ORCID Icon
Pages 527-536 | Received 08 Nov 2021, Accepted 07 Jul 2022, Published online: 29 Jul 2022

Abstract

Phenomenon: Social accountability has become a universal component in medical education. However, medical schools have little guidance for operationalizing and applying this concept in practice. This study explored institutional practices and administrative perceptions of social accountability in medical education. Approach: An online survey was distributed to a purposeful sample of English-speaking undergraduate medical school deans and program directors/leads from 245 institutions in 14 countries. The survey comprised of 38-items related to program mission statements, admission processes, curricular content, and educational outcomes. Survey items were developed using previous literature and categorized using a context-input-process-products (CIPP) evaluation model. Exploratory Factor Analysis (EFA) was used to assess the inter-relationship among survey items. Reliability and internal consistency of items were evaluated using McDonald’s Omega. Findings: Results from 81 medical schools in 14 countries collected between February and June 2020 are presented. Institutional commonalities of social accountability were observed. However, our findings suggest programs focus predominately on educational inputs and processes, and not necessarily on outcomes. Findings from our EFA demonstrated excellent internal consistency and reliability. Four-factors were extracted: (1) selection and recruitment; (2) institutional mandates; (3) institutional activities; and (4) community awareness, accounting for 71% of the variance. McDonald’s Omega reliability estimates for subscales ranged from 0.80-0.87. Insights: This study identified common practices of social accountability. While many medical schools expressed an institutional commitment to social accountability, their effects on the community remain unknown and not evaluated. Overall, this paper offers programs and educators a psychometrically supported tool to aid in the operationalization and reliability of evaluating social accountability.

Background

Social accountability is defined in medical education as the capacity to respond to societal needs and health system challenges.Citation1 This mandate implies a commitment from medical schools to direct their education, research, and service activities toward priority health needs in the communities they intend to serve.Citation2 Over the last decade, social accountability has become a universal component in medical education.Citation3–7 Better alignment between medical education and societal needs is considered a key pathway for improving population health.Citation8 However, the practical implementation of this widespread social commitment remains elusive.Citation9 Social accountability has an internationally acknowledged definition,Citation2,Citation10 but medical schools have little guidance for operationalizing and applying this concept in practice.Citation9 While social accountability focuses on education, research, and service activities, this paper focuses primarily on the educational perspective of social accountability in medical training.

Previous studies examined institutional differences surrounding the core principles of social accountability.Citation11,Citation12 For example, Preston et al.,Citation11 examined how social accountability was conceptualized by key stakeholders using a multi-case study. While commonalities were observed, stakeholder perceptions were multi-dimensional and largely influenced by contextual issues.Citation11 Similarly, Galukande et al.,Citation12 interviewed 12  key informants regarding their perceptions of social accountability. Their findings suggest individual perceptions of social accountability were not homogenous and contextualized by the lack of community resources.Citation12

The lack of clarity surrounding social accountability has resulted in several institution-specific documents.Citation13–25 While these documents differ in terms of application, they express similar social mision statements;Citation26–28 widening admissions policies;Citation29–31 curricular reforms;Citation32–34 and community-based learning opportunities.Citation35,Citation36 Although these attributes are seen as steps in the right direction, they must be strengthened by the commitment to evaluate program outcomes.Citation1,Citation37

There is growing evidence suggesting that institutional social mission activities are associated with increased workforce diversity, primary care selection, and physician distribution.Citation38 For example, Mullen et al.,Citation39 developed a social mission score to evaluate medical school outputs in the United States. This composite score comprised of three dimensions, the percentage of graduates from underrepresented groups, practice in primary care, and those who work in underserved areas. In 2021, Mullan et al.,Citation40 developed a health equity framework for medical schools. Using a multi-phased approach, eight modalities were identified to evaluate schools’ social missions (i.e., institutional mission statement, pipeline programs for underrepresented populations, admissions and selection, curriculum content, location of clinical experience, tuition management, mentorship, and postgraduate engagement).Citation40

Additionally, Morley et al.,Citation28 examined the relationship between social mission statements and school outputs using an expert panel in the United States. Their findings suggest a positive relationship between social mission content and percentage of graduates working in primary care and underserved areas.Citation28 Lastly, Puschel et al.,Citation41 developed the Social Accountability Instrument for Latin American Medical Schools (SAIL) questionnaire to measure institutional achievement in four key domains of social accountability. Using a mixed method approach this study designed and validated an instrument to measure social accountability.Citation41

The task of evaluating social accountability is complex.Citation9 In an effort to begin to understand how social accountability is operationalized in practice, we developed an online survey. This study aimed to construct a reliable social accountability scale and identify common practices and perceptions of social accountability.

Methods

This study investigated administrative perceptions and institutional practices of social accountability in medical schools using an online survey.

Participants

Using purposeful sampling, medical school deans and program directors/leads of English-speaking schools that offer an undergraduate medical program from 265 institutions in 14 countries (Australia and New Zealand, Canada, the Caribbean (Antigua, and Barbuda, Aruba, Barbados, Curaçao, Jamaica, Saint Kitts and Nevis, Saint Vincent and the Grenadines), South Africa, United Kingdom, Ireland, and the United States) were invited to complete an online survey. Individuals in leadership positions were deemed most appropriate based on their expert knowledge regarding institutional policies, program objectives, curricular activities, and institutional approach to program outcomes.

We conducted a hand search of English-speaking medical schools that offer an undergraduate medical program using the World Directory of Medical Schools website.Citation42 We selected this inclusion criterion based on the premise that all medical schools are accountable to the public, regardless of whether they choose to acknowledge and/or address this duty.Citation2 Additionally, due to the complexities surrounding post-graduate programs,Citation43 specifically in the United States,Citation44 we selected only medical schools that offer an undergraduate training program for inclusion. Lastly, the sampling was exclusive to English-speaking medical schools as cultural and language barriers were not always adequately captured through direct language translation. provides an overview of the type and duration of undergraduate medical programs by country included in the sample.

Table 1. Type and length of medical degree program included in the survey sample by county.

Invitation process

Participant contact information (name and corresponding email address of deans and program directors/leads from each school) were retrieved online using publicly available information (e.g., institutional websites and the Internet (using Google)). In an attempt to optimize response rates, contact information obtained from all deans and program directors/leads were invited to participate. The research team allocated a maximum of 15-minute search intervals for each school to locate the targeted contact information. If this information could not be obtained within 15 minutes, it was deemed publicly unavailable, and that school was excluded from the study.

The reliance on publicly available information as the sole source in reaching our target sample resulted in several assumptions that fell outside our control. For example, it was assumed that institutional websites listed names and corresponding email addresses of their academic leadership. Additionally, it was also assumed that these websites were updated regularly and were reflective of any leadership changes. We corrected errors resulting in incorrect contact information, names, and/or email addresses when possible and redistributed survey invitations.

Survey design

We developed a 38-item survey, linked to social accountability indicators using social accountability frameworks, peer-reviewed journal articles, and documents applicable to social accountability in medical education.Citation2,Citation4,Citation6,Citation9–11,Citation37,Citation45–50 These documents represented the core principles, parameters, and/or attributes of social accountability (see Barber et al.,Citation49 for a narrative review of social accountability frameworks). We designed survey items and categorized them using a context-input-process-products (CIPP) evaluation model.Citation49,Citation51,Citation52

The CIPP evaluation model is widely accepted in medical education and used internationally across multiple fields to provide comprehensive evaluation and quality improvement of social policies, programs, and interventions.Citation51 We organized survey items using the four components of the CIPP model. Context referred to items related to social accountability, conceptual perceptions, and medical school characteristics. Inputs captured items related to selection and recruitment of students, faculty, and staff as well as community engagement. Processes included items related to curricular activities and products referred to items concerning graduate outcomes and impact on population health.

We asked participants to reflect upon their institutional practices and answer a series of items related to their programs’ mission statements, admission processes, curricular activities, and educational outcomes. The survey included five items related to respondent demographics; five institutional characteristics items, inclusive of dichotomous (yes/no) items as well as an item asking respondents to rate their institutions’ perceived importance of social accountability using a ten-point scale (1 = not at all important and 10 = extremely important). The survey also included 28 Likert scale items using a 5-point scale (1 = strongly disagree and 5 = strongly agree). The survey is available in Supplemental Digital Appendix I.

Procedure

We developed survey items using an iterative process amongst researchers, over several months of discussions and revisions until we developed a final set of items. An expert panel review, consisting of medical physicians and academic scientists with expertise in social accountability in medical education, survey design, and measurement, validated the survey items. Twenty experts reviewed each survey-item based on relevance and clarity using a 3-point scale (nice to know, must know, and option to rewrite) and provided additional comments regarding item-scales as well as overall fit. Reviewer feedback was incorporated, and the pre-validated survey was disseminated to the targeted sample.

We distributed the survey and collected data electronically using Qualtrics Survey Software between February 24, 2020, and June 30, 2020. The authors intended the survey to take approximately 12 minutes to complete. Email invitations were extended to identified participants and included a brief introduction, survey instructions and expectations, information pertaining to consent, confidentiality, and anonymity as well as the survey link. The survey was voluntary; participants did not receive an incentive for participating. The survey remained open for several months to obtain optimal response rates during the initial stages of the COVID-19 pandemic. We conducted all correspondence between investigators and participants via email through Qualtrics. Following initial contact, bi-weekly email reminders were distributed over a four-month period.

Analysis

All survey responses were deidentified to ensure confidentiality and anonymity. Analyses included frequency distributions and descriptive analysis. To identify underlying constructs of the 28 Likert scale items, we used Exploratory Factor Analysis (EFA) using principal axis factor analysis with oblique rotationCitation53–55 and 3:1 sample to variable ratio.Citation53,Citation56 EFA requires a minimal sample size of approximately 100 cases.Citation53–55 McDonald’s Omega was used to assess the internal consistency of the resulting scales. We selected Omega over Cronbach’s Alpha based on its ability to provide more accurate estimates of a scale’s internal structure.Citation57–59 Analyses were conducted in SPSS (Version 26.0; IBM Corp. Armonk, NY) and Jamovi (Version 1.2; The jamovi project, Sydney, Australia).

Ethics: This study received ethical approval from Queen’s University, Kingston Ontario, Canada (File No. 6028362).

Results

A total of 81 medical schools from 14 countries participated in the study. Institutional response rates varied by country, ranging from 21% to 100%, with an overall response rate of 31% (depicted in ). Demographics and medical school characteristics are presented in . The number of responses for each survey item varied. Approximately, 38 (46.9%) of all respondents were female. Most respondents (80.2%) self-identified as a medical practitioner, years of practice ranging from 5 to 43 (M = 24.85, SD = 9.73). Additionally, respondents reported working at their current institution 1 to 35 years (M = 13.14, SD = 8.83).

Table 2. Social Accountability Survey Response Rates by Country and Medical School.

Table 3. Descriptive Statistics: Mean (M), Standard Deviation (SD), and Range of Possible Scores for Social Accountability Survey Demographic and Medical School Characteristics Item Responses.

All respondents (98.8%) expressed a high importance of social accountability within their school (M = 8.36, SD = 1.79) and most (88.8%) reported their school had an explicit social accountability mandate. Many schools (93.7%) reported having a primary care or family medicine/general practice department or faculty. Exposure to primary care practice and principles or family medicine departments are considered to foster graduates committed to primary care.Citation2,Citation8 Additionally, all respondents (97.5%) reported having student learning opportunities in a hospital setting. However, fewer respondents (45.7%) reported having community-based learning exposures in patient homes or elderly care homes (56.8%). Community-based learning opportunities expose students to a variety of settings as well as disadvantaged populations and underserved groups.Citation2,Citation8 Lastly, most respondents (95.1%) reported that their program’s mission statement was posted publicly.

Perceived agreement of socially accountable practices

The overall variance in the Likert scale items using McDonald’s ω reliability estimate was 0.946, indicating excellent internal consistency. However, means and standard deviations of these items varied (depicted in ). For example, item means related to institutional mission statements and community engagement were generally high (ranging from 4.0 to 4.5). Whereas item means related to coordinating with local organizations to promote health care, producing the right number of specialists needed to serve the local health workforce needs, and collecting data on the impact of graduates on patient outcomes were relatively low (ranging from 2.5 to 3.9).

Table 4. Mean (M), and Standard Deviation (SD) for the 28 Likert Scale Survey Item Responses (1 = strongly disagree, 5 = strongly agree).

Social accountability index

EFA using principal axis factor analysis with oblique rotation on the 28 Likert scale items was conducted. The oblique rotation generated the most meaningful solution. Oblique rotation methods allow for factors to be correlated, and we assumed that any underlying factors would be related. Evaluation of the correlation matrix was favorable: Kaiser–Meyer–Olkin (KMO) Measure of Sampling Adequacy = 0.830, Bartlett’s Test of Sphericity (χ2=742.714, df = 120, p ≤ 0.001) was significant and confirmed sufficient power required to conduct EFA. KMO values >0.70 are considered to indicate adequate sampling for factor analysis.Citation56,Citation60

We determined the number of factors to be extracted using several criteria (e.g., parallel analysis, examination of the resulting scree plot, eigenvalues >1.0, and suppressing all factor coefficients >0.4).Citation61 Several additional rules were applied to determine the number of factors and individual items to retain: (1) factors needed to contain a minimum of three items, (2) the absolute value of all factor pattern coefficients needed to be ≥0.50 on at least one factor, and (3) items with factor pattern coefficients (absolute value) ≤0.30 on more than one factor were dropped.Citation62

An initial solution comprising of six-factors was observed. However, 12 items were excluded from the analysis due to cross loadings or unloading. The ultimate solution comprised of four-factors, accounting for 70.76% of the total variance in the items. All items had high extracted communalities (>0.40), indicating that most of the common variance in the items can be explained by the four extracted factors.Citation62 The factor pattern coefficients from the principal axis factor analysis are displayed in .

Table 5. Results from Exploratory Factor Analysis with Oblique Rotation (Promax; ∂ = 0) on 28 Social Accountability Likert Scale Survey Items.

Based on EFA findings, names, and alignment to CIPP domains were identified for each retained factor (see ). Factor 1 labeled Selection & Recruitment aligned to input evaluation. Factor 2 Institutional Mandate and Factor 4 Community Awareness aligned to context evaluation and Factor 3 Institutional Activities aligned to process evaluation. Mean factor scores were computed and reliability analysis were conducted for each factor. McDonald’s ω values were as follows: Selection & Recruitment (six items) = 0.870; Institutional Mandates (four items) = 0.848; Recruitment & Selection (three items) = 0.803; and Community Awareness (three items) = 0.799. All internal consistency reliability values were ≥0.75 and considered acceptable.Citation57

Discussion

This study explored senior medical school administrators’ perceptions and perceived institutional practices of social accountability. We identified an international representation of perceived socially accountable indices. To our knowledge, this study represents the first survey of administrative perceptions and institutional practices of social accountability, internationally.

We were able to identify several commonalities across medical schools. For instance, all respondents expressed a high importance of social accountability and most reported that their school had an explicit social accountability mandate. These findings are consistent with the broader literature, suggesting that social accountability has become a universal component of medical school’s policy initiatives, mission statements, as well as accreditation standards.Citation1,Citation3–5,Citation7,Citation37,Citation47

While respondents reported high agreement when asked if their institution had access to data containing their local community profile, the extent to which this data is used to inform institutional policies remains unknown. Additionally, respondents also reported high agreement when asked if their institutions were aware of the epidemiological disease profile of the local population. However, it also remains unknown how this data is used to ensure curricular activities are designed to address community priority health needs, risks, or social health determinants.

Findings from our Likert scale items, and EFA demonstrates excellent internal consistency and reliability. However, variations were observed across Likert scale items. As items moved from internal practices (e.g., mission statements, admission policies, and curricular activities) to external practices (e.g., stakeholder engagement and partnerships, and involvement in health human resources) response means dropped considerably. For example, most respondents reported that their institution provides community-based learning. However, very few respondents reported that their institution collects data on the impact of graduates on patient outcomes.

These variations were also reflected in the EFA. The items dropped from the initial six-factor solution comprised of educational product outcomes and community engagement. This finding suggests that institutional practices of social accountability emphasis are placed on inputs and processes but lack evidence related to community context and educational product outcomes. This may suggest a narrow focus and practices as most effort is placed on internal policies surrounding selection and recruitment and curricular activities, rather than how these activities impact society. However, these observations are consistent with previous literature suggesting medical schools often treat social accountability as programmatic checklists rather than fundamental elements.Citation43,Citation63 Despite previous evidence suggesting that social missions are associated with graduate specialty selection, location of practice, and workforce diversity,Citation28,Citation39–41 most studies do not evaluate graduate outcomes or empirically validate the extent to which school’s fulfill their social missions.Citation64

Using data collected from 81 medical schools across 14 countries, we were able to confirm findings consistent with previous research. However, this is the largest known survey that examines administrator perceptions and institutional practices of social accountability internationally. This paper offers programs and educators with a new survey tool to aid in the operationalization and reliability of evaluating socially accountable indicators. Even though our findings indicate that we were able to demonstrate content validity and excellent internal consistency and reliability, there are some important limitations to consider.

First, participation in this study was voluntary. While 81 medical schools participated in our survey, we targeted 265 English-speaking medical schools. However, survey participation has gradually decreased over time and response rates for medical educators, especially physicians are generally lower due to demanding schedules and survey fatigue.Citation65,Citation66 We also relied on publicly available contact information which may have reduced efficiency in the survey delivery. It should also be acknowledged that this survey was distributed during the initial stages of the COVID-19 pandemic and many medical school administrators may have experienced rapidly changing priorities and conflicting clinical and administrative responsibilities. Additionally, the perceived importance of social accountability globally may have resulted in reporting biases both by respondents that elected to complete the survey as well as individual responses as the topics desirability may have prompted more favorably responses to certain items. Due to the desire of many schools to exert socially accountable qualities respondents may have self-reported higher ratings on items based on the perceived importance surrounding the topic. Further research is warranted to investigate how medical schools operationalize social accountability in practice, assess the quality of these practices, and impact on public health. These results also capture individual respondent perceptions and may not be necessarily reflective of their institution. However, this survey purposefully selected administrative leadership, which can be assumed to provide reliable information on institutional practices. Lastly, these outcomes may be specific to English-speaking undergraduate medical programs. However, the CIPP evaluation framework and methodological approach can be easily replicated in non-English contexts.

Conclusion

Despite expanding awareness, social accountability has not necessarily reliably translated effectively in practice. The perceptions captured in this study are reflective of institutional practices and administrative perceptions of social accountability indicators. Social accountability represents an actionable quality, rooted in the identification of societal needs, and evaluated based on how well such needs are achieved.Citation2 While most respondents expressed an institutional commitment to social accountability, the effects of their outcomes on the community remain unknown and not evaluated. Additionally, medical education is largely publicly funding in many countries, and medical schools should be evaluated based on how well they meet societal needs.Citation67 However, the lack of emphasis placed on impact may suggest that perhaps perceived institutional practices reflect acts of responsibility or responsiveness, and not necessarily accountability.Citation5

Institutional practices of social accountability included in this study focused predominately on the commitment to, and adaption of select policies and curricular activities. This study provides empirical evidence to support previous claims suggesting that very few medical schools are truly socially accountable.Citation1 Medical schools must move beyond the commitment to address societal needs.Citation37 Socially accountable medical schools must demonstrate that the outcomes of their activities have positive impacts on public health in communities served.Citation45 Social accountability demands the articulation of measurable results and tangible outcomes where the focus on evaluation is on impact, not inputs and processes.Citation5 However, despite continued progress and positive advancements within the literature, there is a need to establish meaningful relationships between medical school outcomes and community impact.Citation6,Citation68 Perhaps a way we can begin to establish such links is through the wider adaption and use of reliable tools to support the measurement of social accountability.

Ethical approval

Ethical approval for this study was obtained from Queen’s University, Kingston Ontario, Canada (File No. 6028362).

Acknowledgments

The authors would like to thank the expert review panel for validating our measure. Additionally, the authors would like to thank the respondents who participated in this research during a global pandemic.

Additional information

Funding

This research is supported in part by funding from the Government of Canada Social Science and Humanities Research Council (SSHRC).

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