The concept of social accountability (SA) has attained a growing interest worldwide (Emadzadeh et al., 2016). SA includes citizen-led efforts to hold public officials, lawmakers, and service providers accountable for their acts and performance in providing services, enhancing people’s welfare, and preserving their rights (Beck et al., 2007). In 1995, the World Health Organization (WHO) adapted this concept in medical schools (Boelen et al., 1995). The WHO defines SA in the context of medical education as the responsibility to focus education, research, and service activities on tackling the most pressing health issues in the communities, regions, and countries they are intended to serve (Boelen et al., 1995). As SA is considered the foundation of both medical practice and medical schools, four values were introduced by WHO, namely, quality, equity, relevance, and cost-effectiveness, to evaluate the progress of medical schools in addressing SA (Boelen et al., 1995). This implies that SA should emphasize meeting professional standards and satisfying community expectations through providing equal opportunities for healthcare to everyone, addressing locally relevant problems, and ensuring the cost-effectiveness of healthcare service delivery.

The main challenge for medical schools in the twenty-first century resides in the responsibility for achieving community-based medical education that is relevant to the community health needs to produce competent graduates who can provide optimal healthcare status. With the global shift toward anticipating the individual and societal health needs and tailoring curriculum to best meet priority health concerns of a nation, SA was integrated into some medical schools’ educational programs (Boelen et al., 1995; GCSAMS, 2010). Canadian medical schools were the earliest schools that officially adapted the concept of SA to ensure a highly valued Canadian healthcare system (Social Accountability | The Association of Faculties of Medicine of Canada [AFMC], 2022). Furthermore, other countries like Sudan, Saudi Arabia, and Egypt have also taken initiatives toward achieving community-based, socially accountable medical education. A study that assessed the SA of the Faculty of Medicine at the University of Gezira (FMUG), Sudan, concluded their educational program as socially responsible and socially accountable only in certain aspects (Ahmed et al., 2020). Hosny et al. (2015) suggested using the conceptualization production usability (CPU) model to assess SA in medical institutions. The study emphasized compliance with parameters of CPU domains for an institution to be recognized as a proactive, socially accountable medical school (Hosny et al., 2015).

Furthermore, a recent study conducted in Saudi Arabia used the SA grid issued by the WHO as a basis for assessing SA. The study concluded that the educational aspect had the highest compliance for SA. Nevertheless, there is a need for more studies to explore how to achieve accountable social status (Alrebish et al., 2020). Some locally conducted studies in Saudi Arabia have focused on developing an integrated curriculum that is more community-orientated for a new medical college. It was noted that the traditional curriculum was insufficient to graduate doctors, consequently providing lower quality services to their community (El-Naggar et al., 2017). They started formulating the new curriculum by interviewing experts and doing a literature survey/search to gather the needed information (El-Naggar et al., 2017). The study ended up formulating a program that consists of three phases “pre-med (year 1), organ/system, and clinical clerkship to be followed by a year of internship.” The Jazan Faculty of Medicine has adopted this program to improve the outcomes of medical staff (El-Naggar et al., 2017). Both studies have locally provided evidence that some medical schools in Saudi Arabia are socially accountable, although the extent is unknown, and more studies are needed to evaluate SA in the other medical schools.

Although the importance of SA is widely agreed upon, the concept of SA is less familiar among the medical students who are the end product of a medical college. A study conducted at Makerere College of Health Sciences exploring the perceptions of senior medical educators and students discovered that SA was an unfamiliar concept to many of the respondents. Many students are not even aware of this term (Galukande et al., 2012). Another international study conducted in the United Kingdom to assess the concept of SA in a medical school illustrated that students could not express a well-understanding of SA meaning. However, they admitted that the curricula revealed a few core principles around SA (McCrea and Murdoch-Eaton, 2014). A study by Social Accountability in Health Professional Education (SAHPE) showed that the associated supervisors in the hospital rated SAHPE medical workforce higher overall than traditional medical school graduates in socially accountable competencies and the overall performance and clinical skills (Woolley et al., 2019).

The perception of SA among students varies among different institutions across the world. Due to the limited reports on SA in Saudi Arabia, the study aimed to assess the perceived SA of medical students currently studying at the governmental institution following problem-based learning. Also, we wanted to assess whether the concept of SA was clearer among students across different years in medical school.

The research was conducted to understand the SA from the Students’ perspective. Additionally, the association of gender and year of the study with the perceived SA was considered during the research. Results showed that the KSAU-HS medical students perceived their institution as a good, socially accountable institution. No statistically significant differences were noted among male and female students who study at two separate campuses within the same institution. The variation across different years of study with the acceptability of the institution’s SA was also noted.

In Saudi Arabia, almost all medical colleges have segregated male and female campuses. The teaching staff at male campuses is predominantly male and vice versa at the female campus. Yet, in our study, no such differences across gender were noted with the perceived SA. The role of the teaching staff is crucial in developing SA among students. The presence of socially responsible teaching faculty has a significant impact on medical programs progressing toward being fully socially accountable with community-oriented health services. This also ensures higher deployment and consistent retention of healthcare workers in rural or remote areas (Elsanousi et al., 2016). Similarly, the role of gender is also considered an important variable affecting the perception of SA (Alghamdi, 2014).

One of the notable findings of the study was the highest mean score associated with the item evaluating the location of the medical practice and the future posting preference of medical students. The result can be associated with the core of KSAU-HS mission, which is to graduate qualified physicians for community services and promote the concept of SA (Mission Vision and Strategic Goals, 2022). COM offers volunteering opportunities at multiple levels to meet this goal, such as volunteering in the Saudi red crescent authority, the Hajj volunteer program, and a mandatory summer elective course. Hence, allowing the students to be engaged and familiarized with the intended population and well-equipped for serving the community. Dharamsi et al. (2010) also support the effect of community placements in cultivating a sense of SA among students. A recent study conducted in Morocco showed similar results and reported that students who do social services perceived a better perception of SA (Sebbani et al., 2021). It is believed that engaging students in community-based learning sites representing the actual population ensure the acquisition of well-defined competencies for more efficient health service delivery and encourage medical students to feel their school impact on the community and, thereby, improve their perceived SA (Boelen, 2016; Clithero et al., 2017; Roughead et al., 2017; Woolley et al., 2019).

An interesting finding of the study was that students perceived the school did not promote general specialties, such as family medicine and general practice (GP). The finding was supported by another study conducted at KSAU-HS in which two-thirds of the medical students refrained from choosing a general specialty as a future career option (Alshammari et al., 2019). Unlike our study population, medical students from universities in the United Kingdom were more inclined toward opting for GP as a future specialty for practices (Alshammari et al., 2019; Henderson et al., 2020). The National Health System in the United Kingdom has integrated GP within the community at advanced levels, leading to higher earning potential and relatively easily manageable expertise compared to doctors working in other specialties (Henderson et al., 2020). The Saudi Commission for Health Specialties has urged medical colleges to align the curriculum with the newly implemented Saudi MED framework, focusing on the priority health needs of the Saudi population and society (Tekian and Al Ahwal, 2015). Therefore, similar strategic reforms to the United Kingdom may be instilled in Saudi medical colleges and healthcare setup to strengthen SA. Having said that, further research is required to understand the impact of other exogenous social factors such as lifestyle and luxuries on perceived SA among students. As the primary health setups are predominantly in the country’s rural areas, choosing a GP position in rural areas could be a hard decision for many young practitioners (Henderson et al., 2020). Individual motivation and commitment to service is considered as one of the factors that can increase SA among students (Mohammadi et al., 2020).

For the overall level of SA among our study, most participants scored within the range of 18–26 across all the survey questionnaires, indicating signs of weaknesses, despite the school’s improved efforts. The junior students revealed better and positive perceptions about school’s SA compared to final-year students. Similar findings were reported by a study at Qassim University. The higher rates of burnout syndrome and depression were associated with Students’ progression through the medical school, impacting the clinical phased Students’ perception of their school’s SA (Alkhamees et al., 2020). Besides a higher prevalence of burnout syndrome in senior students, depression can also affect their perception of the survey items (Pacheco et al., 2017).

For most items, the academic year of study was significantly associated with the level of Students’ perceptions of their school’s SA. An acceptable reason behind the senior Students’ high scores in the fifth item, which evaluates the presence of the targeted population to be served at Students’ practice sites, is that students start their hospital rotations during fourth and final academic years. In clinical years, learning becomes more patient-oriented, unlike third and fourth years, where most of the learning takes place in the college. Item 9, which assesses whether the learning experience is providing active service to the community, is evaluated through the availability of opportunities for students to create health promotion projects supported by the university faculty that target the community. One example is the “Yakfeek Sharraha” campaign conducted in 2019 by students with support from the university. This project aimed to raise community awareness about motor vehicle accidents and the role of different surgical specialties in saving lives (College Of Medicine Riyadh-Home, 2022). Another awareness campaign was educating the public and correcting the common misconceptions on what to do in emergencies. Thus, community-centered initiatives and the school’s contribution to the community it serves may play a pivotal role in promoting SA amongst medical students (Boelen, 2016; Boelen et al., 2016).

Item 10 of the SA questionnaire focused on evaluating the role of research in the university, whereas item 12 primarily evaluated university’s impact and engagement with the community. On the research front, medical research course is mandatory during the third and fourth academic years at COM. This ensures that students take initiative to conduct research in different priority areas set by the institution on yearly basis. As the medical research course is conducted during the preclinical years, this explains the significantly lower SA acceptance among the fourth- and final-year students in the research domain. Furthermore, the community engagement of the university was assessed through two parts, namely, first, the encouragement of scientific research through the number of publications and Students’ participation in conferences; and second, supporting students to adapt and engage in various community-based activities results in developing a positive landscape of the university among people. At KSAU-HS, the university Student’s club encourages students to engage in various activities to improve their skills and abilities, promote their social responsibility, and provide the maximum benefit to the community. Each college in the university has a student club, including a social team responsible for educating and raising the community’s health awareness through campaigns. Prioritizing the research based on the population’s needs is one of the ways that can successfully improve SA of an institution (Strasser et al., 2013; Ahmed et al., 2020).

Despite the comprehensiveness of this research for capturing the perceptions around SA in medical universities in Saudi Arabia, there were certain limitations to the study approach. The mode of data collection was altered from a face-to-face self-administered approach to an Internet-based survey approach, which may have affected the study results. Additionally, the reporting bias may have affected the overall perception of the medical students. Single-institution-based survey can also limit the generalizability of the results to other medical colleges. Notwithstanding the limitations, efforts were made during the design phase to avoid the over- or underrepresentation of the participants through quota sampling, which is one of the strengths of this study. Our study participants represent the views of students studying in a public university. The private medical universities in Saudi Arabia are only a few; therefore, the results of the study can be generalized to most of the public medical universities.

Going forward, SA is a complex phenomenon and has different aspects that need more advanced understanding. One strategy for all the studying batches of students might not be applicable in medical colleges since each year has its own specific needs. Future research is required to further explore institutional-based evaluation models to identify well-defined indicators for improving SA among students. Additionally, a qualitative research study can also provide meaningful insight into understanding SA from a Student’s perspective. This may help identify the areas for improvement and reinforce the institutional strategy in meeting ideal SA principles.

To summarize, there is an urgent need to integrate SA approaches into healthcare delivery by medical schools and aid the establishment of a more relevant, equitable, high-quality, and cost-effective healthcare system at Saudi Arabia’s medical schools. Additionally, with the changing global dynamics of health as witnessed in the recent pandemic, medical schools must also be ready to adapt to the rapidly changing demand of their community (Minter et al., 2021; Papapanou et al., 2021). That might require more frequent changes to the existing modes of improving SA than expected as the students move along their growth trajectory.

The study concludes that one-third of the medical students had an overall low perceived SA. It was noted that the acceptability of SA varied across different years based on the individual items among preclinical and clinical year students. Therefore, the institution needs to focus its interventions based on the needs of preclinical and clinical year students accordingly. As final-year students were more critical, it is recommended that they require more attention to improve the acceptability of SA. The university should focus specifically on the needs of the graduating final-year students to meet the aim of socially accountable institutions meeting the need of their nation. It is recommended that the graduating students be provided sufficient exposure and spend an adequate length of time in community-based placements during clinical rotations. This can be an opportunity to enhance the overall perceived level of SA of medical institutions among the community and medical students.

The data presented in this study are available on request from the corresponding author. The data are not publicly available due to institutional policies of maintaining the confidentiality of the student data.

The studies involving human participants were reviewed and approved by the King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia. The patients/participants provided their written informed consent to participate in this study.

NM contributed to conceptualization, proposal development, formal analysis and result interpretation, manuscript revision, and finalization for submission to the journal and general supervision as a senior member of the team. SA, OA, DAg, RA, and DAb contributed equally to proposal development and literature review, data acquisition, data cleaning and management, and manuscript writing and editing as junior research team members. SA-N contributed to study designing, data checking, result interpretation, manuscript editing, and technical revision and project management as a senior member. All authors have read and approved the final version of the manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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