Challenges and Facilitators for Physicians and Medical Schools to Promote Social Accountability in Rural Communities: A Scoping Review and Thematic Analysis

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Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Challenges and Facilitators for Physicians and Medical Schools to Promote Social Accountability in Rural Communities: A Scoping Review and Thematic Analysis Aghna Wasim , Ali Abud , Yihan Wang , Ehsan Tavakoli , Athena Moreno-Gris , Samar Joshi , Arthur Wang , Angela Neasadurai , Nikki Shaw doi: https://doi.org/10.1101/2025.01.04.25319991 Aghna Wasim 1 School of Medicine, Keele University , Keele, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site Ali Abud 3 Department of Biology, University of Western Ontario , London, Canada 9 Evidentia Institute of Knowledge Synthesis , Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site Yihan Wang 2 Translational and Clinical Research Institute, Newcastle University , Newcastle upon Tyne, UK 3 Department of Biology, University of Western Ontario , London, Canada 9 Evidentia Institute of Knowledge Synthesis , Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site Ehsan Tavakoli 3 Department of Biology, University of Western Ontario , London, Canada 9 Evidentia Institute of Knowledge Synthesis , Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site Athena Moreno-Gris 5 School of Psychology, University of Ottawa , Ottawa, Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site Samar Joshi 3 Department of Biology, University of Western Ontario , London, Canada 9 Evidentia Institute of Knowledge Synthesis , Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site Arthur Wang 4 Schulich School of Medicine and Dentistry , University of Western Ontario Find this author on Google Scholar Find this author on PubMed Search for this author on this site Angela Neasadurai 6 Department of Biochemistry & Bomedical Sciences, McMaster University , Hamilton, Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site Nikki Shaw 7 NOSM University , Sudbury, Ont 8 Department of Biology, Algoma University , Sault St. Marie, Ont Find this author on Google Scholar Find this author on PubMed Search for this author on this site For correspondence: nikki.shaw{at}algomau.ca Abstract Full Text Info/History Metrics Data/Code Preview PDF 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, acting networks or parties, 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 the rural communities. Methods This scoping review was conducted following the Arksey and O’Malley Framework. Web of Science, MEDLINE, EMBASE, SCOPUS, and CINAHL were searched for peer-reviewed studies published since 2000. Results A total of 2698 abstracts were identified, 180 full-text articles were reviewed, and 53 articles met the eligibility criteria across 15 different countries. 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. 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, a majority of the people residing in these areas belong to vulnerable and socioeconomically disadvantaged groups. 9 Rural communities have generally 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 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 that 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 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 literature, recognizing factors that might ease or hinder their implementation. This scoping review was conducted with the aim to provide 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. Scoping reviews are a type of evidence synthesis that provide 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 followed the Arksey and O’Malley framework 23 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. Search strategy and study selection A comprehensive search strategy using keywords such as “social accountability”, “physicians” and “medical school” was tailored to each database including Web of Science, MEDLINE, CINAHL, Scopus and Embase (Supplemental File 1). Title and abstract and full-text screening was conducted on Covidence. 24 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 (e.g., 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 (e.g., cross-sectional, qualitative, mixed-methods, case report etc.); 6) setting (e.g., rural village, medical institution); 7) participant population (e.g., 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 (e.g., impact on patient outcomes or community wellbeing); 3) measures (e.g., 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; 7) facilitators of social accountability for physicians and medical schools; 8) impact of the intervention; and 9) translation of social accountability in other communities (e.g., 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 analyzed using a thematic analysis approach and the findings were reported narratively. Results Search results The database search was conducted on April 1st, 2024. 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 ). Download figure Open in new tab Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Flow Diagram Descriptive Summary All articles were published after 2005 with six (11.3%) articles being published between 2005-2010, 35 (66.0%) articles between 2011-2020 and 12 (22.7%) articles between 2021-2024 ( 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 ). View this table: View inline View popup Table 1. Original articles (n=53) included in the scoping review View this table: View inline View popup Table 2. Characteristics of original articles included in the study 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 muti-national studies 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. 25 – 45 Professional limitations and poor working conditions were identified as a barrier in nine of these 21 studies, emerging as the most prevalent challenge. 25 , 30 , 31 , 36 – 38 , 41 , 44 , 45 These included long working hours 25 ; higher workloads 45 ; low remuneration 30 , 31 , 36 , 41 ; absence of appropriate medical equipment and facilities to support the community and physicians’ career aspirations 30 , 31 ; unstructured learning environment 44 ; inadequate supervision 44 ; and a lack of opportunities for professional development. 25 , 31 , 37 , 45 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. 38 Negative, progressively worsening attitudes among medical students and physicians were listed as a challenge in seven studies 26 – 28 , 31 , 32 , 42 , 43 These were characterized by a declining sense of idealism, 26 , 42 a lack of understanding and consideration for Indigenous communities, 27 , 28 and diminished interest in working with underserved populations. 42 Family medicine and primary care were poorly understood and viewed as unattractive fields that were perceived as neither valued by the public or by other physicians. 31 , 43 Furthermore, physicians were reluctant to face stigma if they chose to live and work within rural communities. 32 In addition, medical students and physicians had their own preferences of where they would like to practice as mentioned in four studies. 29 , 33 , 34 , 40 The intention to emigrate was noted among individuals belonging to international, urban, and high-income backgrounds. 33 , 34 , 40 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. 33 , 40 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. 29 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. 30 , 36 , 39 , 41 Moreover, geographical isolation 25 , 39 , 41 and language barriers 25 , 31 , 39 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 25 , 30 while one study reported on the reluctance of Indigenous people to engage in projects due to prior negative experiences with medical researchers. 35 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. 31 , 34 , 35 , 38 – 43 , 46 – 59 Curriculum incompetency was the most frequently reported challenge and was listed in 14 articles. 31 , 35 , 39 – 43 , 50 , 52 , 55 – 59 The curricula used within medical schools and clinical training were largely conventional with little focus on primary care. 40 , 43 Components incorporating rural immersion were often short and lacked appropriate support mechanisms for students and physicians. 35 , 41 In addition, options for medical school electives and residency tracks 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. 42 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. 35 , 55 , 58 , 59 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. 52 Financial and resource constraints to establish socially accountable medical education and training programs were discussed in eight studies. 31 , 34 , 35 , 42 , 49 , 51 , 52 , 55 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. 34 , 46 , 54 , 55 Three studies each recognized poorly developed infrastructure 48 , 53 , 55 and training and availability of teaching staff 31 , 35 , 55 as a challenge for medical schools. Moreover, one study criticized the redistribution of graduate training positions for directing future primary care physicians to other specialities due to a relatively larger increase in non-primary versus primary care training. 47 Facilitators of social accountability for physicians Facilitators for physicians to promote social accountability were listed in 17 (32.1%) studies. 30 – 38 , 39 , 44 , 48 , 54 , 60 – 63 Community immersion, the most discussed facilitator, was recognized in 16 studies. 30 , 31 , 33 – 39 , 44 , 48 , 54 , 60 – 63 Exposure to rural communities during their medical education (e.g., rotations) and through their own rural background and upbringing were both found to increase the willingness of physicians to serve these communities. 30 , 31 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 44 , 48 , 54 , 60 , 61 , 62 , 63 Positive attitudes towards rural health and primary care were identified as facilitators in four studies. 30 , 31 , 33 , 60 These included a sense of responsibility towards serving the needs of their country, 30 , 31 , 33 , 60 desire to stay close to their family, 30 , 33 , 60 attachment to their home community 33 , 60 and finding the remoteness of rural areas to be appealing. 30 The importance of peer support and establishing meaningful relationships with colleagues was highlighted in four studies. 32 , 36 , 44 , 60 Similarly, the positive experience of their family members in rural areas encouraged physicians to remain and continue practicing in those communities. 36 Facilitators of social accountability for medical schools and medical educators 45 of the included articles (84.9%) discussed facilitators for medical schools and educators to promote social accountability. 25 , 27 , 29 , 30 – 33 , 35 – 42 , 45 , 46 , 49 – 60 , 62 – 77 Using a community-centered curriculum was reported in 39 studies as a successful intervention. 25,27,29-33,35-37,39-42,45,49,50-52,54-57,59,60,62-64,66,67,69-77 Such curricula were designed in collaboration with community members and local physicians, specifically tailored to the needs of the area and its population. 49 , 59 , 69 , 76 , 77 They typically entailed experiential or service learning opportunities in a rural context, including clinical rotations and research projects. 25,27,30,32,33,35,36,39,40,41,45,49,51,52,54-57,60,62-64,66,67,70-77 Service learning activities were also offered with underserved, low-income and international communities. 42 , 56 , 77 Other components of community-centered curricula included health equity, 77 family medicine, 31 primary care, 33 , 40 public health, 40 and interprofessional education. 50 , 74 Targeted admission policies emerged as a facilitator in 11 studies. 31 , 38 , 45 , 46 , 49 , 53 , 55 , 60 , 62 , 65 , 76 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. 62 , 65 , 76 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. 38 , 45 , 46 , 49 , 53 , 55 , 60 , 62 , 65 The role of medical educators, acting as good role models, in supporting medical school’s social accountability mission was acknowledged in nine studies. 30 , 31 , 33 , 40 , 41 , 52 , 68 , 69 , 72 These instructors encouraged students to consider rural practice by sharing their own passion for the field, relaying their experiences and promoting family medicine. 30 , 31 , 68 , 69 , 72 Government support for socially accountable programs was also reported to facilitate medical schools in their implementation of these initiatives in a single study. 40 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. 58 Discussion This scoping review is the first to identify social accountability practices in a rural context on a global scale. 53 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), 78 suggesting a more significant impact set afoot. 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 multinational studies comprise 13.2%. Despite the inclusion of studies coming from diverse countries, this distribution demonstrated a lack of literature from regions of Latin America, the Middle East, 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 (Jennifer Cleland, 2024). Of the included studies, 12 pertained to NOSM University. 33 , 34 , 35 , 39 , 45 , 57 , 58 , 62 , 67 , 72 – 74 Part of NOSM’s success corresponds to its adoption of a 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 Thematic analysis indicated barriers for physicians and medical school students to contribute towards rural social accountability practice as 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 socio-economic 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 researcher. Barriers decelerating the spread of medical school rural practice of social accountability comprise a) inadequacies in curriculum design with insufficient consideration targeting rural settings while contenting institutional or governmental objections, b) intrinsic monetary and resource reservoir discretions within regions and communities, c) absence of admission diversity and equality considerations, d) inadequate or nascent infrastructure development, and e) human resource redistribution after graduation. Synthesized physician promotion of social accountability efforts can be summarized into the subsequent comportment: a) exposure towards rural communities, b) rural familial background, c) favorable attitudes towards rural regions during medical school studies, and d) underpinning peer-to-peer mitigation. Identified studies have focused on the implementation of medical school in mitigating social accountability challenges, encompassing a) curriculum design centering on the community and assessing the demands of the population, b) targeted admission towards recruitment of students who are inherently representative of the community or region they have the mandate to serve, c) peer, mentor, and institutional support networking through establishing role models, and d) evaluation through external tools as dimensions to measure social accountability engagement. Evaluating the barriers and facilitators of social accountability practice has demonstrated intrinsic challenges due to the multipolar nature on a global scale, this further accentuates the demand for a unified, region-dependent, and flexible framework, extending the challenges beyond infrastructure, retention, socioeconomic status, and recruitment; encompassing philosophical landscape, and cultural differences inherent to the region. Limitations Limitations of this scoping review have been identified, incorporating small sample sizes in included primary research studies, the findings reported were limited to published peer-reviewed primary studies, and all gray literature was excluded, indicating a potential overrepresentation of significant results, heterogeneity in definitions of social accountability between included studies have been considered, the inclusion criteria outlined indicated the definition social accountability in accordance to 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. Statements and Declarations 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. Consent to participate Not applicable Consent for publication Not applicable Declaration of conflicting interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding This scoping review was conducted without financial support. Data Availability The data supporting the findings of this study are available from the Supplement Material. Data Availability All data produced in the present study are available upon reasonable request to the authors. 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