Social actors

To date, following the World Health Organization’s position statement on the SA of medical schools,³ reflections and research on SA have historically been conducted largely through educational institutions^4,5 or at the health policy level primarily in low- and middle-income countries.^6,7 The Global Consensus,⁸ the founding document on the SA of medical schools, underlines the necessity for SA research to evaluate and improve medical schools’ impact in response to individual and societal health needs and challenges. Recently, Maherzi and colleagues⁹ highlighted the impact of the COVID-19 pandemic on training future health professionals, and the unique opportunity for medical schools to strengthen their engagement and better prepare these future professionals to respond to societal needs and future health care challenges. They described structuring actions for medical schools to advance their social mandates. We argue that the application of SA in health goes beyond the scope of medical schools and must extend to all social actors, both individual and collective, and that this is relevant to SA research.

Ecological approach

Bronfenbrenner’s ecological systems theory provides a framework for examining the complexity of individuals’ relationships (micro level) within communities (meso level) and society as a whole (macro level).¹⁰ At the micro (individual) level, this consists of orienting research toward the importance of how social determinants of health affect an individual’s capacity to follow public health recommendations. This involves greater individual understanding and raising awareness in people living in vulnerable situations. At the meso (community) level, we examine whether health systems respond to demographic and geographic population needs and the needs of particular communities. And at the macro (societal) level, we attempt to better understand economic policies and public health measures adopted by various governments and their impacts on population health. An ecological approach to research offers a way of simultaneously emphasizing individual, contextual, and societal systems, as well as situating levels of SA and identifying interconnections for a more participative approach to public health.

Priority research themes

Blind spots in SA. Being socially accountable involves understanding our social reality. The COVID-19 pandemic revealed the interdependence that exists between individuals and between society and the environment. When we exclude one portion of the population or of society, the virus continues to propagate. In that sense, the pandemic has revealed our blind spots. The lack of physical space to treat sick patients and the fragility of our local health systems are among the major problems rendered more visible by the pandemic. Without a doubt, the most important tragedy was the catastrophic loss of life experienced across an entire generation of elderly people. For many countries around the world, the pandemic revealed the extreme inadequacies of existing social safety nets to their fullest extent. For example, in some countries, governments and institutions rapidly produced the resources needed to provide safe housing for homeless people, to prevent the spread of contagion. We saw the growing use of social media to reach different groups, but also as a source of confusion, through contradictory messages, and of suffering due to an increasing number of harmful messages and even hate speech targeting certain groups of people. For example, within the domain of mental health, we saw the necessity to implement mechanisms of collaboration between different stakeholders in health and social services to effectively reach individuals dealing with personal mental health problems exacerbated by the pandemic. We witnessed the impact of service organization policies on managing elderly and vulnerable people whose risk factors were initially underestimated and who were placed in isolation without ensuring the capacity to respond to their needs. Therein lies the need to raise awareness of our social reality: identifying society’s priority health needs. While the barriers to accessing health care in underserved areas were well known before the pandemic, other concerns have been raised regarding the distribution of primary health care support services and staff shortages in rural and remote communities. This is particularly important for deploying a nationwide mass vaccination campaign. Understanding how SA research could increase awareness of our blind spots is very pertinent. We propose further orienting SA research toward unexplored blind spots, including those mentioned here in addition to others that may be identified through future research, to identify our society’s priority health needs. In that sense, perspectives from other disciplines and inter- and transdisciplinary research may provide insight to better understand blind spots in our study and practice of SA.

Partnerships between stakeholders in health. Actions demonstrate SA. Effective action cannot be taken alone. In the context of a public health vision, a system of care is only a subsystem of the broader health system. Addressing the pandemic not only requires community engagement, but the SA of several other political and economic stakeholders and institutions. The partnership pentagon defined by the World Health Organization¹¹ provides a framework through which we can examine the partnership between stakeholders in health. This pentagon consists of 5 health care stakeholders: academic institutions, health professionals, communities, policy makers, and health administrators. These same stakeholders are also the targets of health promotion actions,¹² reflecting the contributions of each component of SA. The pandemic allowed new partnerships to distinguish themselves through socially accountable actions, such as the contributions of food, hygiene, and sanitation workers, and highlighted the unique and often underappreciated contributions of personal support workers and caregivers in long-term care facilities. As a result of the pandemic, we have seen partnerships between stakeholders in health and unconventional partners (eg, manufacturing and industry) emerge. While partnerships were established to respond rapidly to collective needs, some industries profited more from the pandemic response than others, which may contribute to exacerbating health inequities. The pentagon can serve as point of reference for examining all collaborations that developed to address health inequities.

Training future health professionals. Increasingly, health professions education programs are orienting teaching and learning to prepare learners to recognize the relationships between different aspects of their professional work and social obligations. This more recent transformation in health professions education is linked to integrating the values and aspirations expressed through the concept of SA.

For educational institutions, social accountability is defined as the obligation of schools to “direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve.”³ To achieve this objective, teaching activities (eg, clerkships in community or primary care settings, reflection activities) have been implemented because they appear to be effective methods for future health professionals to learn about health-related population needs. The COVID-19 pandemic has demonstrated the transformative repercussions this health crisis has had on health professions education. Programs across the education spectrum (for learners and current practitioners) in many countries have been restructured to respond to this requirement, synonymous with academic and institutional excellence. Schools can learn important lessons from the educational approaches mobilized in the wake of the pandemic, to promote interprofessional and interdisciplinary collaboration aimed at strengthening SA in health.⁹ Indeed, health professionals immediately learn the difference they can make with respect to their own SA to meet society’s health needs. This presents both challenges and opportunities for future SA research (eg, identifying competencies related to SA and the sequential pathways necessary to achieve them).

Conclusion

Researchers have documented the public health changes resulting from global events such as the world wars, civil wars and conflicts, natural disasters, and public health crises.^13,14 While the pandemic has acted, and will continue to act, as an important catalyst for change in several contexts, it will be difficult to ensure that these changes are maintained over time.¹⁵ This specific moment in history calls for an undaunted reflection on the concept of SA supported by renewed engagement in research. While SA research has especially been focused on the impacts of actions, future researchers must turn toward new avenues, such as largely unexplored blind spots, the contributions of new partnerships, and training future health professionals.

Footnotes

References