When I say … social responsiveness

We live in a society that remains beset with substantial social inequalities that influence the quality of people's health and well-being.¹ The global health care system remains highly inequitable, skewed along lines such as race, culture and social class, with the most vulnerable in society still receiving largely inadequate health care. These challenging conditions necessitate that health professionals in training are prepared to be responsive to the complexities evident in health care. The focus of this special issue on ‘Constructive dialogue: Strengthening our knowledge by exploring cross-cultural differences’ provides an opportunity to consider social responsiveness in relation to an important construct such as culture, specifically in the context of health professions education (HPE).

The concept of social responsiveness is understood in a variety of ways across different fields. Within the context of HPE and in reference to medical schools, social responsiveness was conceptualised along a social obligation continuum with social responsibility on one end, social responsiveness in the middle and social accountability on the other end.² At the time, social responsiveness was described by Boelen and Woollard² as ‘the engagement in a course of actions responding to social needs’ (p. 615). Although within the literature there have been efforts to further delineate these concepts, the breadth and connectedness of the social obligation continuum have resulted in many using the various terms interchangeably. Social responsiveness has been described as complementing social accountability, and while much of the work around social accountability has emphasised institutional roles in this regard, social responsiveness has often been considered at the level of the individual.³

In our own work, we have grappled with these terms from an HPE perspective, electing to focus on socially responsive curricula and their potential to produce socially responsive graduates who seek to ‘question the causes of health inequity and intervene in healthcare contexts and systems with a view to transforming them into more socially just spaces’⁴ (p. 116). In this paper, we build on this understanding and highlight some fundamentals underpinning this important concept.

First, social responsiveness is underpinned by conscientisation⁵ for both students and educators. Freire's notion of conscientisation speaks to a critical consciousness, which requires a recognition of the oppressive systems in society and then taking action to transform these for the benefit of all.⁵ Socially responsive health professionals, therefore, while needing to be clinically competent, also have to become deeply mindful of the context within which they practise as clinicians. This approach has implications for how we engage in HPE, for our curricula, for the content that we teach and the knowledge that matters within the educational space.⁶

HPE is situated within diverse contexts that present unique challenges to social responsiveness. Concepts such as race, culture and ethnicity are complex and multifaceted and should be viewed in light of the lived experiences within a specific context. For example, the South African context from which we write is fraught with the detrimental effects of a colonial and apartheid legacy that sought to intentionally justify discrimination based along lines such as race and culture, which had implications at the level of health care. Challenges of this nature are not faced by South Africa alone. Cross-cultural differences are deeply connected to the social discourses, assumptions, beliefs and biases that may foster a cultural hegemony, which may in turn continue to reproduce health inequalities. It is with this consideration that social responsiveness requires HPE to adopt a contextually relevant approach, which would allow for the sensitisation of students and educators to the factors within their unique contexts that continue to support the dominant discourses fueling cultural hegemony and oppressive systems that perpetuate inequalities.

Second, social responsiveness demands acts of resistance^{7, 8} and disruption to move beyond the hierarchies and traditions within HPE that seek to maintain an inequitable status quo. Such resistance and disruption would need to occur across various levels (ontologically, epistemologically, axiologically and practically) to shift and transform ways of doing, thinking and being in the HPE field. There is a need to engage in constructive dialogues regarding whether HPE in its current form contributes to perpetuating health inequity.⁹ This requires a recognition that HPE is not neutral,⁹ and claims of objectivity and neutrality must be challenged. Rather, it is crucial to understand that the choices in HPE are not made in a vacuum; instead, these choices are strongly influenced by the educators; by historical, political and social forces; and by the cultures, values and practices of the respective disciplines and professions.^{10, 11} These choices have implications and hold power to shape and influence who our students become, including their attitudes and values,¹² as well as their approaches to health inequities and social injustices. Therefore, social responsiveness in HPE should involve enabling students and educators to proactively resist and challenge the power dynamics within the ecosystem of HPE and to disrupt and dismantle underlying systems in order to bring about the necessary social change.^{13, 14}

Third, we argue that social responsiveness should emphatically be framed within a social justice agenda. To prepare health professionals in training to proactively take the necessary action to respond to social needs requires more than merely an awareness of the social determinants of health,¹⁵ an appreciation of cross-cultural differences, and constructive dialogue. Rather, it demands that we engage with the socio-political nature of health care. Educators and students need to grapple with the complex and multifaceted dimensions of social justice to promote health equity, health systems strengthening and social change. This would necessitate that we prepare our graduates to be socially, politically and economically engaged¹⁶ such that we are able to work towards social justice, which Busari et al.¹⁷ refer to as ‘a future state in which root causes of inequity, (e.g. racism, ableism, etc.) have been dismantled and barriers have been removed’ (p. 1).

We recognise the current strides made to shift and transform HPE and foreground matters related to social responsiveness and social justice. These have emerged from various perspectives ranging across philosophical considerations to practical strategies.^{9, 17-20} We also acknowledge that work in this area is not easy and places additional responsibilities on the HPE educator. However, there remains much work to be done. Drawing again on the work of Paulo Freire, we suggest that socially just pedagogies,^{21, 22} underpinned by critical approaches, can encourage the sort of engagement that is needed^{18, 23-25} as they seek to foster agency within students and educators to be able to transform society. It remains important that we examine how issues of cross-cultural differences are currently engaged with in HPE to ensure that it does not reproduce biases and stigma. Ultimately, in working towards a future that is more socially just¹⁷ necessitates that we continuously evaluate critically the knowledge base underpinning HPE, as well as the norms of curricula and pedagogical practices that inform them so as to ensure curricula that foster socially responsive health professionals who will challenge and respond to health inequalities in society.^{10, 26}

Anthea Hansen: Conceptualization; writing—original draft; writing—review and editing. Susan Camille van Schalkwyk: Conceptualization; writing—review. Cecilia Jacobs: Conceptualization; writing—review.