Embedding Social Accountability through Transformative Pedagogies: A Case Study from a South African Physiotherapy Curriculum

Embedding Social Accountability through Transformative Pedagogies: A Case Study from a South African Physiotherapy Curriculum | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Embedding Social Accountability through Transformative Pedagogies: A Case Study from a South African Physiotherapy Curriculum Marianne Unger, Dawn Ernstzen, Sue Statham, Adnil Titus This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7327666/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Oct, 2025 Read the published version in BMC Medical Education → Version 1 posted 10 You are reading this latest preprint version Abstract Background Health profession curricula must produce healthcare professionals who are not only clinically competent but also socially accountable. This requires graduates to understand and respond to the health systems and social contexts within which they practice, and lecturers play an important role in facilitating the attainment of these competencies. Despite growing calls for socially accountable health professional education globally, limited research exists on how these principles are understood and implemented within physiotherapy curricula, particularly in low- and middle-income contexts where health inequities are pronounced. Aim To explore how physiotherapy lecturers understand and integrate the principles of social justice and social accountability into a South African undergraduate curriculum and to examine the pedagogical strategies employed to foster transformative learning. Methods A qualitative descriptive case study with an interpretivist paradigm was conducted at the Division of Physiotherapy, Stellenbosch University. Data were collected via two focus groups (n = 10 participants) and eight individual semi-structured interviews with permanent academic staff involved in curriculum coordination and development. Mezirow's transformative learning theory and established theories of social justice and social accountability guided a hybrid inductive and deductive thematic analysis via AtlasTi® software. Results Two key themes emerged: ( 1 ) understanding social accountability and its underpinning elements, including professional accountability, ethics of care, citizenship, health equity, interprofessional engagement, and professional identity formation, and ( 2 ) pedagogical strategies for transformative learning, encompassing contextual and experiential learning, structured reflection, interprofessional collaboration, progressive scaffolding, discursive pedagogy, and role modelling. While lecturers demonstrated a sophisticated understanding of social accountability as a multidimensional construct, significant implementation challenges were identified, including inconsistent student exposure, logistical barriers to authentic learning experiences, limited scaffolding for transformative action, and insufficient faculty development support. Conclusion Social accountability is a recognised but complex goal within the physiotherapy curriculum. While transformative pedagogies are employed, critical gaps remain between curricular intent and implementation, particularly in scaffolding students' progression from critical reflection to transformative action. Strengthening pedagogical coherence, enhancing faculty development, and expanding authentic experiential learning opportunities may support the development of socially responsive physiotherapy graduates equipped to address health system challenges and promote health equity. Trial registration: Not applicable transformative learning responsive curriculum social accountability physiotherapy education social justice Introduction The call for socially accountable health professionals is increasingly urgent globally and in South Africa, where persistent health inequities and a quadruple burden of disease challenge the healthcare system ( 1 – 3 ). Higher education institutions (HEIs) are expected to contribute meaningfully to social justice by producing graduates who are not only clinically competent but also critically aware of and responsive to the health systems and contexts in which they serve ( 4 , 5 ). Social accountability in health profession education can be seen as a shared commitment between universities, communities, and health professionals to address structural determinants of health, promote equity, and advocate for marginalised populations ( 6 , 7 ). As Blignaut (2021) argues, education can lay the foundations for a more just society, guided by human dignity and equity ( 8 ). However, while competencies related to leadership, ethics, and advocacy are often embedded in physiotherapy curricula, how these are translated into pedagogical practice remains inconsistently applied across undergraduate training in SA. While systematic reviews have demonstrated that socially accountable health professional education can positively impact student learning attitudes and increase the likelihood of graduates serving disadvantaged communities ( 9 ), significant gaps remain in understanding how these principles are operationalised within specific disciplinary contexts. Further challenges stem from structural and systemic constraints within the healthcare system. The public sector is overburdened by the consequences of trauma, infectious and noncommunicable diseases, and limited resources to address the rehabilitation needs of the population ( 10 ). Moreover, calls for decolonising health curricula demand renewed attention to contextually relevant, socially just, and community-responsive education ( 11 , 12 ). Transformative learning, as theorised by Mezirow ( 13 ), offers a valuable framework for cultivating the critical consciousness required to navigate these complex realities. By engaging students in self-reflection, contextual learning, and ethical reasoning, transformative pedagogies can support the formation of socially accountable professional identities ( 14 , 15 ). A recent scoping review confirmed that transformative learning theory provides health profession educators with a valuable theoretical lens for understanding student learning in unfamiliar settings, particularly where students are encouraged to be active participants in providing care ( 16 ). Within this context, the undergraduate physiotherapy programme at Stellenbosch University (SU) aims to support South African higher education's transformation and social accountability agenda. The programme combines foundational knowledge with clinical and contextual learning opportunities. Despite these intentions, questions remain about how effectively the curriculum fosters students' development as change agents equipped to address the health and rehabilitation needs of diverse communities and to advance social justice. This study thus explores how physiotherapy lecturers at SUs understand and enact the principles of social justice and social accountability in their teaching. Specifically, it aims to do the following: Explore lecturers' perspectives on social justice, social accountability and equity and how these are embedded in the curriculum; and Explore lecturers’ perspectives on the pedagogies they use to support transformative learning and the development of socially responsive graduates. Methods Study Design and Setting This study used a qualitative descriptive case study design within an interpretivist paradigm ( 17 , 18 ). This study was conducted in the Division of Physiotherapy, Faculty of Medicine and Health Sciences at SU, South Africa. The division offers a four-year undergraduate degree in physiotherapy, with a strong emphasis on foundational sciences in the first two years and clinical integration and contextual learning in the latter two years. At the time of the study, the division was engaged in a curriculum renewal process aligned with national transformation goals. Sampling and Participants A homogenous purposive sampling approach ( 19 ) was used to select participants. Ten permanent academic staff members who held programme or module coordination responsibilities and were actively involved in teaching and curriculum development were recruited to participate. This group was deemed well-positioned to provide insight into how social accountability is conceptualised and implemented in the programme, as they were involved in the delivery of the curriculum content as well as the administration of the curriculum. Data collection Data were collected in two phases: two focus group discussions (FGDs) followed by eight individual semi-structured interviews. The FGDs aimed to explore shared understandings of social justice and social accountability, whereas interviews examined individual pedagogical approaches. The interview guides were developed by the broader Responsive Curriculum Project team based at the Centre for Health Professions Education. The principal investigator conducted the interviews, recorded, and transcribed with participants' consent. Member checking was carried out through transcript review and a post-analysis feedback session. Data analysis Thematic analysis followed a hybrid approach that combines inductive and deductive coding strategies ( 20 ). Thematic content analysis was guided by the steps of analysis advocated by ( 21 ). The deductive analysis was guided by a conceptual framework based on Mezirow’s transformative learning theory and existing theories of social justice and accountability ( 22 , 23 ). Two authors independently analysed the data, assigning initial codes and categories using AtlasTi® (Scientific Software Development, GmbH, Berlin, Germany, version 9). All transcripts were uploaded to AtlasTi® for analysis. One researcher conducted the inductive analysis, developing a codebook from emergent data. Another researcher applied the deductive framework. Codes were then compared and integrated through consensus discussion. The combination of both approaches enhanced the credibility and depth of the analysis. Findings and Discussion This section presents and interprets the findings from two focus group discussions and eight individual interviews with ten physiotherapy lecturers at Stellenbosch University. The focus groups involved six and four participants (FG1 and FG2), respectively, and all ten lecturers participated in the individual interviews (IN1-IN10). Thematic analysis revealed two central themes aligned with the study objectives: (i) understanding of social accountability and its elements, and (ii) pedagogical strategies that support transformative learning. The first theme encompasses lecturers' conceptualisations of professional accountability, ethics of care, equity, and civic responsibility, while the second explores pedagogical approaches including contextual learning, reflection, scaffolding, interprofessional collaboration, role modelling, and professional identity development. Each theme is presented through illustrative quotes integrated with theoretical interpretation and relevant literature to provide a critical synthesis of lecturers' perspectives and curriculum practices. Understanding Social Accountability in the Curriculum This theme explores how physiotherapy lecturers conceptualise social accountability and its foundational elements. The participants framed it as a multilayered construct encompassing professional responsibility, ethics, civic engagement, awareness of systemic inequities, interprofessional collaboration, and identity formation. These dimensions reflect the values the curriculum aspires to instil in graduates who can act as change agents within South Africa's complex healthcare landscape. Professional accountability Lecturers described social accountability as anchored in a broader understanding of professional responsibility, which extended beyond the physiotherapy profession to include patients, families, communities, regulatory bodies, and society. This aligns with Boelen and Woollard's (2011) framework, which conceptualises accountability as encompassing the ethics of care, service orientation, and responsiveness to population health needs. " Professional accountability is a huge domain... it includes key stakeholders such as professional organisations, employers, the regulatory framework, the communities and individual patients or clients we serve ." [FG2] “So, when you think of professional accountability as not just being accountable for the service and being ethical and all of that but making sure it is actually directed towards the needs of that community or that person or that family and that your client management is person- and family-centred.” [FG1] “The notion of the profile of the Stellenbosch graduate, it is something that when you graduate, you can't stay there. You have that accountability towards yourself, towards the profession, towards your clients, even towards the organisation to carry on and develop.” [FG2] “ But as a profession, we claim, we are training graduates that will take the philosophy of the profession at heart, which means not closing a blind eye to what you see, but making a concerted effort, and that you do have a sense of responsibility and accountability towards the people around you.” [FG1] These quotes align with a growing consensus in health profession education that clinical competence alone is insufficient for impactful practice. Ethical sensitivity, cultural humility, and person-centred approaches are equally critical for community-responsive care ( 24 ). Ethics of Care and Moral Dilemmas The participants emphasised the difficulty of teaching students how to act when confronted with ethical dilemmas in practice. While many recognised the curriculum's strength in raising awareness about human rights and inequities, they also acknowledged a gap in training students on how to respond. “Do I teach them to be whistleblowers when I actually know they are putting themselves at a disadvantage? I can’t teach them. So there is a huge amount of difficulty around it for me personally. But I take them to the point of identifying and saying what should be corrected. ” [IN1 ] " We don't teach them that next step of what you do. Who do you rally? Who do you talk to? What are the steps to follow to make change? " [IN3] “…and when to recognize this is a bigger problem that extends beyond what I can do and either I need to make, create awareness in other people, or refer, or to ask.’ [FG2] This aligns with Nortvedt et al. (2011), who emphasise that the ethics of care should be grounded in decision-making strategies that recognise students’ moral agency and professional vulnerability ( 25 ). Clarifying professional roles and intentionally creating space in the curriculum for reflective dialogue and practical guidance are essential for helping students navigate complex ethical dilemmas. Citizenship and civic responsibility Lecturers framed the purpose of the curriculum as extending beyond clinical expertise to cultivate civic-minded graduates who recognise their social responsibility. " This is about being a good citizen. It's not just about being a good physio ." [IN2] “… there's more to life than just within a 10 km radius of yourself, and there's a lot of people suffering out there and that can benefit from your expertise, or your professional expertise, and it's time to do something about it. You can't just say somebody else will do something about it. I think that's why there's a lot of emphasis on the concept again. ” [FG 1] This framing is consistent with Velardo's (2018) view that social accountability requires a shift from individual competence to collective responsibility ( 26 ). In a country with entrenched health inequities, the curriculum must instil a sense of justice and accountability to marginalised communities. Health Equity and System Awareness The participants acknowledged the need to develop students' understanding of social determinants of health and how these determinants contribute to disparities in access and outcomes. They recognised advocacy as a key graduate attribute. ‘I think advocacy and leadership, are part of the graduate attributes. But my feeling is that we can do more to help the students to pick up the problems that aren't being picked up necessarily by the Department of Health. … and I think that we can have a profound effect there if they (students) have the skills to do that.” [FG1] ‘… civic responsibility comes back to …change agents, you know, someone that has some inherent responsibility for the people and communities out there, … and what can I do to change the system that is maybe broken, or how can I improve the health of the community through reflection, enquiry, engagement with that community.” [IN5] This finding reinforces the view that social accountability in physiotherapy education must extend beyond clinical training to include systems thinking, an understanding of the social determinants of health, and a population-level orientation to care ( 6 , 27 ). Interprofessional Engagement Lecturers view interprofessional education (IPE) as a vital mechanism for promoting collaborative practice, patient-centred care, and broader accountability to the health system. They saw IPE not only as an opportunity for students to appreciate the distinct roles of other professionals but also to develop teamwork, communication, and shared problem-solving skills essential to effective rehabilitation in real-world contexts. “ They actually sit together and they do a plan for a patient… then they all work together towards a common goal for the patient .” [IN7] " It’s not about being loyal to my profession... It’s about the patient. In addition, we all have a role in that activity." [IN7] Identity Formation and Graduate Attributes The formation of a strong professional identity was seen as essential for accountability and resilience in complex healthcare environments. " They need to understand themselves and their role, and then how they interlink with others... It’s a progressive thing ." [FG2] “ Their (students’) ability to be a change agent needs to grow out of being very solidly based in your discipline and then having the confidence to act. ” [IN6] This is consistent with the literature that emphasises professional identity development as a dynamic and transformative process shaped by sustained engagement in authentic contexts, critical self-reflection, and exposure to meaningful role modelling ( 28 ). Through these experiences, students gradually internalise professional values, clarify their roles, and build confidence to act ethically and responsively within the healthcare system. Pedagogies Supporting Transformative Learning This theme explores the pedagogical strategies employed by participants to facilitate transformative learning and foster socially accountable practices. The participants identified a range of approaches - both formal and informal -that aim to move students from theoretical understanding to critical reflection and real-world action. These strategies include experiential and contextual learning, structured reflection, interprofessional collaboration, scaffolding, discussion-based teaching, and role modelling. Together, they support the development of critical consciousness, professional identity, and readiness to engage with complex health and social issues. Contextual / experiential learning The participants identified contextual and experiential learning as the most prominent and impactful pedagogical approach for fostering transformative engagement. These forms of learning are widely recognised for their role in bridging classroom-based knowledge with the complexities of real-world practice. Through direct exposure to diverse environments, students were better able to internalise concepts, adapt interventions to context, and reflect critically on their role as emerging professionals. " They actually do home visits... and see how they might need to adapt their treatment to fit the home environment ." [IN6] "I didn’t think a patient could get up the day after that type of surgery… then they see it and realise the patient can go home tomorrow, because they’re far more capable than expected ." [FG1] Such situated learning fosters embodied understanding and enhances the integration of theoretical knowledge with real-world complexity ( 14 ). Reflection and feedback Lecturers highlighted reflection as a vital pedagogical tool for transformative learning, enabling students to develop critical self-awareness and examine their professional values and assumptions. Reflection, particularly when supported by structured models and timely feedback, was seen as essential in helping students make sense of complex experiences, navigate ethical dilemmas, and integrate learning across different settings. The feedback process was recognised not only as evaluative but also as developmental, contributing to both personal growth and professional identity formation. However, the participants acknowledged the variability in how reflection and feedback were facilitated and called for greater intentionality and support in embedding these practices across the curriculum. The DEAL model of reflection was highlighted as a structured way to prompt deeper thinking and emotional processing. " We incorporate the DEAL model... describe, evaluate, and articulate learning academically, civically, and personally ." [IN3] “…and that’s why I’m saying, so that reflective discussion is quite often helpful, because remember, the student comes with a story from their perspective. So they need that other perspective sometimes to understand that perhaps the person said this, but could they have meant that, or could it have been within this context.” [FG1] However, both the students and the lecturers struggled with the depth of reflection. Feedback literacy among staff and the integration of structured reflection remain areas that need attention ( 29 ). Interprofessional Collaboration The participants recognised interprofessional collaboration as an essential learning strategy to prepare students for real-world, team-based healthcare delivery. Working across professional boundaries was seen as key to improving patient care and strengthening students’ appreciation of systems-based practice. Through shared learning opportunities, students begin to understand the roles and contributions of various health professionals and the importance of collaboration in achieving holistic outcomes. Despite its perceived value, logistical challenges were frequently cited as barriers to full integration in the curriculum. While valued, IPE activities are limited by schedules and site variability. " It’s difficult to integrate it fully... The main barrier is timetables and that it’s not happening in all clinical settings." [IN8] This challenge echoes the literature and highlights the need for systemic alignment across faculties to enable meaningful collaborative learning ( 30 ). Scaffolding across the curriculum Lecturers described scaffolding as a deliberate curriculum design feature that supports the development of critical thinking, ethical reasoning, and professional accountability over time. Through structured progression, from foundational principles in the early years to complex, integrated practice in later years, students gradually build the competencies needed to become socially responsive practitioners. Scaffolding also ensures that threshold concepts such as social justice and equity are reinforced across modules, enabling deeper learning and application in various clinical contexts. Lecturers described how the curriculum builds progressively from foundational to complex tasks. " We start low and build up on that... with horizontal and vertical coherence ." [FG2] "So on second year level, it would be case examples, and problem analysis... we would start with the impairments... with case studies and role-playing in second year. Probably in the third year it is more complex... there would be aspects in there about ethical issues surrounding profession... interdisciplinary work, how to engage with the team." [IN8] Such curriculum coherence is essential for embedding transformative learning principles over time ( 31 ). This ensures that students are not only exposed to critical concepts at isolated points but also provided with repeated, progressively complex opportunities to engage with and internalise them across diverse learning contexts. This deliberate repetition and integration help sustain transformative momentum and prepare students for socially responsive practice. Discursive Pedagogy and Role Modelling The participants emphasised the value of discursive pedagogy, creating space for dialogue, reflection, and shared meaning-making, as a vehicle for transformative learning. Facilitated discussions, particularly in response to critical incidents, were seen as vital for helping students process complex emotions and ethical tensions. In parallel, role modelling by lecturers has emerged as a powerful pedagogical tool. Students were viewed as highly observant, often internalising professional behaviours demonstrated by educators, whether in clinical, classroom, or interprofessional settings. Debriefing and discussion were viewed as powerful tools for sense-making, whereas role modelling was considered critical for demonstrating ethical and professional behaviour. " I don’t think we always realise how much students observe and absorb from what they see ." [FG2] “…so that reflective discussion is quite often helpful, because remember, the student comes with a story from their perspective. So, they need that other perspective sometimes to understand that perhaps the person said this, but could they have meant that, or could it have been within this context.” [FG2] “So when an incident arises, spend an hour talking about it, unpacking it and reflecting on it and finding solutions, just in a discussion format… do they really know what a good, what a physio, what kind of physio that hope we hope them to be one day.” [FG1] “So I do believe in role modelling. So you do have the opportunity in terms of with that patient, with that student, to actually role model certain concepts,… and then be able to give them that feedback afterwards in a reflective manner...” [IN4] UNESCO stresses the importance of ‘tipping moments’ in transformative learning, which are often catalysed by such interpersonal engagements ( 15 ). Challenges While transformative pedagogies are present within the programme, participants identified multiple challenges in their consistent implementation. These spans structural, pedagogical, and contextual barriers, which together undermine equitable student learning experiences and dilute the intended impact of transformative learning. In terms of contextual learning , lecturers described increasing difficulties in securing access to clinical and community-based learning environments due to lengthy approval processes and institutional gatekeeping. There were also concerns that rapid changes in healthcare delivery and unequal student placement sites created inconsistent learning opportunities. " I have to then apply and give dates well in advance, almost sometimes a year in advance... then go to that facility and get permission there as well ." [IN5] " One of the fears is lack of equal exposure, and equal opportunity ." [FG1] Students were also reported to face personal and social barriers to meaningful engagement, particularly when encountering patients or contexts that were vastly different from their own experience. " The challenges they face is not something they have ever heard of … and sometimes they have to deal with people who have severe mental issues as well, which is foreign for them. They have no understanding ." [IN1] Reflection was another area of concern. While lecturers acknowledged its importance, they noted a lack of depth in student reflections and limited scaffolding from staff. " The reality is that the reflection is often very limited… it’s not towards future behaviour and the becoming and the steps that follow ." [IN1] " We share a lot of discussion or points or real-life situations, and the students are just expected to reflect." [FG1] Interprofessional collaboration was valued but remained underutilised owing to programme silos and logistical barriers such as scheduling mismatches and limited access to diverse professional teams at some clinical sites. " The main barrier is timetables, different programmes, and also, that it is actually not happening in practice ." [IN8] " There may be a physio, but there’s no opportunities always for the students to work with a speech therapist or with the medical team ." [IN5] For scaffolding , some lecturers noted that foundational-year students struggled to engage with complex cases, highlighting a misalignment between theoretical inputs and the students' clinical or contextual exposure. " They don't really understand the case... because they did not have that experience, that exposure to the practical part of it ." [FG2] For discursive pedagogy , participants reported inconsistencies in whether reflective discussions and debriefings were actively facilitated and highlighted a lack of psychological safety for students needing to process difficult experiences. " Some of the students don't speak to anybody... they’ve voiced a wish for a person to be able to debrief them, but who isn’t in the division ." [IN2] Finally, role modelling was limited by the availability of clinicians and educators who actively embodied the values of social accountability in practice. " I don't think they get exposed enough to what it is we want them to act as physios. There is lack of role modelling ." [FG2] Together, these challenges reveal systemic tensions between curriculum intent and implementation and point to a need for more intentional faculty development, better alignment of placements, and a unified pedagogical strategy to support the social accountability agenda. Strengths and Limitations This study offers a novel contribution to the literature by exploring how social accountability is conceptualised and enacted within a South African physiotherapy curriculum. Methodologically, this study demonstrates how case study design can effectively capture the complexity of curriculum implementation across different contexts, providing a replicable approach for examining social accountability initiatives. The hybrid thematic analysis framework developed here, which combines Mezirow's transformative learning theory with social accountability frameworks, offers a structured yet flexible approach for similar investigations in diverse cultural and resource settings. The study provides a nuanced, theory-informed understanding of the pedagogies and challenges associated with embedding transformative learning and social responsiveness in undergraduate training. The use of a hybrid thematic analysis and multiple data sources (focus groups and interviews) enhanced the depth and trustworthiness of the findings. However, the study is limited by its single-site, case study design, which may constrain the transferability of findings to other institutions or programmes. While participants had diverse roles within curriculum design and delivery, the perspectives were limited to faculty members; incorporating student and stakeholder voices could further enrich understanding. Despite these limitations, the findings offer valuable insights for physiotherapy educators and curriculum developers aiming to advance a social justice agenda in similar low- and middle-income contexts. Synthesis and Curriculum Implications These findings demonstrate that the SU physiotherapy programme has a strong philosophical and pedagogical commitment to social accountability. Lecturers interpret this construct broadly and deeply, drawing connections between professional responsibility, ethical care, health equity, and civic engagement. They employ a wide range of pedagogical strategies aligned with transformative learning theory, including contextual learning, structured reflection, interprofessional engagement, and scaffolding, an approach supported by Mezirow (2018), Jones (2015), and Furze et al. (2011), who argue that such integrated methods foster professional identity development and critical consciousness. This approach aligns with recent umbrella reviews demonstrating that transformative learning theory applications in health profession education consistently support curriculum design, program evaluation, and the development of leadership skills and professional identity ( 32 ). However, systemic and contextual challenges limit the consistency and depth of implementation. Unequal student experiences, time and resource constraints, limited interprofessional opportunities, and insufficient feedback literacy represent critical gaps between curricular intent and reality. These challenges highlight the need for better alignment of the formal, informal, and hidden curriculum ( 5 ) to support holistic graduate development and ensure coherence across learning experiences. Curriculum renewal efforts must explicitly scaffold social accountability across all four years, increasing complexity and opportunity for real-world application ( 31 ). Embedding learning opportunities that span the micro (patient-level), meso (community/ organisation-level), and macro (policy/societal-level) levels is essential for preparing graduates to lead in a changing health system ( 6 , 22 ). The DISCuSS (Diversity, Identify, Search, Create module (with community engagement), Sustainability, Social accountability)model ( 33 ) may serve as a useful framework for creating curriculum‒community connections that reinforce accountability principles. Faculty development is another key lever. Lecturers must be supported to deepen their feedback and facilitation skills ( 29 ), role model socially accountable behaviours, and intentionally structure space for reflection and dialogue ( 15 ). Building educator confidence in these practices is essential to ensuring consistent, meaningful learning experiences that engage students in the moral and social dimensions of care. Ultimately, physiotherapy curricula must shift from fostering awareness of injustice to enabling transformative action ( 34 ). This shift demands intentionally designed tipping points - such as service-learning projects, interprofessional dialogue, and facilitated debriefings - that encourage students to move from critical reflection to civic engagement and advocacy ( 35 , 36 ). A curriculum rooted in transformative pedagogies and underpinned by social accountability not only prepares students to meet complex health needs but also contributes to building a more just and equitable health system. These findings contribute to the broader global agenda for health profession education transformation outlined in the Lancet Commission's call for instructional and institutional reforms ( 5 ). While situated within the South African healthcare context, the challenges identified in this study resonate with documented experiences across diverse geographical and resource settings. The difficulties in securing authentic clinical learning experiences reflect broader trends across medical education contexts: rural settings where geographical isolation limits placement diversity, urban centres where overcrowded public hospitals restrict student access, and post-conflict environments where healthcare infrastructure remains fragmented. Similarly, the tension between raising awareness of injustice and teaching students how to respond mirrors struggles reported in physiotherapy programs globally, where students develop critical consciousness but lack practical frameworks for advocacy and system change. These parallels suggest that translating social accountability from curriculum intent to educational reality represents a universal challenge in health profession education, albeit one that manifests differently across contexts. A recent scoping review of social accountability integration strategies identified similar implementation challenges across medical education programs globally, emphasising the need for context-specific approaches while maintaining core accountability principles ( 37 ). The World Health Organisation's Global Strategy on Human Resources for Health: Workforce 2030 ( 38 ) emphasises the need for socially accountable education that responds to local health needs while building global health capacity. Recent guidance from the Association for Medical Education in Europe reinforces this imperative, providing a comprehensive framework for embedding social accountability into health profession curricula and highlighting the need for systematic implementation approaches across diverse contexts( 39 ). Our study demonstrates how this balance plays out in practice, with educators simultaneously navigating local constraints while attempting to prepare graduates for complex, interconnected health challenges. The identified scaffolding difficulties align with UNESCO's recognition that transformative education requires sustained, systematic approaches rather than isolated interventions, particularly in contexts where resource limitations constrain educational innovation. At the global level, these findings contribute to frameworks for assessing social accountability implementation across diverse contexts, suggesting indicators such as curriculum coherence, faculty modelling behaviours, and graduate preparedness for systems-level engagement. Health profession education globally would benefit from longitudinal studies tracking how transformative learning experiences in diverse contexts influence graduate practice patterns and community impact over time, as well as research examining how different resource environments shape the translation of social accountability from curriculum intent to graduate capability. Conclusion This study highlights the integral role that physiotherapy educators play in fostering social accountability within undergraduate education. Lecturers at Stellenbosch University conceptualise social accountability as a complex, multidimensional construct and employ pedagogies aligned with transformative learning theory to cultivate socially responsive graduates. However, significant gaps exist between curricular intent and implementation, including inconsistent student exposure, logistical barriers, and insufficient scaffolding for transformative action. From a theoretical perspective, these findings extend Mezirow's transformative learning framework by revealing how structural and systemic constraints can interrupt the progression from critical reflection to transformative action. This suggests a need for adapted models that explicitly account for contextual constraints through intermediate steps such as collective problem-solving, advocacy skill development, and supported practice in addressing systemic barriers. For institutions in similar contexts, our findings suggest prioritising faculty development, developing community partnerships to expand authentic learning opportunities, and creating structured pathways for students to translate critical awareness into actionable advocacy skills. For well-resourced institutions, these insights highlight the importance of purposeful constraints and authentic challenges in developing professional resilience and social responsiveness. As South Africa continues to face stark health disparities, physiotherapy education must evolve to equip future professionals with the values, competencies, and courage to lead transformative change within complex health systems. Abbreviations DISCuSS Diversity, Identify, Search, Create module (with community engagement), Sustainability, Social accountability (model) FGD Focus group discussion FG (#) Focus group (number) HEI Higher education institution IN (#) Interview (participant number) IPE Interprofessional education SU Stellenbosch University Declarations Ethics approval and consent to participate This study formed part of a broader multi-institutional project approved by the Research Ethics Committee: Social, Behavioural and Education Research of Stellenbosch University (reference number: TL-2018-8838). This research was conducted in accordance with the ethical principles of the Declaration of Helsinki. All participants provided written informed consent and were informed of their right to withdraw from the study at any time. Focus group discussions and interviews were audio-recorded with permission, and all the recordings were stored securely on the password-protected laptop of the principal investigator. Anonymity and confidentiality were maintained throughout the research process, and participants were allowed to verify the transcripts and findings. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding No funding was received for this study or publication. Authors’ contributions All substantive intellectual content, study design, data analysis, interpretation of findings, and conclusions are the shared work of the authors. DE conducted the inductive analysis and SS conducted the deductive analysis independently, but the research team worked together to finalise the themes and subthemes. The authors utilised Claude (Anthropic) as a large language model to assist with manuscript preparation activities, including literature review support, reference formatting, and editorial refinement of written content. The use of AI tools did not influence the research methodology, data collection, or analytical processes. All authors reviewed and approved the final manuscript content and take full responsibility for the accuracy and integrity of the work presented. Acknowledgements This article forms part of the Responsive Curriculum Project, a multi-institutional collaboration led by the Centre for Health Professions Education at Stellenbosch University. The authors wish to thank Professors Cecelia Jacobs and Susan van Schalkwyk for their support, and we wish to thank the staff of the Physiotherapy Division for their participation. References Pillay-van Wyk V, Msemburi W, Laubscher R, Dorrington RE, Groenewald P, Glass T, et al. Mortality trends and differentials in South Africa from 1997 to 2012: second National Burden of Disease Study. Lancet Glob Health. 2016 Sep 1;4(9):e642–53. Mayosi B, Benatar S. Health and Health Care in South Africa - 20 years after Mandela. N Engl J Med. 2014;371(14):1344–53. Volmink J. Reconceptualising health professions education in South Africa. S Afr J Sci. 2018;114(7–8). Dall’Alba G, Barnacle R. An ontological turn for higher education. Studies in Higher Education. 2007;32(6). Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Vol. 376, The Lancet. 2010. Buchman S, Woollard R, Meili R, Goel R. Practising social accountability from theory to action. Canadian Family Physician. 2016;62(1):15–8. Hixon AL, Yamada S, Farmer PE, Maskarinec GG. Social justice: The heart of medical education. Social Medicine. 2013;7(3). Blignaut S. Transforming the curriculum for the unique challenges faced by South Africa. Curriculum Perspectives. 2021;41(1). Reeve C, Woolley T, Ross SJ, Mohammadi L, Halili S “Ben,” Cristobal F, et al. The impact of socially-accountable health professional education: A systematic review of the literature. Med Teach. 2017;39(1). Carpenter B, Nyirenda M, Hanass-Hancock J. Disability, a priority area for health research in South Africa: an analysis of the burden of disease study 2017. Disabil Rehabil. 2021; Amosun SL, Maart S, Naidoo N. Addressing change in physiotherapy education in South Africa. South African Journal of Physiotherapy. 2018 Mar 27;74(1). Jacobs C, Van Schalkwyk S, Blitz J, Volschenk M. Advancing a social justice agenda in health professions education. Critical Studies in Teaching and Learning. 2020;8(2):112–31. Mezirow J. Transformative Learning: Theory to Practice. New Directions for Adult and Continuing Education. 1997;1997(74). Furze J, Black L, Peck K, Jensen GM. Student perceptions of a community engagement experience: Exploration of reflections on social responsibility and professional formation. Physiother Theory Pract. 2011 Aug;27(6):411–21. UNESCO. Teaching and learning transformative engagement [Internet]. 2019 [cited 2022 Feb 9]. Available from: https://unesdoc.unesco.org/ark:/48223/pf0000368961/PDF/368961eng.pdf.multi Van Schalkwyk SC, Hafler J, Brewer TF, Maley MA, Margolis C, McNamee L, et al. Transformative learning as pedagogy for the health professions: a scoping review. Vol. 53, Medical Education. 2019. Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach. BMC Med Res Methodol [Internet]. 2011;11(1):100. Available from: http://www.biomedcentral.com/1471-2288/11/100 Yin RK. Case study research: design and methods. 5th ed. Los Angeles: SAGE; 2014. Etikan I, Musa SA, Alkassim RS. Comparison of Convenience Sampling and Purposive Sampling. American Journal of Theoretical and Applied Statistics. 2016;5(1):1–4. Fereday J, Muir-Cochrane E. Demonstrating Rigor Using Thematic Analysis: A Hybrid Approach of Inductive and Deductive Coding and Theme Development. Int J Qual Methods. 2006;5(1). Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2). Boelen C, Woollard R. Social accountability: The extra leap to excellence for educational institutions. Med Teach. 2011;33(8). Mezirow J. Transformative learning theory. In: Contemporary Theories of Learning [Internet]. Routledge; 2018 [cited 2021 Dec 15]. p. 114–28. Available from: https://www.taylorfrancis.com/chapters/edit/10.4324/9781315147277-8/transformative-learning-theory-jack-mezirow Green-Thompson LP, McInerney P, Woollard B. The social accountability of doctors: A relationship-based framework for understanding emergent community concepts of caring. BMC Health Serv Res. 2017 Apr 12;17(1). Nortvedt P, Hem MH, Skirbekk H. The ethics of care: Role obligations and moderate partiality in health care. Nurs Ethics. 2011 Mar;18(2):192–200. Velardo S. Social determinants of health: A pedagogical framework for advancing the Citizen Scholar. Educ Citizsh Soc Justice. 2018 Nov 1;13(3):268–79. Sharma M, Pinto AD, Kumagai AK. Teaching the Social Determinants of Health: A Path to Equity or a Road to Nowhere? Vol. 93, Academic Medicine. Lippincott Williams and Wilkins; 2018. p. 25–30. Jones P. Transformative Learning Theory: Addressing New Challenges in Social Work Education. In: Li M, Zhou Y, editors. Exploring Learning & Teaching in Higher Education. Berlin, Heidelberg: Springer-Verlag; 2015. p. 267–86. Boud D, Dawson P. What feedback literate teachers do: an empirically-derived competency framework. Assess Eval High Educ. 2021; Reeves S, Fletcher S, Barr H, Birch I, Boet S, Davies N, et al. A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39. Vol. 38, Medical Teacher. Taylor and Francis Ltd; 2016. p. 656–68. Luckett K, Shay S. Reframing the curriculum: a transformative approach. Critical Studies in Education. 2020;61(1). Ryan CL, Cant R, McAllister MM, Vanderburg R, Batty C. Transformative learning theory applications in health professional and nursing education: An umbrella review. Vol. 119, Nurse education today. 2022. Goez H, Lai H, Rodger J, Brett-Maclean P, Hillier T. The DISCuSS model: Creating connections between community and curriculum - A new lens for curricular development in support of social accountability. Med Teach [Internet]. 2020;42(9):1058–64. Available from: https://doi.org/10.1080/0142159X.2020.1779919 Jemal A. Critical Consciousness: A Critique and Critical Analysis of the Literature. Urban Review. 2017 Nov 1;49(4):602–26. Te M, Blackstock F, Chipchase L. Fostering cultural responsiveness in physiotherapy: Curricula survey of Australian and Aotearoa New Zealand physiotherapy programs. BMC Med Educ. 2019 Aug 30;19(1). Clithero-Eridon A, Albright D, Ross A. Conceptualising social accountability as an attribute of medical education. Afr J Prim Health Care Fam Med. 2020;12(1):1–8. Abdalla ME, Taha MH, Onchonga D, Nour N, Kelly D, Harney S, et al. Exploring strategies, programs, and influencing factors for integrating social accountability into undergraduate medical education: a scoping review. BMC Med Educ. 2024 Dec 1;24(1). World Health Organization. Geneva. 2016. Global strategy on human resources for health: Workforce 2030. Abdalla ME, Taha MH, Onchonga D, Preston R, Barber C, Green-Thompson L, et al. Instilling social accountability into the health professions education curriculum with international case studies: AMEE Guide No. 175. Med Teach. 2025;47(7):1083–96. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7327666","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":507133784,"identity":"2786be3e-a38f-4214-8dbf-f0a7633d479c","order_by":0,"name":"Marianne Unger","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuUlEQVRIiWNgGAWjYPACG9K1pJGu5TAJanVn5B5+8XHPeXuD2w2MH34w1MkT1GJ2Iy/Ncsaz24kb7hxgluxhYDNsIKwlx8yY58DtBIMbCQzSDAw8jMRp+XPgnD1QC/NvBgYJe2K0GD9mOHCAccONBDagLQaJhLWceWPG2HMgOXHmjcQ2yx6DhGTCWo7nGH/4ccDOnu9G8uEbPyrqbAlqAQI2CQgN8rgBEeqBgPkDcepGwSgYBaNgxAIALbE9dEgaOxoAAAAASUVORK5CYII=","orcid":"","institution":"Stellenbosch University","correspondingAuthor":true,"prefix":"","firstName":"Marianne","middleName":"","lastName":"Unger","suffix":""},{"id":507133785,"identity":"f90f5699-828e-4c50-8ed7-4ec6aff67215","order_by":1,"name":"Dawn Ernstzen","email":"","orcid":"","institution":"Stellenbosch University","correspondingAuthor":false,"prefix":"","firstName":"Dawn","middleName":"","lastName":"Ernstzen","suffix":""},{"id":507133786,"identity":"0c57918b-5fb9-454c-9bf9-ac52f1397237","order_by":2,"name":"Sue Statham","email":"","orcid":"","institution":"Stellenbosch University","correspondingAuthor":false,"prefix":"","firstName":"Sue","middleName":"","lastName":"Statham","suffix":""},{"id":507133787,"identity":"aa52d674-49b9-447b-ae1b-b95afb14c650","order_by":3,"name":"Adnil Titus","email":"","orcid":"","institution":"Stellenbosch University","correspondingAuthor":false,"prefix":"","firstName":"Adnil","middleName":"","lastName":"Titus","suffix":""}],"badges":[],"createdAt":"2025-08-08 13:23:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7327666/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7327666/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-08105-7","type":"published","date":"2025-10-24T16:16:56+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":94490637,"identity":"e3770c6f-f1c4-4ff6-8e19-0c062816788c","added_by":"auto","created_at":"2025-10-27 17:13:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":768558,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7327666/v1/73ebdb6a-c6f2-4a43-991a-611cfc6c1f23.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Embedding Social Accountability through Transformative Pedagogies: A Case Study from a South African Physiotherapy Curriculum","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe call for socially accountable health professionals is increasingly urgent globally and in South Africa, where persistent health inequities and a quadruple burden of disease challenge the healthcare system (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Higher education institutions (HEIs) are expected to contribute meaningfully to social justice by producing graduates who are not only clinically competent but also critically aware of and responsive to the health systems and contexts in which they serve (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSocial accountability in health profession education can be seen as a shared commitment between universities, communities, and health professionals to address structural determinants of health, promote equity, and advocate for marginalised populations (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). As Blignaut (2021) argues, education can lay the foundations for a more just society, guided by human dignity and equity (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, while competencies related to leadership, ethics, and advocacy are often embedded in physiotherapy curricula, how these are translated into pedagogical practice remains inconsistently applied across undergraduate training in SA. While systematic reviews have demonstrated that socially accountable health professional education can positively impact student learning attitudes and increase the likelihood of graduates serving disadvantaged communities (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), significant gaps remain in understanding how these principles are operationalised within specific disciplinary contexts.\u003c/p\u003e\u003cp\u003eFurther challenges stem from structural and systemic constraints within the healthcare system. The public sector is overburdened by the consequences of trauma, infectious and noncommunicable diseases, and limited resources to address the rehabilitation needs of the population (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Moreover, calls for decolonising health curricula demand renewed attention to contextually relevant, socially just, and community-responsive education (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTransformative learning, as theorised by Mezirow (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), offers a valuable framework for cultivating the critical consciousness required to navigate these complex realities. By engaging students in self-reflection, contextual learning, and ethical reasoning, transformative pedagogies can support the formation of socially accountable professional identities (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). A recent scoping review confirmed that transformative learning theory provides health profession educators with a valuable theoretical lens for understanding student learning in unfamiliar settings, particularly where students are encouraged to be active participants in providing care (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWithin this context, the undergraduate physiotherapy programme at Stellenbosch University (SU) aims to support South African higher education's transformation and social accountability agenda. The programme combines foundational knowledge with clinical and contextual learning opportunities. Despite these intentions, questions remain about how effectively the curriculum fosters students' development as change agents equipped to address the health and rehabilitation needs of diverse communities and to advance social justice.\u003c/p\u003e\u003cp\u003eThis study thus explores how physiotherapy lecturers at SUs understand and enact the principles of social justice and social accountability in their teaching. Specifically, it aims to do the following:\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eExplore lecturers' perspectives on social justice, social accountability and equity and how these are embedded in the curriculum; and\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eExplore lecturers’ perspectives on the pedagogies they use to support transformative learning and the development of socially responsive graduates.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy Design and Setting\u003c/p\u003e\u003cp\u003eThis study used a qualitative descriptive case study design within an interpretivist paradigm (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This study was conducted in the Division of Physiotherapy, Faculty of Medicine and Health Sciences at SU, South Africa. The division offers a four-year undergraduate degree in physiotherapy, with a strong emphasis on foundational sciences in the first two years and clinical integration and contextual learning in the latter two years. At the time of the study, the division was engaged in a curriculum renewal process aligned with national transformation goals.\u003c/p\u003e\u003cp\u003eSampling and Participants\u003c/p\u003e\u003cp\u003eA homogenous purposive sampling approach (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) was used to select participants. Ten permanent academic staff members who held programme or module coordination responsibilities and were actively involved in teaching and curriculum development were recruited to participate. This group was deemed well-positioned to provide insight into how social accountability is conceptualised and implemented in the programme, as they were involved in the delivery of the curriculum content as well as the administration of the curriculum.\u003c/p\u003e\u003cp\u003eData collection\u003c/p\u003e\u003cp\u003eData were collected in two phases: two focus group discussions (FGDs) followed by eight individual semi-structured interviews. The FGDs aimed to explore shared understandings of social justice and social accountability, whereas interviews examined individual pedagogical approaches. The interview guides were developed by the broader Responsive Curriculum Project team based at the Centre for Health Professions Education. The principal investigator conducted the interviews, recorded, and transcribed with participants' consent. Member checking was carried out through transcript review and a post-analysis feedback session.\u003c/p\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eThematic analysis followed a hybrid approach that combines inductive and deductive coding strategies (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Thematic content analysis was guided by the steps of analysis advocated by (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The deductive analysis was guided by a conceptual framework based on Mezirow’s transformative learning theory and existing theories of social justice and accountability (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Two authors independently analysed the data, assigning initial codes and categories using AtlasTi® (Scientific Software Development, GmbH, Berlin, Germany, version 9). All transcripts were uploaded to AtlasTi® for analysis. One researcher conducted the inductive analysis, developing a codebook from emergent data. Another researcher applied the deductive framework. Codes were then compared and integrated through consensus discussion. The combination of both approaches enhanced the credibility and depth of the analysis.\u003c/p\u003e"},{"header":"Findings and Discussion","content":"\u003cp\u003eThis section presents and interprets the findings from two focus group discussions and eight individual interviews with ten physiotherapy lecturers at Stellenbosch University. The focus groups involved six and four participants (FG1 and FG2), respectively, and all ten lecturers participated in the individual interviews (IN1-IN10).\u003c/p\u003e\u003cp\u003eThematic analysis revealed two central themes aligned with the study objectives: (i) understanding of social accountability and its elements, and (ii) pedagogical strategies that support transformative learning. The first theme encompasses lecturers' conceptualisations of professional accountability, ethics of care, equity, and civic responsibility, while the second explores pedagogical approaches including contextual learning, reflection, scaffolding, interprofessional collaboration, role modelling, and professional identity development. Each theme is presented through illustrative quotes integrated with theoretical interpretation and relevant literature to provide a critical synthesis of lecturers' perspectives and curriculum practices.\u003c/p\u003e\u003cp\u003eUnderstanding Social Accountability in the Curriculum\u003c/p\u003e\u003cp\u003eThis theme explores how physiotherapy lecturers conceptualise social accountability and its foundational elements. The participants framed it as a multilayered construct encompassing professional responsibility, ethics, civic engagement, awareness of systemic inequities, interprofessional collaboration, and identity formation. These dimensions reflect the values the curriculum aspires to instil in graduates who can act as change agents within South Africa's complex healthcare landscape.\u003c/p\u003e\u003ch2\u003eProfessional accountability\u003c/h2\u003e\u003cp\u003eLecturers described social accountability as anchored in a broader understanding of professional responsibility, which extended beyond the physiotherapy profession to include patients, families, communities, regulatory bodies, and society. This aligns with Boelen and Woollard's (2011) framework, which conceptualises accountability as encompassing the ethics of care, service orientation, and responsiveness to population health needs.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eProfessional accountability is a huge domain... it includes key stakeholders such as professional organisations, employers, the regulatory framework, the communities and individual patients or clients we serve\u003c/em\u003e.\" [FG2]\u003c/p\u003e\u003cp\u003e\u003cem\u003e“So, when you think of professional accountability as not just being accountable for the service and being ethical and all of that but making sure it is actually directed towards the needs of that community or that person or that family and that your client management is person- and family-centred.”\u003c/em\u003e [FG1]\u003c/p\u003e\u003cp\u003e\u003cem\u003e“The notion of the profile of the Stellenbosch graduate, it is something that when you graduate, you can't stay there. You have that accountability towards yourself, towards the profession, towards your clients, even towards the organisation to carry on and develop.”\u003c/em\u003e [FG2]\u003c/p\u003e\u003cp\u003e“\u003cem\u003eBut as a profession, we claim, we are training graduates that will take the philosophy of the profession at heart, which means not closing a blind eye to what you see, but making a concerted effort, and that you do have a sense of responsibility and accountability towards the people around you.”\u003c/em\u003e [FG1]\u003c/p\u003e\u003cp\u003eThese quotes align with a growing consensus in health profession education that clinical competence alone is insufficient for impactful practice. Ethical sensitivity, cultural humility, and person-centred approaches are equally critical for community-responsive care (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003ch3\u003eEthics of Care and Moral Dilemmas\u003c/h3\u003e\u003cp\u003eThe participants emphasised the difficulty of teaching students how to act when confronted with ethical dilemmas in practice. While many recognised the curriculum's strength in raising awareness about human rights and inequities, they also acknowledged a gap in training students on \u003cem\u003ehow\u003c/em\u003e to respond.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“Do I teach them to be whistleblowers when I actually know they are putting themselves at a disadvantage? I can’t teach them. So there is a huge amount of difficulty around it for me personally. But I take them to the point of identifying and saying what should be corrected.\u003c/em\u003e” [IN1\u003cb\u003e]\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eWe don't teach them that next step of what you do. Who do you rally? Who do you talk to? What are the steps to follow to make change?\u003c/em\u003e\" [IN3]\u003c/p\u003e\u003cp\u003e\u003cem\u003e“…and when to recognize this is a bigger problem that extends beyond what I can do and either I need to make, create awareness in other people, or refer, or to ask.’\u003c/em\u003e [FG2]\u003c/p\u003e\u003cp\u003eThis aligns with Nortvedt et al. (2011), who emphasise that the ethics of care should be grounded in decision-making strategies that recognise students’ moral agency and professional vulnerability (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Clarifying professional roles and intentionally creating space in the curriculum for reflective dialogue and practical guidance are essential for helping students navigate complex ethical dilemmas.\u003c/p\u003e\u003ch3\u003eCitizenship and civic responsibility\u003c/h3\u003e\u003cp\u003eLecturers framed the purpose of the curriculum as extending beyond clinical expertise to cultivate civic-minded graduates who recognise their social responsibility.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eThis is about being a good citizen. It's not just about being a good physio\u003c/em\u003e.\" [IN2]\u003c/p\u003e\u003cp\u003e\u003cem\u003e“… there's more to life than just within a 10 km radius of yourself, and there's a lot of people suffering out there and that can benefit from your expertise, or your professional expertise, and it's time to do something about it. You can't just say somebody else will do something about it. I think that's why there's a lot of emphasis on the concept again.\u003c/em\u003e” [FG 1]\u003c/p\u003e\u003cp\u003eThis framing is consistent with Velardo's (2018) view that social accountability requires a shift from individual competence to collective responsibility (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). In a country with entrenched health inequities, the curriculum must instil a sense of justice and accountability to marginalised communities.\u003c/p\u003e\u003ch3\u003eHealth Equity and System Awareness\u003c/h3\u003e\u003cp\u003eThe participants acknowledged the need to develop students' understanding of social determinants of health and how these determinants contribute to disparities in access and outcomes. They recognised advocacy as a key graduate attribute.\u003c/p\u003e\u003cp\u003e\u003cem\u003e‘I think advocacy and leadership, are part of the graduate attributes. But my feeling is that we can do more to help the students to pick up the problems that aren't being picked up necessarily by the Department of Health. … and I think that we can have a profound effect there if they (students) have the skills to do that.”\u003c/em\u003e [FG1]\u003c/p\u003e\u003cp\u003e\u003cem\u003e‘… civic responsibility comes back to …change agents, you know, someone that has some inherent responsibility for the people and communities out there, … and what can I do to change the system that is maybe broken, or how can I improve the health of the community through reflection, enquiry, engagement with that community.”\u003c/em\u003e [IN5]\u003c/p\u003e\u003cp\u003eThis finding reinforces the view that social accountability in physiotherapy education must extend beyond clinical training to include systems thinking, an understanding of the social determinants of health, and a population-level orientation to care (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003ch3\u003eInterprofessional Engagement\u003c/h3\u003e\u003cp\u003eLecturers view interprofessional education (IPE) as a vital mechanism for promoting collaborative practice, patient-centred care, and broader accountability to the health system. They saw IPE not only as an opportunity for students to appreciate the distinct roles of other professionals but also to develop teamwork, communication, and shared problem-solving skills essential to effective rehabilitation in real-world contexts.\u003c/p\u003e\u003cp\u003e“\u003cem\u003eThey actually sit together and they do a plan for a patient… then they all work together towards a common goal for the patient\u003c/em\u003e.” [IN7]\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eIt’s not about being loyal to my profession... It’s about the patient. In addition, we all have a role in that activity.\"\u003c/em\u003e [IN7]\u003c/p\u003e\u003ch2\u003eIdentity Formation and Graduate Attributes\u003c/h2\u003e\u003cp\u003eThe formation of a strong professional identity was seen as essential for accountability and resilience in complex healthcare environments.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eThey need to understand themselves and their role, and then how they interlink with others... It’s a progressive thing\u003c/em\u003e.\" [FG2]\u003c/p\u003e\u003cp\u003e“\u003cem\u003eTheir (students’) ability to be a change agent needs to grow out of being very solidly based in your discipline and then having the confidence to act.\u003c/em\u003e” [IN6]\u003c/p\u003e\u003cp\u003eThis is consistent with the literature that emphasises professional identity development as a dynamic and transformative process shaped by sustained engagement in authentic contexts, critical self-reflection, and exposure to meaningful role modelling (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Through these experiences, students gradually internalise professional values, clarify their roles, and build confidence to act ethically and responsively within the healthcare system.\u003c/p\u003e\u003cp\u003ePedagogies Supporting Transformative Learning\u003c/p\u003e\u003cp\u003eThis theme explores the pedagogical strategies employed by participants to facilitate transformative learning and foster socially accountable practices. The participants identified a range of approaches - both formal and informal -that aim to move students from theoretical understanding to critical reflection and real-world action. These strategies include experiential and contextual learning, structured reflection, interprofessional collaboration, scaffolding, discussion-based teaching, and role modelling. Together, they support the development of critical consciousness, professional identity, and readiness to engage with complex health and social issues.\u003c/p\u003e\u003ch3\u003eContextual / experiential learning\u003c/h3\u003e\u003cp\u003e The participants identified contextual and experiential learning as the most prominent and impactful pedagogical approach for fostering transformative engagement. These forms of learning are widely recognised for their role in bridging classroom-based knowledge with the complexities of real-world practice. Through direct exposure to diverse environments, students were better able to internalise concepts, adapt interventions to context, and reflect critically on their role as emerging professionals.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eThey actually do home visits... and see how they might need to adapt their treatment to fit the home environment\u003c/em\u003e.\" [IN6]\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I didn’t think a patient could get up the day after that type of surgery… then they see it and realise the patient can go home tomorrow, because they’re far more capable than expected\u003c/em\u003e.\" [FG1]\u003c/p\u003e\u003cp\u003eSuch situated learning fosters embodied understanding and enhances the integration of theoretical knowledge with real-world complexity (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003ch3\u003eReflection and feedback\u003c/h3\u003e\u003cp\u003eLecturers highlighted reflection as a vital pedagogical tool for transformative learning, enabling students to develop critical self-awareness and examine their professional values and assumptions. Reflection, particularly when supported by structured models and timely feedback, was seen as essential in helping students make sense of complex experiences, navigate ethical dilemmas, and integrate learning across different settings. The feedback process was recognised not only as evaluative but also as developmental, contributing to both personal growth and professional identity formation.\u003c/p\u003e\u003cp\u003eHowever, the participants acknowledged the variability in how reflection and feedback were facilitated and called for greater intentionality and support in embedding these practices across the curriculum.\u003c/p\u003e\u003cp\u003eThe DEAL model of reflection was highlighted as a structured way to prompt deeper thinking and emotional processing.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eWe incorporate the DEAL model... describe, evaluate, and articulate learning academically, civically, and personally\u003c/em\u003e.\" [IN3]\u003c/p\u003e\u003cp\u003e\u003cem\u003e“…and that’s why I’m saying, so that reflective discussion is quite often helpful, because remember, the student comes with a story from their perspective. So they need that other perspective sometimes to understand that perhaps the person said this, but could they have meant that, or could it have been within this context.”\u003c/em\u003e [FG1]\u003c/p\u003e\u003cp\u003eHowever, both the students and the lecturers struggled with the depth of reflection. Feedback literacy among staff and the integration of structured reflection remain areas that need attention (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\u003ch2\u003eInterprofessional Collaboration\u003c/h2\u003e\u003cp\u003eThe participants recognised interprofessional collaboration as an essential learning strategy to prepare students for real-world, team-based healthcare delivery. Working across professional boundaries was seen as key to improving patient care and strengthening students’ appreciation of systems-based practice. Through shared learning opportunities, students begin to understand the roles and contributions of various health professionals and the importance of collaboration in achieving holistic outcomes. Despite its perceived value, logistical challenges were frequently cited as barriers to full integration in the curriculum. While valued, IPE activities are limited by schedules and site variability.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eIt’s difficult to integrate it fully... The main barrier is timetables and that it’s not happening in all clinical settings.\"\u003c/em\u003e [IN8]\u003c/p\u003e\u003cp\u003eThis challenge echoes the literature and highlights the need for systemic alignment across faculties to enable meaningful collaborative learning (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003ch2\u003eScaffolding across the curriculum\u003c/h2\u003e\u003cp\u003eLecturers described scaffolding as a deliberate curriculum design feature that supports the development of critical thinking, ethical reasoning, and professional accountability over time. Through structured progression, from foundational principles in the early years to complex, integrated practice in later years, students gradually build the competencies needed to become socially responsive practitioners. Scaffolding also ensures that threshold concepts such as social justice and equity are reinforced across modules, enabling deeper learning and application in various clinical contexts. Lecturers described how the curriculum builds progressively from foundational to complex tasks.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eWe start low and build up on that... with horizontal and vertical coherence\u003c/em\u003e.\" [FG2]\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"So on second year level, it would be case examples, and problem analysis... we would start with the impairments... with case studies and role-playing in second year. Probably in the third year it is more complex... there would be aspects in there about ethical issues surrounding profession... interdisciplinary work, how to engage with the team.\"\u003c/em\u003e [IN8]\u003c/p\u003e\u003cp\u003eSuch curriculum coherence is essential for embedding transformative learning principles over time (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). This ensures that students are not only exposed to critical concepts at isolated points but also provided with repeated, progressively complex opportunities to engage with and internalise them across diverse learning contexts. This deliberate repetition and integration help sustain transformative momentum and prepare students for socially responsive practice.\u003c/p\u003e\u003ch2\u003eDiscursive Pedagogy and Role Modelling\u003c/h2\u003e\u003cp\u003e The participants emphasised the value of discursive pedagogy, creating space for dialogue, reflection, and shared meaning-making, as a vehicle for transformative learning. Facilitated discussions, particularly in response to critical incidents, were seen as vital for helping students process complex emotions and ethical tensions. In parallel, role modelling by lecturers has emerged as a powerful pedagogical tool. Students were viewed as highly observant, often internalising professional behaviours demonstrated by educators, whether in clinical, classroom, or interprofessional settings. Debriefing and discussion were viewed as powerful tools for sense-making, whereas role modelling was considered critical for demonstrating ethical and professional behaviour.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eI don’t think we always realise how much students observe and absorb from what they see\u003c/em\u003e.\" [FG2]\u003c/p\u003e\u003cp\u003e\u003cem\u003e“…so that reflective discussion is quite often helpful, because remember, the student comes with a story from their perspective. So, they need that other perspective sometimes to understand that perhaps the person said this, but could they have meant that, or could it have been within this context.”\u003c/em\u003e [FG2]\u003c/p\u003e\u003cp\u003e\u003cem\u003e“So when an incident arises, spend an hour talking about it, unpacking it and reflecting on it and finding solutions, just in a discussion format… do they really know what a good, what a physio, what kind of physio that hope we hope them to be one day.”\u003c/em\u003e [FG1]\u003c/p\u003e\u003cp\u003e\u003cem\u003e“So I do believe in role modelling. So you do have the opportunity in terms of with that patient, with that student, to actually role model certain concepts,… and then be able to give them that feedback afterwards in a reflective manner...”\u003c/em\u003e [IN4]\u003c/p\u003e\u003cp\u003eUNESCO stresses the importance of ‘tipping moments’ in transformative learning, which are often catalysed by such interpersonal engagements (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eChallenges\u003c/p\u003e\u003cp\u003eWhile transformative pedagogies are present within the programme, participants identified multiple challenges in their consistent implementation. These spans structural, pedagogical, and contextual barriers, which together undermine equitable student learning experiences and dilute the intended impact of transformative learning.\u003c/p\u003e\u003cp\u003eIn terms of \u003cb\u003econtextual learning\u003c/b\u003e, lecturers described increasing difficulties in securing access to clinical and community-based learning environments due to lengthy approval processes and institutional gatekeeping. There were also concerns that rapid changes in healthcare delivery and unequal student placement sites created inconsistent learning opportunities.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eI have to then apply and give dates well in advance, almost sometimes a year in advance... then go to that facility and get permission there as well\u003c/em\u003e.\" [IN5]\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eOne of the fears is lack of equal exposure, and equal opportunity\u003c/em\u003e.\" [FG1]\u003c/p\u003e\u003cp\u003eStudents were also reported to face \u003cb\u003epersonal and social barriers\u003c/b\u003e to meaningful engagement, particularly when encountering patients or contexts that were vastly different from their own experience.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eThe challenges they face is not something they have ever heard of … and sometimes they have to deal with people who have severe mental issues as well, which is foreign for them. They have no understanding\u003c/em\u003e.\" [IN1]\u003c/p\u003e\u003cp\u003e\u003cb\u003eReflection\u003c/b\u003e was another area of concern. While lecturers acknowledged its importance, they noted a lack of depth in student reflections and limited scaffolding from staff.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eThe reality is that the reflection is often very limited… it’s not towards future behaviour and the becoming and the steps that follow\u003c/em\u003e.\" [IN1]\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eWe share a lot of discussion or points or real-life situations, and the students are just expected to reflect.\"\u003c/em\u003e [FG1]\u003c/p\u003e\u003cp\u003e\u003cb\u003eInterprofessional collaboration\u003c/b\u003e was valued but remained underutilised owing to programme silos and logistical barriers such as scheduling mismatches and limited access to diverse professional teams at some clinical sites.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eThe main barrier is timetables, different programmes, and also, that it is actually not happening in practice\u003c/em\u003e.\" [IN8]\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eThere may be a physio, but there’s no opportunities always for the students to work with a speech therapist or with the medical team\u003c/em\u003e.\" [IN5]\u003c/p\u003e\u003cp\u003eFor \u003cb\u003escaffolding\u003c/b\u003e, some lecturers noted that foundational-year students struggled to engage with complex cases, highlighting a misalignment between theoretical inputs and the students' clinical or contextual exposure.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eThey don't really understand the case... because they did not have that experience, that exposure to the practical part of it\u003c/em\u003e.\" [FG2]\u003c/p\u003e\u003cp\u003eFor \u003cb\u003ediscursive pedagogy\u003c/b\u003e, participants reported inconsistencies in whether reflective discussions and debriefings were actively facilitated and highlighted a lack of psychological safety for students needing to process difficult experiences.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eSome of the students don't speak to anybody... they’ve voiced a wish for a person to be able to debrief them, but who isn’t in the division\u003c/em\u003e.\" [IN2]\u003c/p\u003e\u003cp\u003eFinally, \u003cb\u003erole modelling\u003c/b\u003e was limited by the availability of clinicians and educators who actively embodied the values of social accountability in practice.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eI don't think they get exposed enough to what it is we want them to act as physios. There is lack of role modelling\u003c/em\u003e.\" [FG2]\u003c/p\u003e\u003cp\u003eTogether, these challenges reveal systemic tensions between curriculum intent and implementation and point to a need for more intentional faculty development, better alignment of placements, and a unified pedagogical strategy to support the social accountability agenda.\u003c/p\u003e\u003cp\u003eStrengths and Limitations\u003c/p\u003e\u003cp\u003eThis study offers a novel contribution to the literature by exploring how social accountability is conceptualised and enacted within a South African physiotherapy curriculum. Methodologically, this study demonstrates how case study design can effectively capture the complexity of curriculum implementation across different contexts, providing a replicable approach for examining social accountability initiatives. The hybrid thematic analysis framework developed here, which combines Mezirow's transformative learning theory with social accountability frameworks, offers a structured yet flexible approach for similar investigations in diverse cultural and resource settings. The study provides a nuanced, theory-informed understanding of the pedagogies and challenges associated with embedding transformative learning and social responsiveness in undergraduate training. The use of a hybrid thematic analysis and multiple data sources (focus groups and interviews) enhanced the depth and trustworthiness of the findings.\u003c/p\u003e\u003cp\u003eHowever, the study is limited by its single-site, case study design, which may constrain the transferability of findings to other institutions or programmes. While participants had diverse roles within curriculum design and delivery, the perspectives were limited to faculty members; incorporating student and stakeholder voices could further enrich understanding. Despite these limitations, the findings offer valuable insights for physiotherapy educators and curriculum developers aiming to advance a social justice agenda in similar low- and middle-income contexts.\u003c/p\u003e\u003cp\u003eSynthesis and Curriculum Implications\u003c/p\u003e\u003cp\u003eThese findings demonstrate that the SU physiotherapy programme has a strong philosophical and pedagogical commitment to social accountability. Lecturers interpret this construct broadly and deeply, drawing connections between professional responsibility, ethical care, health equity, and civic engagement. They employ a wide range of pedagogical strategies aligned with transformative learning theory, including contextual learning, structured reflection, interprofessional engagement, and scaffolding, an approach supported by Mezirow (2018), Jones (2015), and Furze et al. (2011), who argue that such integrated methods foster professional identity development and critical consciousness. This approach aligns with recent umbrella reviews demonstrating that transformative learning theory applications in health profession education consistently support curriculum design, program evaluation, and the development of leadership skills and professional identity (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, systemic and contextual challenges limit the consistency and depth of implementation. Unequal student experiences, time and resource constraints, limited interprofessional opportunities, and insufficient feedback literacy represent critical gaps between curricular intent and reality. These challenges highlight the need for better alignment of the formal, informal, and hidden curriculum (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) to support holistic graduate development and ensure coherence across learning experiences.\u003c/p\u003e\u003cp\u003eCurriculum renewal efforts must explicitly scaffold social accountability across all four years, increasing complexity and opportunity for real-world application (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Embedding learning opportunities that span the micro (patient-level), meso (community/ organisation-level), and macro (policy/societal-level) levels is essential for preparing graduates to lead in a changing health system (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The DISCuSS (Diversity, Identify, Search, Create module (with community engagement), Sustainability, Social accountability)model (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) may serve as a useful framework for creating curriculum‒community connections that reinforce accountability principles.\u003c/p\u003e\u003cp\u003eFaculty development is another key lever. Lecturers must be supported to deepen their feedback and facilitation skills (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), role model socially accountable behaviours, and intentionally structure space for reflection and dialogue (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Building educator confidence in these practices is essential to ensuring consistent, meaningful learning experiences that engage students in the moral and social dimensions of care.\u003c/p\u003e\u003cp\u003eUltimately, physiotherapy curricula must shift from fostering awareness of injustice to enabling transformative action (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). This shift demands intentionally designed tipping points - such as service-learning projects, interprofessional dialogue, and facilitated debriefings - that encourage students to move from critical reflection to civic engagement and advocacy (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). A curriculum rooted in transformative pedagogies and underpinned by social accountability not only prepares students to meet complex health needs but also contributes to building a more just and equitable health system.\u003c/p\u003e\u003cp\u003eThese findings contribute to the broader global agenda for health profession education transformation outlined in the Lancet Commission's call for instructional and institutional reforms (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). While situated within the South African healthcare context, the challenges identified in this study resonate with documented experiences across diverse geographical and resource settings. The difficulties in securing authentic clinical learning experiences reflect broader trends across medical education contexts: rural settings where geographical isolation limits placement diversity, urban centres where overcrowded public hospitals restrict student access, and post-conflict environments where healthcare infrastructure remains fragmented. Similarly, the tension between raising awareness of injustice and teaching students how to respond mirrors struggles reported in physiotherapy programs globally, where students develop critical consciousness but lack practical frameworks for advocacy and system change. These parallels suggest that translating social accountability from curriculum intent to educational reality represents a universal challenge in health profession education, albeit one that manifests differently across contexts. A recent scoping review of social accountability integration strategies identified similar implementation challenges across medical education programs globally, emphasising the need for context-specific approaches while maintaining core accountability principles (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe World Health Organisation's Global Strategy on Human Resources for Health: Workforce 2030 (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) emphasises the need for socially accountable education that responds to local health needs while building global health capacity. Recent guidance from the Association for Medical Education in Europe reinforces this imperative, providing a comprehensive framework for embedding social accountability into health profession curricula and highlighting the need for systematic implementation approaches across diverse contexts(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Our study demonstrates how this balance plays out in practice, with educators simultaneously navigating local constraints while attempting to prepare graduates for complex, interconnected health challenges. The identified scaffolding difficulties align with UNESCO's recognition that transformative education requires sustained, systematic approaches rather than isolated interventions, particularly in contexts where resource limitations constrain educational innovation.\u003c/p\u003e\u003cp\u003eAt the global level, these findings contribute to frameworks for assessing social accountability implementation across diverse contexts, suggesting indicators such as curriculum coherence, faculty modelling behaviours, and graduate preparedness for systems-level engagement. Health profession education globally would benefit from longitudinal studies tracking how transformative learning experiences in diverse contexts influence graduate practice patterns and community impact over time, as well as research examining how different resource environments shape the translation of social accountability from curriculum intent to graduate capability.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the integral role that physiotherapy educators play in fostering social accountability within undergraduate education. Lecturers at Stellenbosch University conceptualise social accountability as a complex, multidimensional construct and employ pedagogies aligned with transformative learning theory to cultivate socially responsive graduates. However, significant gaps exist between curricular intent and implementation, including inconsistent student exposure, logistical barriers, and insufficient scaffolding for transformative action.\u003c/p\u003e\u003cp\u003eFrom a theoretical perspective, these findings extend Mezirow's transformative learning framework by revealing how structural and systemic constraints can interrupt the progression from critical reflection to transformative action. This suggests a need for adapted models that explicitly account for contextual constraints through intermediate steps such as collective problem-solving, advocacy skill development, and supported practice in addressing systemic barriers.\u003c/p\u003e\u003cp\u003eFor institutions in similar contexts, our findings suggest prioritising faculty development, developing community partnerships to expand authentic learning opportunities, and creating structured pathways for students to translate critical awareness into actionable advocacy skills. For well-resourced institutions, these insights highlight the importance of purposeful constraints and authentic challenges in developing professional resilience and social responsiveness. As South Africa continues to face stark health disparities, physiotherapy education must evolve to equip future professionals with the values, competencies, and courage to lead transformative change within complex health systems.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDISCuSS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Diversity, Identify, Search, Create module (with community engagement), Sustainability, Social accountability (model)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFGD\u0026nbsp; \u0026nbsp; \u0026nbsp;Focus group discussion\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFG (#)\u0026nbsp;\u0026nbsp;Focus group (number)\u003c/p\u003e\n\u003cp\u003eHEI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Higher education institution\u003c/p\u003e\n\u003cp\u003eIN (#) \u0026nbsp;\u0026nbsp;Interview (participant number)\u003c/p\u003e\n\u003cp\u003eIPE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Interprofessional education\u003c/p\u003e\n\u003cp\u003eSU \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Stellenbosch University\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eThis study formed part of a broader multi-institutional project approved by the Research Ethics Committee: Social, Behavioural and Education Research of Stellenbosch University (reference number: TL-2018-8838).\u0026nbsp;This research was conducted in accordance with the ethical principles of the Declaration of Helsinki. All participants provided written informed consent and were informed of their right to withdraw from the study at any time.\u0026nbsp;Focus group discussions and interviews were audio-recorded with permission, and all the recordings were stored securely on the password-protected laptop of the principal investigator. Anonymity and confidentiality were maintained throughout the research process, and participants were allowed to verify the transcripts and findings.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eNo funding was received for this study or publication.\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026rsquo; contributions\u003c/h3\u003e\n\u003cp\u003eAll substantive intellectual content, study design, data analysis, interpretation of findings, and conclusions are the shared work of the authors. DE conducted the inductive analysis and SS conducted the deductive analysis independently, but the research team worked together to finalise the themes and subthemes. \u0026nbsp;The authors utilised Claude (Anthropic) as a large language model to assist with manuscript preparation activities, including literature review support, reference formatting, and editorial refinement of written content. The use of AI tools did not influence the research methodology, data collection, or analytical processes. All authors reviewed and approved the final manuscript content and take full responsibility for the accuracy and integrity of the work presented.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eThis article forms part of the Responsive Curriculum Project, a multi-institutional collaboration led by the Centre for Health Professions Education at Stellenbosch University. The authors wish to thank Professors Cecelia Jacobs and Susan van Schalkwyk for their support, and we wish to thank the staff of the Physiotherapy Division for their participation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePillay-van Wyk V, Msemburi W, Laubscher R, Dorrington RE, Groenewald P, Glass T, et al. Mortality trends and differentials in South Africa from 1997 to 2012: second National Burden of Disease Study. Lancet Glob Health. 2016 Sep 1;4(9):e642\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eMayosi B, Benatar S. Health and Health Care in South Africa - 20 years after Mandela. N Engl J Med. 2014;371(14):1344\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eVolmink J. Reconceptualising health professions education in South Africa. S Afr J Sci. 2018;114(7\u0026ndash;8). \u003c/li\u003e\n\u003cli\u003eDall\u0026rsquo;Alba G, Barnacle R. An ontological turn for higher education. Studies in Higher Education. 2007;32(6). \u003c/li\u003e\n\u003cli\u003eFrenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Vol. 376, The Lancet. 2010. \u003c/li\u003e\n\u003cli\u003eBuchman S, Woollard R, Meili R, Goel R. Practising social accountability from theory to action. Canadian Family Physician. 2016;62(1):15\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eHixon AL, Yamada S, Farmer PE, Maskarinec GG. Social justice: The heart of medical education. Social Medicine. 2013;7(3). \u003c/li\u003e\n\u003cli\u003eBlignaut S. Transforming the curriculum for the unique challenges faced by South Africa. Curriculum Perspectives. 2021;41(1). \u003c/li\u003e\n\u003cli\u003eReeve C, Woolley T, Ross SJ, Mohammadi L, Halili S \u0026ldquo;Ben,\u0026rdquo; Cristobal F, et al. The impact of socially-accountable health professional education: A systematic review of the literature. Med Teach. 2017;39(1). \u003c/li\u003e\n\u003cli\u003eCarpenter B, Nyirenda M, Hanass-Hancock J. Disability, a priority area for health research in South Africa: an analysis of the burden of disease study 2017. Disabil Rehabil. 2021; \u003c/li\u003e\n\u003cli\u003eAmosun SL, Maart S, Naidoo N. Addressing change in physiotherapy education in South Africa. South African Journal of Physiotherapy. 2018 Mar 27;74(1). \u003c/li\u003e\n\u003cli\u003eJacobs C, Van Schalkwyk S, Blitz J, Volschenk M. Advancing a social justice agenda in health professions education. Critical Studies in Teaching and Learning. 2020;8(2):112\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eMezirow J. Transformative Learning: Theory to Practice. New Directions for Adult and Continuing Education. 1997;1997(74). \u003c/li\u003e\n\u003cli\u003eFurze J, Black L, Peck K, Jensen GM. Student perceptions of a community engagement experience: Exploration of reflections on social responsibility and professional formation. Physiother Theory Pract. 2011 Aug;27(6):411\u0026ndash;21. \u003c/li\u003e\n\u003cli\u003eUNESCO. Teaching and learning transformative engagement [Internet]. 2019 [cited 2022 Feb 9]. Available from: https://unesdoc.unesco.org/ark:/48223/pf0000368961/PDF/368961eng.pdf.multi\u003c/li\u003e\n\u003cli\u003eVan Schalkwyk SC, Hafler J, Brewer TF, Maley MA, Margolis C, McNamee L, et al. Transformative learning as pedagogy for the health professions: a scoping review. Vol. 53, Medical Education. 2019. \u003c/li\u003e\n\u003cli\u003eCrowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach. BMC Med Res Methodol [Internet]. 2011;11(1):100. Available from: http://www.biomedcentral.com/1471-2288/11/100\u003c/li\u003e\n\u003cli\u003eYin RK. Case study research: design and methods. 5th ed. Los Angeles: SAGE; 2014. \u003c/li\u003e\n\u003cli\u003eEtikan I, Musa SA, Alkassim RS. Comparison of Convenience Sampling and Purposive Sampling. American Journal of Theoretical and Applied Statistics. 2016;5(1):1\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eFereday J, Muir-Cochrane E. Demonstrating Rigor Using Thematic Analysis: A Hybrid Approach of Inductive and Deductive Coding and Theme Development. Int J Qual Methods. 2006;5(1). \u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2). \u003c/li\u003e\n\u003cli\u003eBoelen C, Woollard R. Social accountability: The extra leap to excellence for educational institutions. Med Teach. 2011;33(8). \u003c/li\u003e\n\u003cli\u003eMezirow J. Transformative learning theory. In: Contemporary Theories of Learning [Internet]. Routledge; 2018 [cited 2021 Dec 15]. p. 114\u0026ndash;28. Available from: https://www.taylorfrancis.com/chapters/edit/10.4324/9781315147277-8/transformative-learning-theory-jack-mezirow\u003c/li\u003e\n\u003cli\u003eGreen-Thompson LP, McInerney P, Woollard B. The social accountability of doctors: A relationship-based framework for understanding emergent community concepts of caring. BMC Health Serv Res. 2017 Apr 12;17(1). \u003c/li\u003e\n\u003cli\u003eNortvedt P, Hem MH, Skirbekk H. The ethics of care: Role obligations and moderate partiality in health care. Nurs Ethics. 2011 Mar;18(2):192\u0026ndash;200. \u003c/li\u003e\n\u003cli\u003eVelardo S. Social determinants of health: A pedagogical framework for advancing the Citizen Scholar. Educ Citizsh Soc Justice. 2018 Nov 1;13(3):268\u0026ndash;79. \u003c/li\u003e\n\u003cli\u003eSharma M, Pinto AD, Kumagai AK. Teaching the Social Determinants of Health: A Path to Equity or a Road to Nowhere? Vol. 93, Academic Medicine. Lippincott Williams and Wilkins; 2018. p. 25\u0026ndash;30. \u003c/li\u003e\n\u003cli\u003eJones P. Transformative Learning Theory: Addressing New Challenges in Social Work Education. In: Li M, Zhou Y, editors. Exploring Learning \u0026amp; Teaching in Higher Education. Berlin, Heidelberg: Springer-Verlag; 2015. p. 267\u0026ndash;86. \u003c/li\u003e\n\u003cli\u003eBoud D, Dawson P. What feedback literate teachers do: an empirically-derived competency framework. Assess Eval High Educ. 2021; \u003c/li\u003e\n\u003cli\u003eReeves S, Fletcher S, Barr H, Birch I, Boet S, Davies N, et al. A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39. Vol. 38, Medical Teacher. Taylor and Francis Ltd; 2016. p. 656\u0026ndash;68. \u003c/li\u003e\n\u003cli\u003eLuckett K, Shay S. Reframing the curriculum: a transformative approach. Critical Studies in Education. 2020;61(1). \u003c/li\u003e\n\u003cli\u003eRyan CL, Cant R, McAllister MM, Vanderburg R, Batty C. Transformative learning theory applications in health professional and nursing education: An umbrella review. Vol. 119, Nurse education today. 2022. \u003c/li\u003e\n\u003cli\u003eGoez H, Lai H, Rodger J, Brett-Maclean P, Hillier T. The DISCuSS model: Creating connections between community and curriculum - A new lens for curricular development in support of social accountability. Med Teach [Internet]. 2020;42(9):1058\u0026ndash;64. Available from: https://doi.org/10.1080/0142159X.2020.1779919\u003c/li\u003e\n\u003cli\u003eJemal A. Critical Consciousness: A Critique and Critical Analysis of the Literature. Urban Review. 2017 Nov 1;49(4):602\u0026ndash;26. \u003c/li\u003e\n\u003cli\u003eTe M, Blackstock F, Chipchase L. Fostering cultural responsiveness in physiotherapy: Curricula survey of Australian and Aotearoa New Zealand physiotherapy programs. BMC Med Educ. 2019 Aug 30;19(1). \u003c/li\u003e\n\u003cli\u003eClithero-Eridon A, Albright D, Ross A. Conceptualising social accountability as an attribute of medical education. Afr J Prim Health Care Fam Med. 2020;12(1):1\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eAbdalla ME, Taha MH, Onchonga D, Nour N, Kelly D, Harney S, et al. Exploring strategies, programs, and influencing factors for integrating social accountability into undergraduate medical education: a scoping review. BMC Med Educ. 2024 Dec 1;24(1). \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Geneva. 2016. Global strategy on human resources for health: Workforce 2030. \u003c/li\u003e\n\u003cli\u003eAbdalla ME, Taha MH, Onchonga D, Preston R, Barber C, Green-Thompson L, et al. Instilling social accountability into the health professions education curriculum with international case studies: AMEE Guide No. 175. Med Teach. 2025;47(7):1083\u0026ndash;96. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"transformative learning, responsive curriculum, social accountability, physiotherapy education, social justice","lastPublishedDoi":"10.21203/rs.3.rs-7327666/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7327666/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eHealth profession curricula must produce healthcare professionals who are not only clinically competent but also socially accountable. This requires graduates to understand and respond to the health systems and social contexts within which they practice, and lecturers play an important role in facilitating the attainment of these competencies. Despite growing calls for socially accountable health professional education globally, limited research exists on how these principles are understood and implemented within physiotherapy curricula, particularly in low- and middle-income contexts where health inequities are pronounced.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e\u003cp\u003eTo explore how physiotherapy lecturers understand and integrate the principles of social justice and social accountability into a South African undergraduate curriculum and to examine the pedagogical strategies employed to foster transformative learning.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA qualitative descriptive case study with an interpretivist paradigm was conducted at the Division of Physiotherapy, Stellenbosch University. Data were collected via two focus groups (n\u0026thinsp;=\u0026thinsp;10 participants) and eight individual semi-structured interviews with permanent academic staff involved in curriculum coordination and development. Mezirow's transformative learning theory and established theories of social justice and social accountability guided a hybrid inductive and deductive thematic analysis via AtlasTi\u0026reg; software.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eTwo key themes emerged: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) understanding social accountability and its underpinning elements, including professional accountability, ethics of care, citizenship, health equity, interprofessional engagement, and professional identity formation, and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) pedagogical strategies for transformative learning, encompassing contextual and experiential learning, structured reflection, interprofessional collaboration, progressive scaffolding, discursive pedagogy, and role modelling. While lecturers demonstrated a sophisticated understanding of social accountability as a multidimensional construct, significant implementation challenges were identified, including inconsistent student exposure, logistical barriers to authentic learning experiences, limited scaffolding for transformative action, and insufficient faculty development support.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eSocial accountability is a recognised but complex goal within the physiotherapy curriculum. While transformative pedagogies are employed, critical gaps remain between curricular intent and implementation, particularly in scaffolding students' progression from critical reflection to transformative action. Strengthening pedagogical coherence, enhancing faculty development, and expanding authentic experiential learning opportunities may support the development of socially responsive physiotherapy graduates equipped to address health system challenges and promote health equity.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e","manuscriptTitle":"Embedding Social Accountability through Transformative Pedagogies: A Case Study from a South African Physiotherapy Curriculum","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-29 07:41:25","doi":"10.21203/rs.3.rs-7327666/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-08T07:12:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-04T19:37:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-28T22:44:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"308909089309164992476203680568125183106","date":"2025-08-27T12:53:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"270192537966832582869361893492081804998","date":"2025-08-23T08:26:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-21T04:24:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-21T04:12:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-20T19:10:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-20T10:27:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-08-20T10:08:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"52d5e110-8279-46ac-bf63-0bb94f6b20a3","owner":[],"postedDate":"August 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-27T16:34:50+00:00","versionOfRecord":{"articleIdentity":"rs-7327666","link":"https://doi.org/10.1186/s12909-025-08105-7","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-10-24 16:16:56","publishedOnDateReadable":"October 24th, 2025"},"versionCreatedAt":"2025-08-29 07:41:25","video":"","vorDoi":"10.1186/s12909-025-08105-7","vorDoiUrl":"https://doi.org/10.1186/s12909-025-08105-7","workflowStages":[]},"version":"v1","identity":"rs-7327666","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7327666","identity":"rs-7327666","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}