Background Many mHealth technologies do not meet the needs of patients with complex chronic disease and disabilities (CCDDs) who are among the highest users of health systems worldwide. Furthermore, many of the development methodologies used in the creation of mHealth and eHealth technologies lack the ability to embrace users with CCDD in the specification process. This paper describes how we adopted and modified development techniques to create the electronic Patient-Reported Outcomes (ePRO) tool, a patient-centered mHealth solution to help improve primary health care for patients experiencing CCDD. Objective This paper describes the design and development approach, specifically the process of incorporating qualitative research methods into user-centered design approaches to create the ePRO tool. Key lessons learned are offered as a guide for other eHealth and mHealth research and technology developers working with complex patient populations and their primary health care providers. Methods Guided by user-centered design principles, interpretive descriptive qualitative research methods were adopted to capture user experiences through interviews and working groups. Consistent with interpretive descriptive methods, an iterative analysis technique was used to generate findings, which were then organized in relation to the tool design and function to help systematically inform modifications to the tool. User feedback captured and analyzed through this method was used to challenge the design and inform the iterative development of the tool. Results Interviews with primary health care providers (n=7) and content experts (n=6), and four focus groups with patients and carers (n=14) along with a PICK analysis—Possible, Implementable, (to be) Challenged, (to be) Killed—guided development of the first prototype. The initial prototype was presented in three design working groups with patients/carers (n=5), providers (n=6), and experts (n=5). Working group findings were broken down into categories of what works and what does not work to inform modifications to the prototype. This latter phase led to a major shift in the purpose and design of the prototype, validating the importance of using iterative codesign processes. Conclusions Interpretive descriptive methods allow for an understanding of user experiences of patients with CCDD, their carers, and primary care providers. Qualitative methods help to capture and interpret user needs, and identify contextual barriers and enablers to tool adoption, informing a redesign to better suit the needs of this diverse user group. This study illustrates the value of adopting interpretive descriptive methods into user-centered mHealth tool design and can also serve to inform the design of other eHealth technologies. Our approach is particularly useful in requirements determination when developing for a complex user group and their health care providers. ...

The study assessed the impact of an EPI (Expanded Programme on Immunization) intervention package, implemented within the existing service-delivery system, to improve the child immunization coverage in urban slums of Dhaka, Bangladesh. This intervention trial used a pre- and post-test design. An intervention package was tested from September 2006 to August 2007 in two urban slums. The intervention package included: (a) an extended EPI service schedule; (b) training for service providers on valid doses and management of side-effects; (c) a screening tool to identify immunization needs among clinic attendants; and (d) an EPI support group for social mobilization. Data were obtained from random sample surveys, service statistics and qualitative interviews. Analysis of quantitative data was based on a 'before and after' assessment of selected immunization-coverage indicators. Qualitative data were analysed using content analysis. Ninety-nine per cent of the children were fully immunized after implementation of the interventions compared with only 43% before implementation. Antigen-wise coverage after implementation was also significantly higher compared with before implementation. Only 1% drop-out was observed after implementation of the interventions while it was 33% before implementation. At baseline, a significantly higher proportion of children of non-working mothers (75%) were fully immunized compared with children of working mothers (14%). Although the proportion of fully immunized children of both non-working and working mothers was significantly higher at endline, fully immunized children of working mothers dramatically improved at endline (99%) compared with baseline (14%). The findings suggest the effectiveness of a 'package of interventions' in improving child immunization coverage in urban slums. However, further research is needed to fully assess the effectiveness of the package, to assess the individual components in order to identify those that make the biggest contribution to coverage, and to assess the sustainability of this package within the existing service delivery system, particularly on a wider scale.

Mucosal-associated invariant T (MAIT) cells are unconventional T lymphocytes with a semi-conserved TCR-alpha, activated by the presentation of vitamin B metabolites by the MHC-I related protein, MR1, and with diverse innate and adaptive effector functions. The role of MAIT cells in acute intestinal infections, especially at the mucosal level, is not well known. Here, we analyzed the presence and phenotype of MAIT cells in duodenal biopsies and paired peripheral blood samples, in patients during and after culture-confirmed Vibrio cholerae O1 infection. Immunohistochemical staining of duodenal biopsies from cholera patients identified MAIT cells in the lamina propria, but not in the lining of villous and crypt epithelia. We observed significantly higher frequencies of duodenal MAIT cells at the acute stage (day 2) of V. cholerae infection as compared to late convalescence (day 30, p = 0.0049). By flow cytometry, we showed that duodenal MAIT cells are more activated than peripheral MAIT cells (p < 0.01 across time points), although there were no significant differences between duodenal MAITs at day 2 and day 30. We found fecal markers of intestinal permeability and inflammation to be correlated with the loss of duodenal (but not peripheral) MAIT cells, and single-cell sequencing revealed differing T cell receptor usage between the duodenal and peripheral blood MAIT cells. In summary, we show that MAIT cells are present and highly activated in the lamina propria of the duodenum during V. cholerae infection. Future work into the trafficking and tissue-resident function of MAIT cells is warranted.

21Background: Malnourished children are more prone to infectious diseases including severe 22 diarrhea compared to non-malnourished children. Understanding of the differences in the 23 presentation of severe diarrhea such as cholera in children with varying nutritional status may 24 help in the early identification and management these children. However, data are scarce on 25 differences in the presentation in such children. Thus, we aimed to identify the clinical 26 differentials among children with cholera with or without malnutrition. 27 Methods: Data were extracted from diarrheal disease surveillance system (DDSS) of the Dhaka 28 Hospital of icddr,b for the period, January 2008 to December 2017. Among under-five children, 29 cholera positive (culture confirmed) and malnourished children (weight-for-age, weight-for-30length or height-for-age Z score (WAZ, WHZ or HAZ) ˂-2) were considered as the cases 31 (n=305) and children with cholera but non-malnourished (WAZ, HAZ, and WHZ ≥-2.00 to 32 ≤+2.00) were the controls (n=276). 33 Results: A total of 14,403 under-five children were enrolled in the surveillance system during 34 the study period. After adjusting for potential covariates such as maternal illiteracy and slum 35 dwelling, it was revealed that under-five malnourished children with cholera significantly more 36 often presented to the hospital during evening hours (6 pm to 12 mid-night) (OR=1.64, 95% 37 CI=1.16-2.31, P<0.05), had fathers who were illiterate (OR=1.70, 95% CI=1.11-2.62, P<0.05), 38 presented with history of cough within last 7 days (OR=1.64, 95% CI=1.10-2.43, P<0.05), 39 dehydrating diarrhea (OR=1.70, 95% CI=1.15-2.53, P<0.05), and had longer hospitalization 40 (OR=1.50, 95% CI=1.05-2.14, P<0.05).3 41 Conclusions: The study results underscore the importance of understanding of the basic 42 differences in the presentation of severe cholera in malnourished children for prompt 43 identification and the subsequent management of these children. These observations may help 44 policy makers in formulating better case management strategy. 45 Author Summary: 48 Malnourished children are more vulnerable to infectious diseases including cholera in 49 comparison to the non-malnourished children. They often have suboptimal immune function, 50 though there is no precise information on whether there is any difference in associated factor(s) 51 or clinical course of cholera in under-five children with varying nutritional status. Therefore, this 52 study was conducted to elucidate these insights by using the surveillance data of the Dhaka 53 hospital of icddr,b. Among all the under-five children with cholera, 305 malnourished (WAZ or 54 WLZ or HAZ ˂-2) children constituted as the cases (malnourished), and another 276 non-55 malnourished (WAZ, HAZ, and WHZ ≥-2.00 to ≤+2.00) cholera children formed the comparison 56 group. 57In this study we revealed that care seeking at evening time was more common in the 58 malnourished children with cholera compared to those without malnutrition. Dehydrating 59 diarrhea was...

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