This study examines the democratic orientations and political practices of Indian university students through two independent cross-sectional surveys conducted at national student parliament events in 2016 and 2022. The analysis reflects on the findings from these two large descriptive snapshots of students participating in these events in distinct socio-political contexts. Drawing on survey data complemented by focus group discussions (FGDs), it explores how students in these two time periods expressed their democratic engagement, institutional trust and priorities for development. Across both study cohorts, the findings reflect particularly low levels of support for formal institutions in the year 2022, while a strong concern for democratic values and principles is upheld, as well as an interest in solving issues such as social inequality, lack of access to education, and poverty. Interpreted through life-course and post-materialist frameworks, these findings are described as indicative of how students navigate their commitments to democracy within their respective contexts. The study develops the concepts of political plasticity to offer the idea that students are certainly not abandoning democracy, but re-imagining it as a relational and ethical practice in India's political climate.
Efraim Joel Hart,1,2 Giliam Kuijpers,3,4 Hans van der Schoot,5 Teun Zuiderent-Jerak,1 Fedde Scheele1,6 1Athena Institute, Faculty of Science, VU University Amsterdam, Amsterdam, Netherlands; 2Department of Medical Education, OLVG Hospital, Amsterdam, Netherlands; 3Training Institute and Social Enterprise MedGezel, Bussum, Netherlands; 4The Central Military Hospital, Utrecht, Netherlands; 5VvAA Association, Utrecht, Netherlands; 6Academic Center for Dentistry University of Amsterdam (ACTA), Amsterdam, NetherlandsCorrespondence: Efraim Joel Hart, Email Efraim.hart@gmail.comBackground: Transformative learning in health professions education aims to develop health professionals as “enlightened change agents”, who critically question routines and contribute to health system improvement. In hospital governance contexts, dissent from professionals acting as enlightened change agents may be framed as nuisance.Objective: To explore how executive hospital board members interpret and respond to dissent from health professionals acting as enlightened change agents, and how they involve these professionals in governance and decision-making.Methods: We conducted a qualitative phenomenological interview study with six experienced hospital board members from academic and non-academic hospitals. Semi-structured interviews were thematically analyzed using an iterative inductive–deductive approach until data saturation was reached.Results: Board members portrayed themselves as translators of societal and technological trends into organizational policy who seek broad support while retaining final authority. They operated under ongoing financial and continuity pressures, which constrained room for innovative ideas that fell outside immediate priorities. Board members described dissent as welcome when it was perceived as constructive and actionable within current priorities. When dissent was perceived to delay decision-making or challenge strategic agendas, it was more likely to be reframed as “nuisance power”. Three response pathways to dissent were identified: acceptance, tolerance and intervention. Interventions included appealing to majority rule, ignoring dissenters, using hierarchical authority, facilitating exit, or even involving external regulators.Conclusion: In this hospital governance context, change agency by professionals may be reframed as “nuisance power” when it is perceived to impede board priorities, highlighting how governance conditions shape whether dissent is engaged or marginalized.Implications: Hospital boards may reduce informal marginalization by explicitly organizing how dissent is heard and fed back within governance processes. Educational programs should better prepare future change agents to work strategically within governance processes through framing, alliance-building, and negotiation.Keywords: transformative learning, enlightened change agent, hospital governance, organizational dissent, healthcare leadership, dissent
Introduction Globally many people are suffering from poor mental health, with conflict-affected populations like refugees particularly affected. Task-sharing between mental health specialists (e.g. psychiatrists, and psychotherapists) and non-specialists (e.g. community workers, social workers, and lay health workers) can strengthen the health workforce and enhance access to psychological care. Despite their potential, task-sharing interventions in global mental health have rarely been successfully implemented at scale. The aim of this thesis was to gain insights into how novel psychological interventions for refugees can be embedded into existing systems, and ultimately contribute to health system strengthening and improved refugee’ mental health. Methodology All case studies (chapters 5-7) were guided by the same conceptual framework (chapter 3) and used semi-structured interviews as primary method of data collection. Rapid appraisals, using a health responsiveness framework, were conducted in eight countries hosting Syrian refugees (chapter 4). This PhD research was embedded in the STRENGTHS study, which ran from 2017 to 2022. Results Chapter 3 presents the conceptual framework. First, a case was made for using a “system innovation perspective”. Second, key concepts were described and defined. Third, a three-phased plan was presented to operationalise the conceptual framework in our scalability research. Chapter 4 shows findings from the systems analysis. Numerous constraints were found in health system responsiveness towards the MHPSS needs of Syrian refugees in all eight countries part of STRENGTHS: i) Too few appropriate mental health providers and services; ii) Travel-related barriers impeding access to services; iii) Cultural, language, and knowledge-related barriers to timely care; iv) High out-of-pocket costs ; v) Long waiting times for specialist mental health services; and vi) Information gaps. Chapter 5 explores the factors influencing the potential for scaling up Problem Management Plus (PM+) in the Netherlands. Findings suggested that the feasibility of wider implementation will largely depend on whether barriers like stigma, attrition, fragmentation, competition, legal, and financial challenges can be overcome. Formalising the roles of new non-specialist workers was found important, including developing structures for their accreditation and supervision. Three scenarios for institutional anchoring of PM+ were identified. Chapter 6 examines the factors influencing the potential for scaling up PM+ in Jordan. Political momentum was identified as a landscape trend likely facilitating scaling up, while predicted reductions in financial aid was regarded as a constraint. The medicalised approach to mental health, stigma, and gender were reported culture-related barriers for scaling up PM+. Using non-stigmatising language, and offering different modalities, childcare options, and sessions outside of working hours were suggestions to reduce stigma, accommodate individual preferences, and increase the demand for PM+. In relation to structure, the feasibility of scaling up PM+ largely depends on the ability to overcome legal barriers, limitations in human and financial resources, and organisational challenges. Chapter 7 examines the scalability of Step-by-Step (SbS) in Egypt, Germany, and Sweden. Contextual factors were: increasing use of e-health; reduced contact during the COVID-19 pandemic; and political instability. Factors related to culture: perceived need and acceptability of the innovation. Factors related to structure: financing; regulations; accessibility; competencies of e-helpers; and quality control. Factors related to practice were barriers in initial and continued engagement of end-users. Nineteen powerful stakeholders were identified and several context-specific integration scenarios were developed. Conclusions This in-depth research has improved knowledge on factors influencing the potential for scaling up task-sharing and digital psychological interventions for refugees in different countries. The interactions between an innovation, potential adoptive systems, and its wider context are complex and difficult to predict. The factors influencing scalability identified through the case studies and the developed integration scenarios will be an important starting point for actors involved in taking such innovations to scale.
