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Interdisciplinary Action Research Plan

Maggie Dennis Jana Lee

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Table of Contents

Executive Summary…………………………………………………………………………….... 3 Sankara Profile and Research Needs…………………………………………………………….. 4 Research Deliverables…………………………………………………………………………… 5 Core Issues Addressed…………………………………………………………………………... 6 Research Questions……………………………………………………………………………… 7 Description of Data and Data Collection………………………………………………………... 8 Ethical Issues…………………………………………………………………………………… 11 Vocational Discernment………………………………………………………………………... 12 India’s National and Country Context………………………………………………………...... 13 Action Research Work Plan……………………………………………………………………. 15 Health and Safety Plan…………………………………………………………………………. 18 Bibliography……………………………………………………………………………………. 24

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Executive Summary

We are a team of two undergraduate Global Social Benefit Fellows with the Miller Center for Social Entrepreneurship at Santa Clara University. During our eight-week field placement, we will work with Sankara Eye Care in Coimbatore to help document the social impact of eye care services and assess the deployment of a web application designed to track student eye records. Sankara Eye Care is a social enterprise dedicated to eliminating needless blindness among India’s rural populations by offering accessible, high quality, comprehensive eye care. Sankara has developed multiple programs that target a diverse range of patients including the rural poor, urban middle class and school children. To date, Sankara has opened 14 hospitals across 10 different states in India and provided over 1.2 million free eye surgeries for the rural poor. As Sankara continues to expand its reach, we hope to contribute to the organization’s mission of providing quality care for all through the compellation of case studies and the implementation of technology.

While at Sankara, we will be conducting two main research projects. First, we will be collecting data for a set of 6-7 comprehensive patient case studies. These be used in presentations to donors and investors, in the annual report and on the Sankara website. Second, we will be assessing a web application that tracks student eye records by school. We will be evaluating the functionality and usability of the application. At the end of our stay in August, we will provide a summary of our findings. We will provide an official report by the end of October. This report will have two primary components: 1) a set of in-depth case studies reflecting Sankara’s diverse customer segments and social impact; and 2) a detailed assessment of the usability of the web application, including recommendations for development and improvement. Our report will also be published for public use on the Miller Center’s website. We hope these deliverables will be an added resource for Sankara and will help the organization scale their social impact. We look forward to working with Sankara to help solve the problem of curable blindness in India. The following is a detailed research plan outlining our research methodology and planned deliverables.

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Sankara Profile and Research Needs Background

Sankara Eye Care is a large, comprehensive eye care provider in India. The prevalence of curable blindness in India is one of the highest in the world. Blindness can have a detrimental effect on an individual’s life and there is a strong association between blindness and poverty. Sankara seeks to address this problem by providing high quality, equitable and affordable eye care to the rural poor in India. Founded in 1997 by Dr. R.V Ramini and Dr. Radha, Sankara has expanded into 14 eye hospitals located in 10 states. Since its inception, Sankara has performed over 1 million sight restoring surgeries and has become one of the major eye care providers in India. Sankara combines highly skilled healthcare workers and advanced technology in order to provide excellent care to individuals at all socioeconomic levels. Their impact model involves eliminating curable blindness, allowing individuals to lead more productive lives and increasing job and empowerment opportunities within communities.

Sankara operates using a cross-subsidy payment model, which allows them to provide eye care service to low-income individuals free of charge. Sankara has two main customer segments: the urban middle class, who pay for service, and poor rural customers who receive services for free. Using this hybrid payment model, 20% of Sankara’s paying customers generate enough revenue to pay for 80% of free customers. This business model has allowed Sankara to become 90% self-sustainable.

Sankara operates multiple different types of treatment facilities. They have 14 base hospitals in urban areas and conduct regular eye camps in rural areas. Rural patients are screened and diagnosed at the eye camps and then transported to a base hospital if they require surgery. Services include routine check ups, cataract removal and intraocular lens (IOL) clinics, cornea and refractive services, vitreo- retinal services, glaucoma services, Lasik surgery, pediatric ophthalmology and ocular oncology. In addition to the eye camps, Sankara operates several other outreach programs including the Sankara Eye Bank, the Gift of Vision Program (rural outreach program), Rainbow Program (preventative eye care for school children) and the Sankara Academy of Vision, which trains healthcare workers in advanced eye care techniques. Research Needs

Sankara requires further research in two different areas: social impact assessment and technological evaluation. One research project that our team will be working on this summer will be continued documentation of Sankara’s social impact through a set of comprehensive, qualitative patient case studies. The case studies will be used in annual reports, websites and presentations to donors. We will also be conducting research to assess a newly deployed web application to track student eye records. Sankara’s current method of documenting student records is pencil and paper. This application will help improve efficiency and make tracking student records significantly easier. The application was designed by Santa Clara University students at the Frugal Innovation Lab and our research will evaluate how well this application functions and meets Sankara’s requirements. This assessment will provide information to help further develop the application to fully meet Sankara’s needs.

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Research Deliverables The main research products that we plan on delivering to Sankara in the fall are a collection of case studies and an assessment of the mobile application. Case Studies

We plan on compiling a set of 6-7 in depth patient case studies for Sankara. The purpose of the case studies is to articulate the social impact that Sankara has. These case studies will cover general patient information, socioeconomic status, family information and prognosis after treatment. The case studies will also include high quality photographs of patients before and after surgery and in their homes or workplaces. The studies will be used by Sankara in their presentations to donors and investors, in their annual report and on their website. Case studies will be limited to patients who are 4-9 or over 50, are non-paying and have congenital, bilateral or developmental cataracts treated by Sankara. We will use the Sankara case study framework that Sankara has provided. As we develop case studies, we may change aspects of this template so that case studies can more effectively tell the story of Sankara’s social impact. We plan on structuring our case studies in four parts:

1. Background story of patient and the struggles that they faced because of blindness or visual impairment.

2. How patient became involved with Sankara. 3. How the patient's life has improved since receiving care from Sankara. 4. Quantitative statistics about how many people have the same condition as subject.

Mobile Application Evaluation

The Sankara application is a webpage designed to track school children’s eye records. This will likely be deployed shortly before or soon after we arrive in India. We will report on the deployment and usability of app. Since we do not know how long the deployment process for this application will take, we do not know if we will be able to assess how the app is being used. If we are able to do a field assessment, our report will include feedback from Sankara about the functions of the app, how it is being used in the field and recommendations for possible next steps. We plan on conducting the field analysis of the app using the POEMS framework and our report will contain information answering the following questions:

1. People: what kinds of people are using the application? 2. Objects: do Sankara personnel enjoy using the application? 3. Environments: when do Sankara personnel use the app? 4. Messages: are Sankara personnel interacting with each other if they need assistance with

the app? 5. Services: do Sankara personnel view the app as useful? Will it continue to be used in the

field?

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Core Issues Addressed

Growing businesses in the developing world face many challenges. While some of the issues that organizations face are common for any scaling business, others, like measuring social impact, are problems unique to social enterprises. Our research for Sankara will focus on two main areas of their business model: social impact and resources. The patient case studies will address Sankara’s social impact and provide tangible evidence that Sankara is fulfilling their social value proposition and theory of change. The evaluation of the mobile application will address the key resources Sankara needs to maximize social impact. Understanding Social Entrepreneurship outlines several benefits of measuring social impact, one of which is that effective assessment enables entrepreneurs to prove to current and potential stakeholders that the enterprise is achieving its value proposition. The qualitative case study data that we gather in the field will support the quantitative impact data that Sankara already has. By documenting different ways in which Sankara has impacted individuals, we will provide additional success stories and photos for Sankara to use in various marketing platforms. This will strengthen Sankara’s investor profile and provide more material for Sankara to use on other marketing platforms. Our research project concerning the impact of the mobile application will address the key resources component of Sankara’s business model. By reporting on how deployment of the application goes and assessing how the application functions, we will be able to provide recommendations to app developers for how the application can be adapted to fit Sankara’s needs.

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Research Questions

Research Questions Data Type From whom or what?

How Gathered? Material form?

What purpose?

How has Sankara’s eye service impacted patient lives?

Qualitative, Photographs, ethnographic field notes, recordings, interview notes

Patients, Healthcare Workers, Sankara database

Structured and semi-structured interviews, observation

Hand written notes, recordings, photos

Compile case studies for individuals that capture the social impact of Sankara.

How can photos be used effectively in case studies?

Qualitative, photos Patients and patient families, eye camps

Observation of patients home, work and general environment when possible

Photographs Take effective photos to use in patient case studies.

Which patients should be used for case studies?

Qualitative, field notes, interviews

Patients, Sankara Healthcare workers

Short, semi-structured interviews, surveys

Hand written notes, surveys, observation

Choose patients for in-depth case studies that will best capture information about the impact that Sankara has and ensure that we compile a diverse collection of cases that reflect the prevalent eye problems that Sankara treats.

What information does Sankara already have and how is it being used?

Qualitative, quantitative, notes, interviews

Sankara database, old case studies, annual reports, Sankara employees

Observation gathered through archiving the current case studies, past annual reports and speaking to Sankara employees

Notes Assess the case studies that Sankara already has in order to see what additional information may be helpful. Look at how the case studies are currently being used to enhance marketing and see if any additional information could be beneficial.

Does the current case study template support Snakara’s mission? How can it be utilized to advance the mission?

Qualitative, observational

Current Sankara template, complete case studies,, consultation with Prof. Stephen Carroll and Dr. Laura Chyu

Trial and error using current template, looking at past case studies

Notes By assessing what information needs to be included in the case studies, we will determine what additional questions can be added to the additional template.

Does the mobile application serve Sankara’s needs?

Qualitative, interview notes, photography, quantitative showing how many Sankara personnel use the application

Sankara personnel: healthcare workers, teachers, volunteers

Semi-structured interviews, observations of app being used in the field

Handwritten notes, photos

Provide assessment of deployment process and acquiring feedback from Sankara personnel and users about the applications usability and function.

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Description of Data and Data Collection

Our data collection will be divided into two sections: compiling case studies and evaluating the mobile application. Data collection will be primarily qualitative, obtained from databases at base hospitals, interviews and observations in the field at eye camps and follow up visits. Case studies: photography, archival system and framework

Compiling in-depth case studies of Sankara beneficiaries to document social impact will be one of our main focuses while in the field. Case studies will cover general patient information, socioeconomic status, family information and prognosis after treatment. The case studies will also include photographs of patients before and after surgery and in their homes and workplaces. Case studies will be limited to patients who are 4-9 or over 50, are non-paying and have congenital, bilateral or developmental cataracts treated by Sankara. Sankara has provided a template for the information they would like in the case studies. This template will serve as the basis for our interview questions.

We will use primarily qualitative data, collected by taking ethnographic field notes, photography, and conducting interviews. We plan on using semi-structured interviews to collect data from patients with the help of a translator affiliated with Sankara. Data collected will be in the form of notes, interview recordings and photography. After taking notes and photos we will transcribe the notes and upload the photos to our computers and dropbox so that they are easily accessible in the fall. In the fall, we intended to use the data collected to construct in depth case studies that Sankara can use for presentations to donors and investors, in annual reports, on websites and for other marketing purposes.

An ideal case study will showcase a patient with a compelling backstory who is eager to share his or her positive experience with Sankara. Case studies should also be representative of the main issues that Sankara addresses, such as cataract blindness. We will likely need to interview many people to find case study subjects. We plan on conducting short, semi-structured interviews in order to gain a sense of the patient’s story and then peruse additional information from patients we feel will make good case study subjects. We will gather information directly from patients and healthcare workers who may know patients well enough to guide us in the right direction. The purpose of gathering this information is to compile moving case studies for Sankara that accurately capture the social impact of eye care. By interviewing many patients and then choosing which patients to use in case studies, we will be able to ensure we obtain a diverse range of stories for Sankara to use.

Since photos of beneficiaries will be an essential part of our case studies, we will need to

be cognizant of taking usable patient photos. Sankara has requested that case studies include before and after photos of each patient as well as photos of patients in their home and workplace. After obtaining informed consent from patients, we are planning on taking pictures of patients doing everyday tasks in their home or workplace. After taking the photos, we will upload them to our computers, flash drive and dropbox so that they are accessible to us in the fall. These photos will be very important for the case studies because of the large role that the case studies play in Sankara’s investor acquisition efforts.

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Sankara has requested that we come up with an archival system to organize the case

studies that they already have. We have proposed organizing case studies into these five categories:

a. Complete case studies b. Photos of Eye Camps and Hospitals c. Photos of patients d. Economic and education information e. Quantitative impact information

Looking at the case studies that Sankara already has will help us see how information is

currently being gathered and see which categories have the most and least material. This may inform the types of patients we should focus on for our case studies to ensure that Sankara has a variety of patient profiles. This data will be qualitative and quantitative and will be gathered from the current Sankara case studies and the Sankara database.

Sankara is currently using a general template to conduct case studies. This framework is broad and addresses the main categories of information that Sankara would like the case studies to cover. As we begin to conduct interviews, we will draw on our resources at Santa Clara University to help us refine the template and write specific questions. We will look at complete case studies to determine the information we will need to gather to achieve the desired story arch. We then plan on consulting with science and technology expert Dr. Stephen Carroll and Professor Dr. Laura Chyu during our placement. If needed, we will work with them to create interview questions that will best capture Sankara’s social impact.

An additional aspect of understanding how to best construct case studies will be looking at how case studies are currently being used. We will look at annual reports, the Sankara website and any other marketing or presentation materials available to us. This will tell us what aspects of case studies are being used most and which types of photographs are most effective. We can then work on adjusting our interviews and data collection accordingly. Evaluation of Sankara mobile application

We plan on evaluating the usability and function of the mobile application. This will include how Sankara personnel (healthcare workers, teachers, and volunteers) interact with the application and what suggestions they may have to improve its usability and function. The first aspect of our application research will be determining if the applications meets Sankara’s requirements. The final features of the application include storing both demographic and student medical information, storing screening sites, authenticating users prior to access of confidential information, and search suggestions. Student demographic information will record a student’s first and last name, biological sex, birthdate, guardian name, address, class number, section number, roll number, contact number, and teacher’s name. Primary screening information will ask for who screened the student, the date of the screening, and whether the screening was classified as “normal” or “defective”. There are also fields to input the physician diagnoses, medications, and recommendations for the individuals, in addition to recording other specific eye information.

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Assuming that the application has the features that Sankara requires, our next step will be to do a field assessment of the app. This will include observing how people interact with the application and measuring individual’s willingness to use it in the field. Our assessment will rely on qualitative data obtained from users and our own observations about how users interact with the application. Obtaining user feedback will be important because the web application will have recently been deployed. If there are problems with the application we will be able to consult Santa Clara University engineering professors and students about how it can be improved.

To gather information from users, we plan on using a short, forced answer survey and

semi-structured interviews. The interviews will be kept to a maximum of 5 questions, so that we can respect the participants’ time. A translator will help us facilitate interviews and surveys when needed. This plan is based off the assumption that the application will be able to be deployed and tested by healthcare workers while we are in India.

In terms of trouble-shooting the web application, both Christine Rohacz and Christiane

Kotero, part of the iKure Team, will be visiting during the fourth week of our field placement, and they will be able to fix any minor bugs that may appear on the application. After we have received some usability feedback about the Sankara webpage, we will analyze our results and consult the expertise of Dr. Silvia Figuiera and Dr. Natalie Linnell about future improvements for the application.

The primary purpose of this data collection is to help Sankara deploy a usable and

simplified web application to document children’s eye records. After we obtain information about the web application, we will report on the deployment and usability of the app. After outlining any major changes that the app may need to meet Sankara’s expectations and requirements, we will analyze the results of our field assessment data by drawing upon common themes that arise during the interviews we conduct. We can interpret the data to make recommendations for improving the web application. This information can be presented through participant feedback and we can attach photographs or videos that show how Sankara personnel are using the application.

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Ethical Issues

Since our project focuses on showing social impact through case studies, the largest ethical issue that we will face while in field will be obtaining informed consent. Sankara’s customer segment includes both paying and non-paying patients, however, Sankara has requested patient case studies on non-paying patients only. Based on specifications dictated in Sankara’s case study framework, we will document social impact by creating profiles of children, ages 4-9, and the elderly, ages 50 or older. Although informed consent is something that we will have to address with all patients we interview or photograph, we will also need to be cognizant of obtaining parental consent when we interview children. We will consult Dr. Pooja Sangvhi and other personnel at Sankara to see what the current protocol on informed consent is and if a confidentiality agreement is in place. Respecting the anonymity and privacy of the patients we interview is a significant issue we will be concerned with. Obtaining consent may be challenging because many patients may be illiterate or apprehensive about speaking and sharing information with foreigners. Our team must be wary of the ethical issues at play regarding patient confidentiality and a respect for persons. Language barriers will pose an additional challenge when getting consent from patients. Although written consent may not always be an option, we will record or otherwise document patient consent.

We believe it will be best to approach the patients in a conservative and cautious manner so that we can gradually gain their trust. To do this, we plan to visit the outreach camps, observe social interactions between locals, and familiarize ourselves with Sankara procedures before we start collecting our data. When interviewing children, we can participate in an activity with them, such as a game of soccer, in order to build rapport and gain their trust. We plan on utilizing Sankara’s resources, such as translators and field workers, to put is in contact with patients in the community. Sankara employees who work at the camps regularly may know patients who will be willing to give us an in-depth interview. We will rely entirely on Sankara staff to recruit and screen appropriate patients to interview. We will work with Sankara staff so that they negotiate informed consent with patients, including permission to photograph. Interviewing child patients raises special ethical considerations. We will have to work very closely with Sankara staff to obtain appropriate informed consent for profiling any children. In the U.S., it would never be appropriate to interview or photograph a child about health issues without a parent present, giving active consent. The situation in India is likely to be different. We will work closely with Sankara staff to ensure that they obtain informed consent. If we take pictures of children, we will turn them over to Sankara to use them, since they would not likely be used on the Miller Center’s webpage.

During our data collection process, we will ask the individual if he or she would like their name to be included in our case study. We will also inform all participants that their names and other information may be used by Sankara and published on the Internet as part of our final report. Since there will most likely be a language barrier when speaking to participants, we will ensure that our translator is aware that this needs to be conveyed very clearly to patients. It is especially important for the participants to know of the risks involved with the release of information on the Internet.

Since our final deliverables will include photography, audio recordings, direct quotes from patients and use of Sankara’s hospital statistics, our team will proactively ensure that

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informed consent is gained before engaging in any of these activities. We will also ensure that consent is well documented as either a written form or recording.

In order to respect the rights of our participants, we will not disclose any information that would allow participants to be identified. If we decide to report on a participant that chose to remain anonymous, we will use a pseudonym when writing the case study. Lastly, we will consult Sankara about all decisions made about patient privacy and reference the standards that are already in place at Sankara during our fellowship process. Vocational Discernment Maggie Dennis

Thus far, I have learned an enormous amount though participating in this fellowship. At Santa Clara, and Silicon Valley generally, I feel like a lot of emphasis is put on business and entrepreneurship as a way to personal gain. I love the idea that business can be used to empower communities and make a sustainable difference. As an economics major, it has been really exciting for me to see how the business principles and tools I have been learning over the past three years can be applied in meaningful ways. Similarly, I am very eager to get into the field and see the concepts we have studied in class in practice. Through working with Sankara this summer, I hope to gain a better understanding of what I like doing and start to answer the question of what my next steps will be after Santa Clara. I have enjoyed the preparation for this project and have found the topic of social entrepreneurship really interesting, but will I like actively conducting research and being in the field? Is this the type of work I would want to continue after college? This experience has already expanded the career possibilities I can see for myself. I am hoping that this summer will help me start to narrow down the list of things I may want to pursue so that I can begin to answer the questions of where I will go next and what my career path may look like. Jana Lee

Within this stage of my college career, I am still uncertain about which path I should take within the vast public health field. Santa Clara University has given me many opportunities to explore different areas of study, such as healthcare administration, research, global health, and health communication that are all related to public health, but I have yet to see how these diverse areas fit together. Since the Global Social Benefit Fellowship will be my first experience working with a health-related social enterprise, I hope that after my experience I will be able to further narrow my interests. In this way, I expect that there will be numerous cultural challenges that I will face during the fellowship. There are two main questions about my personal vocation I wish to answer during my fellowship experience: what aspects of the fellowship motivate me to work with Sankara every day? In addition, how adaptable can I be in an environment and culture I am not familiar with? While I believe that I will be productive during my time in India, I would like to pinpoint what area of social impact action research makes me happy. Although I have little exposure to the field of business and social entrepreneurship, my passion for helping marginalized communities within a health organization like Sankara would help me reach my personal vocational goal of addressing the social disparities still present in the world.

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India’s National and Country Context

India is a Southeast Asian country located between Burma and Pakistan. The population is estimated to be 1.22 billion people, making it the second-most populous country in the world. India is known for its rich culture, religion, and language. It is the world’s largest secular democracy and has a diverse range of religious communities including Hindus, Muslims, Christians, Sikhs, Buddhists, and Jains among others.

India gained independence from the United Kingdom relatively recently in 1947. British

influence is still present in India, but the country has many other cultural traditions worth mentioning. Typical food, clothing, dance and language vary between different regions. For example, southern Indian food may include a whole host of spices like coconut, tamarind, curry leaves and many other ingredients that are not found in northern Indian food. Similarly, language is a significant aspect of Indian culture to consider. While Hindi is by far the most common Indian dialect spoken, there are many regional languages such as Bengali, Telugu, Tamil, Urdu, Kannada, and Punjabi, which are spoken in different areas. Although not an official language, English is common and serves as a primary tool when dealing with national, political, and commercial affairs. Language is a barrier that our team is likely to face while interviewing patients. In order to overcome this challenge, we can gain their trust by showing them photographs of our homes, families, and school.

While India may be significantly developed in some areas, other areas still have many societal disparities that hinder the overall health of the population. India has an extremely high population density. There are 421 people per square mile in India, compared to the U.S., which has 35 people per square mile. High population density combined with a lack of proper sanitation and basic infrastructure has led to many water and foodborne infectious disease outbreaks, especially in rural communities. Despite the health risks that many people in India face, the government spends only 4% of GDP on health expenditures. These conditions make India an optimal location to identify and analyze how healthcare inaccessibility affects the general health of the country. In addition, since two-thirds of the population lives in rural areas, the social impact potential for individuals at a community level may be enormous. Health organizations like Sankara use high population density to their advantage and rely on word-of-mouth strategies to raise awareness about health and eye care services provided.

One cultural difficulty our team may encounter is India’s caste system. This may present

a challenge because of the large social stratification the system represents. While the caste system was particularly prominent in the past, the Indian government had officially outlawed it. Despite this, some aspects of the system may still be prevalent in communities today. Gender roles are also an important factor to take into consideration when looking at how communities function. Gender inequality can be seen in many aspects of Indian culture. For example, statistics show that 81% of males are literate compared to 61% of females. Keeping the cultural context in mind, our team will proactively conduct our action research while simultaneously respecting the cultural norms around us.

Understanding India’s unique cultural and historic background is crucial for understanding the belief systems of our field placement. Although there may be many different social and cultural norms, our team will meet these challenges with open attitudes and genuine

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respect. We will take advantage of Sankara’s understanding of the social needs among India’s population so that we can better integrate into the culture and help Sankara scale their impact. No matter what challenges we may encounter in the future, our team will be certain make decisions that align with Sankara’s mission, our research goals, and our vocational discernments.

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Action Research Work Plan Week 1: June 15 – June 18

Monday, June 15 Depart from San Francisco International Airport (SFO): 16:45

Tuesday, June 16 Arrive in Dubai International Airport (DXB): 19:25 Transfer: Depart from DXB: 21:30

Wednesday, June 17 Arrive in Bengaluru International Airport (BLR): 3:00 Check into hotel Hotel Logistics: We will be staying at Goldfinch Retreat, Chikkajala. The address is New International Airport Road, Chikkajala, Karnataka, 562157 India (Telephone Number: 91 (80) 22011500). We will have the reservation booked for June 16-18 (Reference number: 7115596731957).

Thursday, June 18 Depart from BLR: 9:55 Arrive in Coimbatore International Airport (CJB): 10:55

Pick up by Sankara hospital team member (pending, need to review with Dr. Sanghvi)

Week 1 continued: June 18 – June 21 Upon our arrival in Sankara Eye Hospital in Coimbatore, we will meet Dr. Pooja Sanghvi and other Sankara personnel. Since we will be jet-lagged and adjusting to the weather and time difference, the remainder of this week will include an orientation of Sankara’s hospital, where we will be touring the headquarters and meeting other medical personnel. We would like to familiarize ourselves with different departments within Sankara, including the Communication and Marketing, Information Technology, and Field Outreach departments. Week 2: June 22 – June 28 During this week, we hope to prepare for our first field visit at Sankara’s eye camps. We will ask Dr. Sanghvi what transportation we can take to these eye camps, but we believe that Sankara has some transportation organized already. During our first field visit, we will take general notes on the community, environment, and social interactions that may occur. This would be a good opportunity to take general photographs of the eye camps and what the rural communities look like. We will also have a translator during the field visit, and he or she can help introduce us to some of Sankara’s customers. Week 3: June 29 – July 5 We will continue to conduct interviews with Sankara customers who are willing to interview us. We want to establish a sense of trust between our team and the customers, and we intend on doing this by getting to know our customers through informal conversations with a translator beforehand. The equipment we bring to the field will be identical each time we visit the eye camps. We will bring a DSLR camera, our iPhones, a notebook to take notes in, and appropriate paperwork

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needed to acquire informed consent. In addition, we will need a translator for this part of our project as well, and Dr. Sanghvi is informed of our needs. Dr. Laura Chyu will also be around in the summer, and she is available to Skype in order to check-in with us about our work. We will schedule a Skype call sometime during this week. Similarly, Dr. Stephen Carroll will be around during this time, and we will consult both mentors sometime during this week. Week 4: July 6 – July 12 During this week, we excitedly anticipate Team iKure’s visit to Sankara Eye Hospital in Coimbatore. Team iKure can arrive in Coimbatore International Airport, take a taxi from the airport to Sankara (distance = 8.7 km, approximately 21 minutes), and meet us at the hospital. While this is still tentative, we will confirm this date and book appropriate plane tickets when we arrive in India. With Team iKure, we may be able to begin interviewing Sankara personnel about the usability of the web application. This may give both teams some insight on how the application is used, and Team iKure will be able to grasp some of the technicalities of the application that Sankara may want for a future pilot. We may also want to take Team iKure to visit the eye camps and schools, where the application will most likely be used. While Dr. Natalie Linnell will not be available during the first two weeks of July, we will be able to collect some feedback on the webpage application and contact her, if needed. Week 5: July 13 – July 19 We will continue to conduct interviews with Sankara customers who are willing to interview us. We want to establish a sense of trust between our team and the customers, and we intend on doing this by getting to know our customers through informal conversations with a translator beforehand. The equipment we bring to the field will be identical each time we visit the eye camps. We will bring a DSLR camera, our iPhones, a notebook to take notes in, and appropriate paperwork needed to acquire informed consent. In addition, we will need a translator for this part of our project as well, and Dr. Sanghvi is informed of our needs. Week 6: July 20 – July 26 During this week, we hope to visit Team iKure in Kolkata, West Bengal and help assess the social impact of their mobile application. iKure’s mobile application will have only been launched for one week (and the deployment date may change), so our team will observe interactions with iKure’s staff, using the same framework we developed to assess the social impact of Sankara’s web application. In addition, granted it is possible, we may want to join Team iKure on a field assessment.

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Appropriate technologies needed to document social impact include: DSLR camera, iPhone for possible videography, our personal laptops for processing and backing up data, and our Moleskine notebooks for field research notes. Week 7: July 27 – August 2 At the beginning of this week, we will continue to conduct interviews with Sankara customers who are willing to interview us. We want to establish a sense of trust between our team and the customers, and we intend on doing this by getting to know our customers through informal conversations with a translator beforehand. The equipment we bring to the field will be identical each time we visit the eye camps. We will bring a DSLR camera, our iPhones, a notebook to take notes in, and appropriate paperwork needed to acquire informed consent. In addition, we will need a translator for this part of our project as well, and Dr. Sanghvi is informed of our needs. At the end of this week, our team may want to organize an independent travel with Team iKure for a couple of days, where we can explore some of India’s famous landmarks. This is still pending, and we need to confirm with Dr. Sanghvi. Week 8: August 3 – August 7 During the final days of our fellowship, we want to compile all the interviews we have done with Sankara customers and begin our data analysis. As part of our overall deliverable, we will arrange for a presentation to Sankara’s personnel, including Dr. Sanghvi, so that we can not only present what we have been working on in the past few weeks, but also ask for recommendations on how to improve our rough case studies. We will also draft our research plan for the action research paper. We may need some quantitative statistics, which would be ideally provided from Sankara’s database, and we will ensure that we have that data before we depart from India. Week 8 continued: August 8 – August 9

Saturday, August 8 Depart from BLR: 20:45 Arrive in DXB: 23:05 Travel from DXB to hotel (pending, may use a taxi from the airport) Check into hotel Hotel arrangements in Dubai (pending, need to check-in with Spencer)

Sunday, August 9 Travel from Hotel to DXB (pending, may use a taxi from hotel)

Depart from DXB: 8:25 Arrive in SFO: 13:15 Picked up from SFO by parents / friends

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Health and Safety Plan Health and Medical Vaccinations & Infectious Diseases Health risk in India includes infectious diseases. The Centers for Disease Control and Prevention (CDC) recommends that individuals who travel be updated with routine vaccinations, such as Hepatitis A, Hepatitis B, Diphtheria, Tetanus, and Polio (DTaP), Polio, Flu, Measles, Mumps, and Rubella (MMR), Chickenpox, and Human papillomavirus (HPV), to name a few. While these vaccinations may have primarily been obtained at a young age, some vaccinations, like the flu vaccine or Tetanus, are routinely recommended for adults. For travellers going to India, Hepatitis A, Typhoid, Hepatitis B, and Japanese Encephalitis are also recommended for certain regions. Malaria medication is strongly recommended, and we will begin medication a couple weeks before departing from the U.S. In addition, the risk of Tuberculosis (TB) is higher in India in comparison to the U.S. To help prevent TB, we can avoid spending time in enclosed spaces with individuals who may be infected. If we are in an area where people infected, we can use facemasks. Lastly, Schistosomiasis is a disease caused by parasitic worms that live in certain types of freshwater snails. There is low risk in India, but they may be present in swimming pool, lakes or rivers. We will take precautions to avoid contact with the parasites.

There have been few reports about infectious diseases in Bangalore. The last “High Risk” report occurred in January and February of this year, when there was a large surge in confirmed cases of H1N1 Influenza Virus. There have been no other high-risk reports in Bangalore since then. Water and Dietary Concerns

Drinking water should be from a bottled water or tap water that has been boiled, filtered, or chemically disinfected. Since we will not always be sure if tap water has been boiled or filtered, bottled water will be the safest option and may be easier to obtain. Similarly, we must be wary of un-bottled beverages and especially, drinks containing ice at all costs. Hot coffee, tea, and milk that have been pasteurized should also be fine.

Food safety is can also be a concern when living in India. It is not uncommon to consume meat from different types of game. For example, bush meat is meat made from monkeys, bats, or other wild game. It should not be consumed. Additional steps that our team can take to make sure that we both remain healthy are to avoid street food, drink bottled or purified water, bring medication to help with food poisoning, and avoid foods that have been left at room temperature for extended periods of time. Other Preventative Measures

Preventative measures against bug bites are covering exposed skin by wearing lightly colored long-sleeved shirts, pants, and hats and staying and sleeping in air-conditioned rooms. We will bring appropriate clothing and use insect repellent to reduce the likelihood of

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contracting an infectious disease. For protection against ticks and mosquitoes, we will use repellents that contain 20% or more DEET for protection. While DEET is a recommended insect repellent, other alternatives we can use are Picaridin and oil of lemon eucalyptus (OLE). Safety and Security

The overall risk rating for India is “Low” across all categories: Unrest, Terrorism, Crime, Natural Hazards, Police Conduct, and Conflict. The most recent terrorism attack in Bangalore was a bomb attack in April 2013. Terrorism is currently a low to moderate threat. Crime

While safety is important across all categories, we must be especially wary for petty crime, such as pickpocketing and purse snatching, which are commonly experienced by foreigners. Some tourists have also reported being robbed after consuming drugged food in train stations and other public settings. Furthermore, crimes against tourists have become more and more common. Sexual assault is the fastest growing crime in India and recent incidents have involved female travelers who may be travelling alone or travelling at night. Sexual assault is a major concern for our team and will require extra observation within our surroundings. Natural Hazards As our placement in Bangalore will be during the southwestern monsoon season (usually from June to August), Bangalore is prone to flooding during this rainy season. The seismic activity zone is rated a “2,” which is considered a Stable Zone. Unrest, Conflict, & Terrorism

As a major city center, Bangalore is a natural place for some civil unrest. Usually this consists of non-violent demonstrations and protests, which may block roads and increase traffic. Political protests commonly occur before elections and the government usually imposes a curfew in response to any demonstrations that become violent. Conflict is usually present in cities that border other countries like Bangladesh, China, and Pakistan. Because Bangalore is not close to any foreign borders, it is removed from the risk of northern Indo-Pakistani violence. However, some conflict may occur in rural villages between different political and religious groups. Police Conduct

Bangalore has a large police force that is well equipped to respond to any major incident. However, response time is generally slow and corruption is a problem. The police force is highly susceptible to bribery. Although most police officers speak some English, assistance to travelers can be limited due to lack of resources and training. The emergency police number is 100.

To protect ourselves individually and in a group, we can be aware of our surroundings,

not leave any of our possessions unattended and avoid traveling alone or after sunset when possible.

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Courses of Action

If one of our P-Cards were stolen, our first step would be to contact Spencer as soon as possible. If one of us received a minor injury we would assess the situation to see if we could handle it ourselves and then seek medical attention if needed and notify Spencer. If we were involved in a major accident we would first call the police and then contact Spencer as soon as possible. If we lost our passports we would report theft or loss to the police in the location where we lost it and then contact the nearest US embassy or consulate so that they could issue us a FIR to leave the country. We should have three copies of our passports and visas. We should keep one copy on our person and the others should be stored in multiple different places, for example one the lining of our suitcases, one in our wallets and one in an inside pocket of our backpacks. The overall risk in Bangalore is low. The biggest thing that we need to be aware of is petty crime and theft. Risk can best be mitigated by being aware of surroundings and possessions at all times, especially while traveling. Transportation

There are several risks associated with ground transportation available. Methods of transportation include Airports, Public Transport, Taxis and Public Transportation, Self Drive, and Walking. Airports It would be helpful to know that Bengaluru International Airport (BLR) is located 40 kilometers (25 miles) northeast of the city center. There is only one terminal that handles both domestic and international flights. Taxis & Public Transport

Upon arrival from the airport, we may be using taxis (or be picked up) to travel to our host location. If taxis are necessary, they should be prepaid from an airport or hotel. There are three official taxi companies that operate from the airport: KSTDC, Meru, and MegaCabs. These companies may be more trustworthy than taxis that are hailed off the street. Rickshaws are more common than taxis, however they are expensive for foreigners and can be unsafe. The Namma (Bangalore Metro) is a rail service that runs throughout Bangalore. There is also a bus system, but routes are inconvenient and the system is hard to use, and we are not familiar with the area. Self Drive Roughly speaking driving in international countries is incredibly dangerous. Legally, we would need a valid Indian driver’s license or an international driver’s license. In addition, because India has the most traffic-related deaths, we will avoid this option at all costs.

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Walking

When walking, it is safest to stay on the sidewalks and used marked crosswalks. People on foot do not always have the right away and roads are very chaotic, so staying aware is important. It is best to avoid traveling alone and past sunset when possible. Foreign women who are alone are at higher risk for harassment, theft and assault. If traveling alone is necessary, it should be in the daylight.

We will make a plan of where to meet when we arrive in each new destination. For

example, if we are visiting an eye camp and are separated, we will plan to meet at the entrance. Hotel lobbies and large restaurants are also good options. Local Tips

There will be three days of significance during our time India: July 17- Jamat Ul Vida, July 18- Rath Yatra, and July 19th- Eid-ul Fitr. All involve large religious gatherings. There should not be a lot of additional risk posed, however there are likely to be large gatherings so we should just make sure that we stay aware. Since Ramadan involves fasting from dawn to dusk, we will need to be mindful about when and where we eat or drink during that time so that we do not offend anyone. Languages Spoken

The official languages of India include Hindi and English, which is used for official purposes of the Union and for use in Parliament. In Bangalore, we will come across other languages like Kannad (commonly spoken in the state of Karnataka), Telugu, and Hindi. Electricity Usage

We do expect to have reliable electricity at our placement, along with relatively reliable Wi-Fi to access the Internet. Electricity is usually at 110 volts in the US and 220 volts in India. Below is an image of the adapter we would need to use with our electronics. We are planning on taking our computers, cameras, phones, and corresponding chargers with these items.

Adaptor for India:

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Risk Mitigation Health & Medical: 1. Making sure water comes from a reliable source. Is the water safe? Where did the water come from? Being aware of the drinking items we consume and questioning the source of the water will help us avoid needless stomach problems. 2. Don’t eat street food! Although tempting, street food may be unreliable for safe consumption. We have received multiple accounts of friends who have visited Bangalore and have experienced stomach problems. We will avoid street food. 3. Taking steps to prevent disease. Being healthy in India is our primary goal. By taking extra steps to consider the safety of items we consume and environments we will be researching in, it is imperative for us to monitor our own health during our stay. For instance, setting up weekly or daily reminders to take malaria pills will help us stay on track with our medications. This can also be done for other medications as well. Safety & Security: 1. Being aware of belongings when in public areas. Theft is a common petty crime that occurs in India. Sometimes, thieves act in groups by trying to converse with foreigners. While this is happening, another thief will try to open bags or take items that can be easily obtained. Being wary of our surroundings and not engaging with locals unless it is necessary can be helpful. 2. Don’t travel alone! Female foreigners are at higher risk for harassment when traveling alone. We will make sure that we do not travel alone unless it is truly necessary. If we are put in a situation where we would have to travel alone, we will travel in the daylight. 3. Avoiding travel at night. We will avoid travelling at night because there have been increases in gang violence and harassment among women who travel alone. We will ask our host enterprise contact for recommendations on what is considered “late” in Bangalore, and we will set curfews to avoid dangerous situations. Transportation: 1. Using caution when walking. Because pedestrians will not have the right of way in Bangalore, it is especially important for us to watch for cars, rickshaws, or motorcyclists when crossing the streets. We will also stick to designated sidewalks and not take unfamiliar roads when walking to our destination.

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2. Don’t hail taxis off the street. As mentioned before, taxis off the street could be scams, so we will not use this method of transportation unless it is associated with an airport or hotel. 3. Having a plan for where to meet if separated. Since Bangalore is a bustling city and we will most likely be travelling as a team, we will establish easily identifiable buildings or landmarks and relocate to these places if we are separated. It is important that we stay in public places, where security is higher, such as hotels or restaurants. We will also have our host enterprise address, phone number, and other information memorized before we leave.

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Finger, R., Kupitz, D., Holz, F., Fenwick, E., Balasubramaniam, B., Ramini, R. & Gilbert, C. (2012). Impact of successful cataract surgery on quality of life, household income and social status of south India. PLOS one, 7(8), 1-8. Frick, K., Riva-Clement, L. & Shankar, M. (2009). Screening for refractive error and fitting with spectacles in rural and urban India: cost effectiveness. Ophthalmic Epidemiology, 16(6), 378-379. Gupta, S. K., Viswanath, K., Thulasiraj, R. D., Murthy, G. V. S., Lamping, D. L., Smith, S. C., ... & Fletcher, A. E. (2005). The development of the Indian vision function questionnaire: field testing and psychometric evaluation. British Journal of Ophthalmology, 89(5), 621-627. Hashemi, H., Mohammadi, S. F., Z-Mehrjardi, H., Majdi, M., Ashrafi, E., Mehravaran, S., ... & KhabazKhoob, M. (2012). The Role of Demographic Characteristics in the Outcomes of Cataract Surgery and Gender Roles in the Uptake of Postoperative Eye Care: A Hospital-based Study. Ophthalmic Epidemiology, 19(4), 242-248. Khan, J., Hassan, T. & Shamshad, T. (2014). Incidence of poverty and level of socio-economic deprivation in India. The Journal of Developing Areas, 48(2), 21-38. Kumar, V. (2012). 101 design methods: A Structured Approach for Driving Innovation in Your Organization. John Wiley & Sons. Kumar, V., & Whitney, P. (2003). Faster, cheaper, deeper user research. Design Management Journal (Former Series), 14(2), 50-57. Lewallen, S., Lansingh, V. & Thulasiraj, R. (2014). Vision 2020: moving beyond blindness. International Health, 6(3), 158-159. Muralikrishnan, R., Venkatesh, R., Prajna, N. & Frick, K. (2004). Economic cost of cataract surgery procedures in established eye care centers in Southern India. Ophthalmic Epidemiology, 11(5), 369-380. Nangia, V., Jonas, J., Gupta, R., Anshu, A. & Sinha, A. (2011). Prevalence of cataract surgery and postoperative visual outcome in rural central India. Journal of Cataract & Refractive Surgery. 37(11), 1932-1937. Nirmalan, P., Robin, A., Katz, J., Tielsch, J., Thulasiraj, R., Krishnadas, R. & Ramakrishnan, R. (2004). Risk Factors for age related cataract in a rural population of southern India: the Aravind comprehensive eye study. British Journal of Ophthalmology, 88(8), 989-994. Nirmalan, P. K., Katz, J., Robin, A. L., Krishnadas, R., Ramakrishnan, R., Thulasiraj, R. D., & Tielsch, J. (2004). Utilisation of eye care services in rural south India: the Aravind Comprehensive Eye Survey. British Journal of Ophthalmology, 88(10), 1237-1241. Srivastava, S. C., & Shainesh, G. (2015). Bridging the Service Divide Through Digitally Enabled Service Innovations: Evidence from Indian Healthcare Service Providers. ISSUES.

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