Importance of Mobile Medical Clinics in Rural Healthcare: A Systematic Review

The study evaluates the benefits and efficacy of mobile medical clinics (MMC) in rural healthcare. It aims to identify barriers faced during the process, evaluate health outcomes, and understand the significance of MMC in reducing mortality rate and disease burden. The study used a systematic review approach by following the PRISMA guideline. The results showed that MMCs were successful in improving disease screening process and identifying individuals at risk of chronic disease at an early stage. The study highlights the importance of MMCs in reducing health disparities in rural areas.

Running head: MEDICAL MOBILE CLINIC
Medical Mobile Clinic
Name of the student
University name
Author’s note

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Table of Contents
Introduction and Background..........................................................................................................2
Research questions...........................................................................................................................5
Aim and objective............................................................................................................................5
Methodology:...................................................................................................................................5
Results:..........................................................................................................................................11
Discussion:.....................................................................................................................................21
Conclusion:....................................................................................................................................27
References......................................................................................................................................27

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Abstract
The current study highlights the benefits along with the efficacy of the mobile medical
clinic (MMC) in a setting of rural healthcare. The importance of this MMC can be seen in the
context of the rural population who lack access to the health care services.
This study aims to evaluate the ability of the MMC in improving the health care in the
rural setting with the aim to identify the barriers faced during the process, evaluate the outcomes
of health and finally to understand the significance of the MMC in terms of reduction of
mortality rate and disease burden. The study used a systematic review approach by following the
PRISMA guideline that provides an evidence-based framework for reporting systematic reviews.
The results obtained from the study showed that distance still remained an issue in the
path of effectiveness of MMC, however the factors like reduction of burden of disease, evaluate
the acceptability of services were successfully met. The implications indicate that the utility of
mobile medical clinics was successful in improving disease screening process and identifying
individual at risk of chronic disease at an early stage.
Introduction and Background
The current study focuses upon the importance and the benefits of mobile medical clinic
(MMC) in rural healthcare setup. The concept of mobile medical clinic emerged from the aspect
of providing community care services closer to home. It has been found that the people living in

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the rural areas cannot avail adequate healthcare services as the healthcare services are located at
distance from them (Abbasi et al.2016). Therefore, the government needs to focus upon the
implementation of adequate community care services which are closer to the residential places of
the rural population. The goal is to provide the healthcare services at cost effective prices.
The assignment discusses the importance of mobile medical clinics in reducing health
disparities in the rural areas. As mentioned by Chibet al. (2015), the location of the basic
government facilities far away from the rural areas makes them inaccessible to the rural
population. As identified by the National Commission on Prevention Priorities, the minority
groups with low incomes have insufficient access to top 25 cost effective preventive
interventions (Gillispie et al.2016). The health care services particularly remain inaccessible to
the ethnic minorities, elderly, females and geographically unreachable (Lien et al.2014). There
are various factors which contribute to the accessibility to healthcare services which are- waiting
times, complexities of navigating the system, low health literacy , unaffordable service, lack of
insurance, complexities in getting appointments (Schwitters et al.2015). As suggested by
Schwitterset al.(2015), insufficient access to healthcare services is shared loss of individual and
society as it leads to increased disease burden.
The current study focuses upon the importance of mobile medical clinic in rural
healthcare setting. It has been seen that the people living in the poor and the downtrodden areas
are often devoid of the basic healthcare services. It has been seen that most of the times distance
becomes a problem, which prevents the people living in rural places from availing the healthcare
services. Additionally, the lack of adequate health literacy along with cultural paradoxes is some
of the other factors, which prevents an individual from receiving the basic healthcare services. It
has been found that in developing nations like India much of the women living in the poor or

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rural areas do not want to visit a healthcare professional or get a thorough check up done owing
to privacy concerns. Additionally, the lack of sufficient health awareness also hinders an
individual for using the required health services.
The importance of the mobile medical clinic could be discussed with respect to the Indian
health scenario. The slum population of Indian cities and towns consists of 50,000 people and
above and amounts to 42.6 million. Majority of the diseases are affecting the population emerge
due dirty living habitats, unsafe drinking water, overcrowding. Some of these often lead to the
development of communicable diseases which are transferred through vectors. The effects of
the poor living habits could be reflected through certain alarming figures such as 33% stunting
rate in children, underweight children and anaemia (Silva et al.2015). More than half of the
women in the reproductive age group were found to be anaemic.
A study conducted in the slum areas pointed towards the presence of certain health habits
which contributed towards the poor health within the population. Some of these were found in
the form of propensity towards alcohol intake, smoking, obesity, lack of fibre intake in diet, etc.
A number of reasons have been discovered which contribute significantly towards inequitable
health and support care distribution in the rural areas. Some of these are- high costs associated
with healthcare, discrimination and unfriendly environmental at government hospitals, lack of
assistance to proper healthcare facilities. As mentioned by Whiteet al.(2015), the lack of
employment makes it difficult to pay for the healthcare services. Additionally, the discriminatory
behaviour and displayed by the health and support care staffs at the government based hospitals
further deteriorates the quality of the healthcare services. It has been found that the
communication gaps between the healthcare staffs and the patients often build an environment of

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mistrust. Additionally, a negative image or stigma associated with the care quality of the
government hospitals further prevents people from utilizing the resources.
One interim which has been suggested by the federal level government for
coping up with the health inequalities in the slum areas are the provision of mobile medical
clinics. These were aimed at providing primary healthcare services to the undeserved people. In
Delhi, mobile healthcare services were launched in the year 1989 with 20 mobile dispensaries.
The numbers have presently arisen to 45 dispensaries where some of these are run in
collaboration with the non-governmental organizations. The mobile vehicle vans are available on
a hire basis where they start from the zone offices and reach to the individual slums. For each
particular day they cover almost 6-7 slums. The services provided by them are in the form of
free medicines along with free health checkups. The mobile healthcare serviced also serves as
educational means where they educate the population on the importance of vaccinations and the
timing for administering them. As mentioned by Naharet al.(2017), 23% of the children living in
the rural slums cannot avail the healthcare service due to distance and lack of literacy. Therefore,
the free medical visits along with free provision of vaccination can reduce the chances of
occurrence of disease along with reducing the mortality rates.
The purpose of the research is- to review the importance of mobile medical clinics for
prevention and management of disease in rural areas of India.
Research questions
How efficient and cost effective are mobile healthcare clinics in rural areas which lacks
quality healthcare?

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Aim and objective
Aim:
To evaluate the efficiency and cost efficiency of mobile health care clinics in rural areas
of different countries in the world.
Objectives:
To critically evaluate the ability of mobile health clinic (MMC) to improve the quality of
health care in rural areas, the main aim of the systematic review is:
 To identify barrier or challenges in delivery of health care through MMC in rural areas
 To evaluate health outcome and acceptance of MMC in rural areas
 To understand the potential of mobile healthcare clinics in reducing mortality rate and
burden of disease
● To understand the potential of MMC in reducing staffing issues in health care
● To assess the adaptation of the MMC in rural areas of developing countries
Methodology:
The study is conducted using systematic review, suing which a meticulous summary of
the study can be delivered. The systematic review is delivered in terms of the primary research
that is based on the research question. The research philosophy used here is based on positivism
hence having a deductive approach in order to formulate more research on a theory that is pre-
existing. The study aims to examine whether the previous researches conducted in this filed fit
the proposed phenomenon or not. The study allows the development of a hypothesis using the
positivist approach. Here the study uses a qualitative approach that implements the research
strategy of systemic literature review. The research is carried out using the materials that already

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exist. Using this systematic review of literature the patterns of the existing materials of research
are deduced and finally summarised. The method of data collection and analysis depends on the
method of approach of the research. Here the study used the secondary data obtained from the
literature which is based on the opinion of the other researchers. The sample size used in the
study is not that important in case of qualitative research hence a sample was chose which bides
by the guidelines which helps to validate the research.
For answering the research question, systematic review format will be followed.
PRISMA guideline will guide the current research that acts as evidence-based framework for
reporting systematic reviews. It focuses on the reports of reviews that help in critical appraisal of
systematic reviews that are published. PRISMA checklist comprises of 27 items and 4 phase
flow diagram that guide in conducting systematic reviews demonstrating quality of review and
assessing the strengths and weaknesses of the articles (Moher et al. 2015). It comprises of steps
like author information, summary, methods, review protocol, search strategy, selection process
of the study, bias assessment and data analysis.
The search for articles that is relevant to research question is guided by inclusion and
exclusion criteria. This criterion will help in establishing boundary for systematic review and
research process (Moher et al. 2010). This extensive strategy for search will help to retrieve
research articles that are relevant to objectives of the research and in answering the research
question. The final list of retrieved articles is obtained after using the extensive search strategy in
the form of PRISMA flow diagram. Electronic databases support extraction of maximum
research articles that is related to research objectives. Moreover, Boolean operators are also used
for literature search that helps in answering the research question. In addition, truncations and
Boolean operators are also used for getting a productive and focused result. Articles will also be

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reviewed by reading the abstracts and full-text articles along with reviewing of references of the
studies. The extraction of data is also an important step in search strategy of systematic literature
review where there is categorization of data encompassing population, author, research design,
target population, strength and limitation of the study, health intervention and outcomes
(Almeida and Goulart 2017). The judgment of validity and quality of research is also important
for bias assessment in the studies.
Search strategy
Databases used:
Search engines are beneficial tools for conducting systematic literature reviews and it is
important to identify databases that provide optimal level of required literature. Electronic
databases that were used for the current study were PubMed, Google Scholar and Web Search.
These databases are commonly used for accessing literature in science providing updated
information on different topics. These databases provide full-text articles that are peer-reviewed,
reliable and authentic.
Search terms/Keywords:
The keywords or search items used for the review are crucial components for a
systematic review. Short phrases or commonly used words that are extracted from research
question and objectives are entered on the search bar of the search engines for extracting relevant
articles. For a successful search, keywords should be appropriate to the research topic and
objectives so that relevant articles can be retrieved for the systematic review. For the present
review, the keywords used are mobile medical service, efficiency, challenges, rural areas, mobile
health, mobile medical clinic, and mobile healthcare services, developing countries.
Table for Search Strategy:

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Search terms used Search Engine No. of outputs
Mobile medical clinics OR
Mobile health care service
PubMed 1521 hits
Mobile medical clinics AND rural
areas
PubMed 1055 hits
Mobile medical clinics AND
efficiency
PubMed 425 hits
Mobile medical clinics and
challenges
PubMed 555 hits
Inclusion and exclusion criteria
As per the systematic review guidelines, inclusion and exclusion criteria are important
that define the current research. This criterion fulfils the eligibility criteria for articles selection.
This selection process is considered meticulous and abides strictly to the selection criteria prior
the search. In the current study, the following inclusion criteria will be used:
Study design Primary research sources will be used as it is most preferred choice for the
current systematic review for the inclusion criteria. The specific studies are of
better quality as compared to others according to level of evidence in the
hierarchy.
Study participants In the current study, the research question focuses on effectiveness of mobile
healthcare clinics across developing countries; research articles should have
professionals like nurses, community health workers, primary care staffs,
research participants and primary care staffs.

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Publication Research articles published during 2004 to 2018 will be included for the study in
the current systematic review of literature.
Interventions The current research includes studies that have mobile healthcare services or
clinics as the main intervention in rural areas of developing countries. The
research question is focused on the evaluation of this intervention for regions that
lack quality healthcare in developing counties like India.
Research question The chosen research articles must address the research question that studies the
effectiveness of mobile health clinics or services in rural areas of developing
countries.
Outcome variable The articles that are included in the study must have outcomes variables like
mobile health services or clinics, quality mobile healthcare provided to rural
population in developing countries.
Language All those articles that are published in English language are included in the
present systematic literature review.
The exclusion criteria for the present systematic review are as follows:
Publication date Studies that are published before 2004 will not be included in the present
systematic review
Research aim Research studies that investigated about effectiveness of services other than

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mobile health will be excluded from the present systematic review.
Research topic Research articles that does not has mobile health services and its effectiveness
are excluded from the present systematic review
Language of articles Articles that are published in languages other than English will be excluded
from the present study
Data analysis
Quality and internal validity of each research articles will be judged through potential
sources of bias, research rigor and confounders. The evaluation of studies was done according to
criteria of level of research evidence (Ahmed et al., 2012). This is useful in extensive analysis of
methodological approach and rigor of studies. In addition, to systematically present data, the data
were analysed by means of categorization of research evidence. This was used to categorize
different types of services provided by MMC in rural areas. Categorization by service type was
done to understand challenges faced in delivery of specific types of services. This enhanced the
relevance of study and promoted the application of study findings in real setting.
Meta-analysis was not conducted due to the heterogeneity of populations and services. As
an alternative, effectiveness of different types of MMC was evaluated by associated successful or
non-successful outcomes in research. It was planned to identify features like target of each
service, how it was designed, identify the setting of the intervention and outcome of each type of
MMC. Extensive review was done to identify whether the outcome of study was statistically
significant or not. Judgments were done based on primary clinical outcome measures and
people’s acceptance of the services (Edgerley et al. 2017).

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Data extraction
To complete a systematic review within stipulated time, specific method is used for
extracting data that is aimed at identifying, synthesizing and interpreting published evidence that
is relevant to the current research topic. Strategies that are used for extracting data determine the
time that is consumed in conducting a review (Ahmed, Sutton and Riley 2012). For the current
study, data were extracted that is relevant to year of publication, intervention, country, industry,
comparison group, dependent and independent variables. This method helps to select and
categorize research evidence as per the research question and objectives of the review.
Quality assessment/risk of bias
Bias is something that deviated from truth or systematic error resulting in inferences.
Differences that are witnessed in risks of bias are helpful in explaining variation in studies results
that are included in the systematic review (Almeida and Goulart, 2017). In a review, it is
important to assess the risk of bias irrespective of anticipated variability in results or validity of
included studies. In order to reduce bias and improve rigor in the present systematic review,
those research articles will be included in the review that comprises of more than two authors.
This helps in the minimization of individual biases and opinion differences while categorizing
research evidence. Inclusion criteria should be effective as it helps in avoiding risk of bias in the
selected studies (McDonagh et al. 2013). Clear specification of research outcomes in the selected
studies is also vital for reducing variation in the study selection. Conflict of interest of authors
can also contribute to chances of bias during conduction of systematic literature review and that
needs to be addressed by using specific tools or by a third person that categorizes research
evidence based on quality. Therefore, it is important to identify and reduce risk of bias in a
systematic review.

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Cochrane Collaboration Risk of Bias Tool will be used for assessing risk of bias
categorizing them into high and low risk of bias. This tool assesses bias as judgment in the form
of low, high or unclear for the individual components from domains of performance, selection,
reporting, attrition and others (Moher et al., 2015). This will be conducted by presence of
publication, selection and performance bias that is important for enhancing credibility and
reliability of systematic review.
Data synthesis
Along with categorization of research evidence, thematic analysis will also be conducted
for the current research literature. Thematic analysis is a common method that is performed for
analysing data in primary qualitative research (McDonagh et al., 2013). It helps in the
identification and deriving of patterned meaning in a dataset that emphasizes on pinpointing,
examination and recording of patterns with the data.
 Assigning of codes: To gain an understanding of study, codes such as phrases or
keywords will be used for the categorization of research studies that have similar
meanings
 Themes generation: After the research evidence is categorized as per similarity in
meanings, for the present study, major themes will be developed that is based on research
evidence analysis through in-depth analysis. Themes generation will help in the
integration of multiple findings in an appropriate manner. This method of analysis is
tested and tried helpful in establishing link between selected studies and in drawing
conclusion (Merriam, 2015).
 Themes description: For the review, themes or sub-themes will be generated that provide
detailed discussion of result findings according to the themes.

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Results:
Study selection:
After the screening and assessment of articles based on specific eligibility criteria, a total
of 28 articles were selected for the systematic review. The searches for articles were done by
going through the process of identification, screening, eligibility and selection process. After
entering the specified key terms in relevant databases, a total of 120 articles were identified
through database search and from reference list of selected articles. 30 articles were removed at
this stage after identifying duplicates. Furthermore screening of articles based on review of
abstract and title and identifying its suitability according to research question yielded a total of
80 articles. The next process of eligibility of articles for the systematic review method was
identified by comparing the research articles with inclusion and exclusion criteria. 80 articles are
assessed for eligibility criteria and out of this, 28 articles were included in the systematic review.
Other articles were excluded with reasons based on inclusion and exclusion criteria. 10 studies
were excluded because of poor methodological quality and high rate of loss to follow-up cases.
The summary of the search process and the total number of articles selected for the literature
review has been summarized in the form of PRISMA flow diagram in Figure 1 below.

Records identified through
database searching
(n = 100)
Additional records identified
through other sources
(n = 20 )
Records after duplicates removed
(n = 30 )
Records screened
(n = 90 )
Records excluded
(n = 10 )
Full-text articles assessed for
eligibility
(n = 80 )
Studies included in
qualitative synthesis
(n = 28 )
Full-text articles
excluded, with
reasons
(n = 52 )
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Figure 1: PRISMA flow chart for the systematic review
Characteristics of the studies included in the systematic review:
The selected 28 articles mainly had primary research design. It includes various types of
research design such as randomized controlled trials, cohort study, qualitative studies and various
other studies. The effective of mobile clinic or mobile medical vans were identified in different

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countries. The mobile medical vans were found to be used for various purposes (Ortiz, 2018). 24
studies covered use of mobile medical van for medical purpose and there were four studies
which used medical vans for relief during natural disaster. From the systematic review of all the
selected articles, it has been found that mobile health clinic has found application in various
types of care services such as child care, prenatal care and reproductive services, disease
screening services, HIV testing, disaster relief, mental health and intensive care (Marcolino et al.,
2018). This shows the wide application of mobile health clinic in different setting. However, the
details regarding challenges faced in rural areas needs to be discussed after further analysis. A
large number of studies investigating about mobile medical van were found to provide services
related to child care. The type of services differed however outcomes were evaluated mainly for
child. The table below summarizes number of research articles that describes various types of
service delivery through the new model of care:
Types of services provided Number of articles covering these services
Child care 4
Prenatal care and reproductive services: 4
Disease screening and prevention services: 8
HIV testing 3
Disaster relief 4
Mental health 2
Intensive care 2

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The graphical representation for the characteristics of studies is as follows:
Cross-sectional
Quantitative survey
Qualitative
Cohort study
Retrospective
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
Characteristics of studies
Characteristics of studies
The summary table for the characteristics of each study included in the review are as follows:
Sl.
No.
Author Characteristics of the study
1. Dawkins et al. (2013) Cross sectional study
2. Oriol et al. (2009) Quantitative analysis
3. Molete, Chola and Hofman (2016) Quantitative cost analysis study
4. Hill et al. (2012) Quantitative analysis
5. Jiménez-Ramírez et al. (2015) Quantitative screening study

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6. Lindgren et al. (2011) Qualitative study
7. Kojima et al. (2017) Quantitative evaluation based study
8. Aneni et al. (2013) Cohort based study
9. Schnippel et al. (2015) Retrospective study
10. Van Dijk et al. (2014) Cohort study
11. Taylor et al. (2007) Quantitative survey
12. Lein et al. (2014) Qualitative analysis
13. Crouse et al. ( 2010) Prospective descriptive study
14. Raatiniemi et al. (2015) Retrospective analysis
15. Kessel et al. (2017) Quantitative survey
16. Peter et al. (2013) Qualitative analysis
17. Philip et al. (2017) Quantitative observation based study
18. O’Carroll et al. (2017) Qualitative study
19. Morishita et al. (2017) Retrospective
20. Mobula et al. (2016) Retrospective observational study
21. Bassett et al. (2015) Quantitative geographic analysis
22. Yuki et al. (2014) Retrospective case series study

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23. Geoffroy et al. (2014) Retrospective cross-sectional study
24. Maheswaran et al. (2012) Quantitative study
25. Peritogiannis et al. (2017) Quantitative study
26. Fils-Aimé et al. (2018) Retrospective study
27. Govindasamy et al. (2013) Quantitative study
28. Evans et al. (2016) Quantitative study
Synthesis of results of individual studies:
The following services were covered in the research articles investigating about the
effectiveness of mobile medical services in rural areas of different countries. Effectiveness of
mobile health clinic with respect to different purpose of utilization is understood from the review
of outcome of these studies.
Child care related services: Four studies gave insight regarding impact of mobile health clinic
on child health. Two studies examined the role of mobile medical clinic for dental care, whereas
one studies cover role of mobile medical van for delivering pediatric care too. Dawkins et al.
(2013) investigated about the issue of untreated dental caries among children visiting mobile
dental clinic at South Central Kentucky. Children between 6-15 years attending dental sealant
program through mobile dental clinic took part in the study and the main outcome variables were
dental caries status. About 49.7% children were found to have dental caries and living in rural
areas without any insurance was found to be the main reason for untreated dental caries. Follow-
up treatment was lowest. Molete, Chola and Hofman (2016) is also similar to the above studies

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as it evaluated cost of a school based dental service in South Africa. It indicated about factors
that drive cost and those that influence cost-effectiveness. Highest cost was found for personnels
followed by vehicles and dental equipments. Lower uptake of mobile dental services was also
found as a problem and this mainly occurred because of poor coordination between school
teachers and parents regarding usage of services. The above mentioned studies gives the
common theme, which is to optimize usage of the service by community engagement and
increasing awareness of parents regarding the importance of oral health. Crouse et al. (2013)
gave overview about the role of mobile clinics in delivering pediatric services in the bateys,
which is an impoverished area in the Dominican Republic. It also gave similar outcomes as
above evidenced efficiency of services and the need to involved promoters to increase awareness
about mobile clinics in community.
Apart from cost, Aneni et al. (2013) specifically focused on summarizing the
effectiveness of mobile health clinic on health of children in rural areas. The research was done
in the rural areas of Namibia and during the six month period, information related to
immunization status, diagnosis of various disorders and referrals were collected. Regular mobile
clinic visit was found to significantly reduce health indices of children and reduce the burden of
disease in resource limited settings.
Prenatal care and reproductive services:
Issues related to prenatal care and services utilized by pregnant women through mobile
health clinic were covered by three articles and it mainly gave idea regarding the feasibility and
acceptability of the care model for safe child delivery and antenatal care. Kojima et al. (2017)
investigated about the impact of mobile medical clinic for prenatal care in rural Mysore, India. It
gave implication regarding the feasibility and acceptability of patient-centered mobile medical

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clinics in rural India and to increase management of vertically transmitted infection. Analysis of
other research related to reproductive mobile service delivery in other countries gives idea
regarding challenges in staffing cost too. Schnippel et al. (2016) evaluated this service delivery
model in rural district of South Africa and it showed positive impact of mobile vans on
improving access to cervical cancer screening and reproductive health services in rural regions.
Phillips et al. (2017) also compared care delivery and quality of mobile clinics in providing
antenatal care in Central Haiti. Significant qualities issues were found in the services as they
failed to adhere to guidelines and the provider communication and documentation process was
also poor.
Disease screening, primary care and prevention services:
Govindasamy et al. (2013) and Evans et al. (2016) gave insight into the utility of mobile
clinic for non-communicable disease testing and communicable disease testing.Oriol et al.
(2009) evaluated effectiveness of mobile health care in terms of return on investment. The study
recognized the use of such clinics for homeless people, people living in rural areas and those
with diabetes. The value of the mobile van services in the area of hypertension, obesity,
depression, diabetes and screening was analyzed. The mobile health clinic was found useful in
preventing emergency visits and reducing. It shows that every investment can be returned in
combined emergency cost avoided and no. of life years saved. Hill et al. (2012) also discussed
about the effectiveness of mobile clinic model for disease prevention in underserved
communities. The uniqueness of the study is the use of community based ‘knowledgeable
neighbour’ model. Compared to Oriol et al. (2009) which focused on return on investment, the
main goal of Hill et al. (2012) was to evaluate the role of collaboration and continual outreach in
health promotion. Jiménez-Ramírez et al. (2015) specifically evaluated the impact of mobile

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screening unit for screening of diabetic retinopathy. It evaluated outcome both in rural and urban
areas and this study also reported greater prevalence of diabetic retinopathy in rural areas. The
result suggests that screening procedure in rural areas are less effective and there is a need of
more number of such clinics in the future. Morishita et al. (2017) also targeted mobile unit for
screening of tuberculosis in vulnerable population in Philippines. The screening process in
different setting was found be effective and improve the likelihood of successful treatment
outcomes.
The assessment of utilization patterns for mobile clinic services in rural population in
Katsina state, Nigeria was done by Peters et al. (2016). The researcher conducted interviews with
community leaders and providers received mobile clinic services. The positive outcome from the
study was that it reported high levels of satisfaction with care. However, varied responses were
obtained regarding the quality of care. It gave the lesson that such services can be accepted in
rural areas. However, there is a need to work on increasing the quality of such service provision.
Access to primary care was also improved by the implementation of GP-led mobile health
clinical for homeless people. The significant result was that GP registrars working in such clinic
were found to have increased empathy and knowledge regarding homeless issues. This helped to
improve access to care and the study suggested steps needed to address discrimination in future
practice (O’Carroll et al. 2017). Geoffroy et al. (2014) gave insight into the feasibility of mobile
health clinic in providing primary care too rural population living in Malawi, whereas
HIV testing:
The systematic review of literature also gave insight into the utilization of mobile
medical clinic for HIV testing. One such study is the research by Lindgren et al. (2011) which
evaluated the work of two mobile clinics to reduce service gap related to HIV testing in Mulanje

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district of Malawi. The lesson learned report suggests that flexibility and responsiveness is
critical to increase HIV testing and promote integration of services. Van Dijk et al. (2014)
highlighted about the importance of mobile clinics for care of HIV-infected children in rural sub-
Saharan Africa. The significance of the study was that by comparison of outcomes for HIV
infected children receiving care in mobile and hospital affiliated HIV clinics in rural Zambia, it
could depict the utility of mobile health clinics in rural regions. The study gave the evidence that
mobile clinics can effectively deliver HIV care and treatment and reduce the barrier to uptake
and retention of services. Distance to the clinic and transportation are some barriers to utilization
and retention of services in rural areas and mobile HIV care service significantly reduce travel
time cost, barriers to access and waiting times at clinic. Bassett et al. (2015) suggested the
potential of geospatial technique in optimizing the use of mobile units in hard-to-reach
population. Maheswaran et al. (2012) explained about the challenges in starting a mobile HIV
testing service in rural area of South Africa.
Disaster relief:
Mobile medical health services have also found application in emergency care during
disaster relief. The evidence regarding this is given by Taylor et al. (2007) which evaluated the
action of federal and local agencies in providing medical care to person affected by hurricane
Wilma through mobile medical units. Nine mobile medical clinics delivered care in hurricane hit
regions. Acute care needs were resolved by mobile medical units and it played a major role in
minimzing the number of patients whose conditions might have deteriorated due to the
storm.Using these evidence, local agencies and government can promote use of mobile medical
units to reach that population who fail to access local medical clinics during natural disasters. A
recently published research literature also reported about health care delivery through medical

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mobile unit post Hurricane Sandy. This study is also consistent with the outcome of the above
literature as the study also revealed the effectiveness of mobile health in identifying needs of
displaced individuals (Lien et al. 2014). The uniqueness of the study by Mobula et al. (2016) was
that it focused on the prevalence of hypertension among patients seeking care at medical clinic
after Typhoon Haiyan. It suggested improvement in current practice by introducing evidence
based guidelines for management of hypertension in such settings.
Apart from disaster relief during hurricanes, evidence also exists for utilization of mobile
clinic in Great East Japan. Yuki et al. (2014) evaluated the function of Vision Van, a mobile
ophthalmic outpatient clinic in Great East Japan Earthquake. It brought the issue of loss of
contact lens during such emergencies and the need to reduce infections in such setting. Hence,
mobile clinical can serve valuable eye care to people living in remote location.
Intensive care and chronic disease management:
Although emergency medical care is mostly delivered in hospital setting, however two
studies were identified which provided evidence regarding the utility of mobile health clinic for
intensive care. Raatiniemi et al. (2015) compared outcome of urban and rural mobile intensive
care unit for trauma patients in Northern Finland. Rural trauma patients were found to enter the
medical system with wide range of impairment and this increases mortality and physical
abnormalities for patient compared to those in urban area. However, high mortality rate in urban
patients was a surprising finding in the study. Kessel et al. (2017) contributed to the research
question by showing the potential of mobile health in oncology. The study evaluated
theacceptance of app-assisted cancer care among patients and the reasons for refusing such form
of care. mHealth devices are found beneficial in management of symptoms and improving

25MEDICAL MOBILE CLINIC
quality of life of patients. However, the study is weak as it should have also compared
differences in outcome of patient after the use of such devices.
Mental health services:
Very few evidence has been found for utilization of mobile health services for mental
health care delivery. Peritogiannis et al. (2017) is one of the studies that give an account of the
mobile mental health unit in rural Greece. The 10 years study revealed the success of such low
cost service in promoting mental health in rural areas. Integration of mobile health with
community mental health care services may further increase the outcome of the population.
Another study revealed the effectiveness of mobile clinic to deliver community based mental
health service in rural Haiti. Substance abuse and mental disorders was common in rural people
and the clinic was found to overcome accessibility issues and staffs shortage in primary care
(Fils et al. 2018).
Discussion:
Mobile health clinics Units (MHCUs) are widely being introduced in community setting
to reduce the burden of care providers and reduce the barriers found in tradition health care
services. MHCUs have found wide application in community to improve accessibility issues
utilization of health care services. People living in rural and remotes areas are found to have poor
health outcomes than those living in urban areas because time constraints, transportation issues
and distrust in the health care system (Schwitters et al. 2015).Hence, MHCUs has been regarded
as a solution to improve health of the rural population and address issues found in the tradition
form of care delivery. The systematic review on research literatures were done to find out the
efficiency and cost-effectiveness of mobile health care clinics in rural areas of countries around

26MEDICAL MOBILE CLINIC
the world. By conducting the systematic review, the main aim was to identify the utilization of
mobile health care clinics in rural areas and identify it effectiveness in decreasing cost, reducing
mortality rate, preventing diseases and promoting population health. A total of 28 articles were
found relevant to the research topic and the systematic review summarized the utilization of
MHCUs for delivery of various types care services in rural regions of various countries across
the world. There were four-five studies that gave evidence on cost effective of such clinic and
the rest explained about the challenges or efficiency of such service for specific population
setting. Findings shows use of MHCUs in diverse setting to promote health and this discussion
provides strengths and gap in the research findings.
For the purpose of systematic review a number of primary source journal articles have
been reviewed. The articles have been analysed and compared for understanding the various and
pros and cons associated with mobile medical clinic. For all the four studies where mobile clinics
were used to provide care to children, the research findings highlighted several issues in health
care services of rural regions. For example, Dawkins et al. (2013) highlighted the problem of
dentist shortage as reason for high rate of dental problem in children in rural areas. The health
and dental outcome of rural population were also affected by different level of knowledge
regarding oral health and healthy behaviours. Lower uptake of mobile dental services was also
found due to poor parental awareness (Molete, Chola and Hofman 2016). Hence, both studies
gave similar results. The result is also consistent with many other research literatures. For
example,the systematic review revealed that no insurance and living in rural areas prevents
uptake of mobile services. However, Vashishtha et al. (2014) argues that many children are
deprived of dental care despite receiving insurance because their parents lack motivation to take
them to such clinics. Ganavadiya et al. (2014) justifies that oral disease is prevalent in rural

27MEDICAL MOBILE CLINIC
population of India because of poor awareness on etiological factors for oral disease (Dawkins et
al. 2013).
Crouse et al. (2013) gave insight about the effectiveness of mobile medical van in
delivering pediatric care to impoverished housing in Dominican Republic. It suggested social
issue of marginalization and lack of access to health care as a presenting complaint for patient.
This was found to be prevalent not only in child care services, but also for delivery of other types
of services through mobile medical vans. Schwitterset al. (2015) gave the evidence that there is
a huge amount of stigma regarding availing the treatment and care services from HIV-AIDS in
the sub-Saharan Africa. Therefore, the provision of the care services through easily accessible
mobile health clinics could help in reducing the stigma associated with HIV AIDS. It was found
that the participants were accepting towards the mobile health clinics provided it served as a
means for early detection of HIV-AIDS. However as argued by Schwitterset al. (2015), there
were limitations such as the availability of funds which were necessary to purchase fuel for
running the vehicles. A study by Steinhubl, Muse and Topol, (2015), also that showed that the
women who were involved in the utilization of the van services for the prenatal care gained
access to the prenatal care much earlier in comparison to the women who were involved in
initiating care at the community based health clinic. However, Lien et al. (2014), depicted in a
study that there was an increased chance of children getting enterobiasis while they attended the
mobile health clinics. The study showed that the average rate of infection was approximately
21.91% in children. In the lack of fund and fuel reaching out to the patients would have been
difficult. The limitation of the study was that it failed to identify the cold spots as it could have
helped in drawing a neat comparison based upon the factors which serve as a barrier in reception

28MEDICAL MOBILE CLINIC
of the mobile healthcare services. Hence, the main goal of the mobile medical vans should be to
reach out to marginalized section of rural population.
Some of implementation related errors that were found in mobile van used to provide
child care services were that very few diagnosis were made based of laboratory findings.
Furthermore, service utilization might also be affected by remoteness of location and rainy
season which was not considered while presenting outcomes (Crouse et al. 2013). However,
based on analysis of gap in mobile medical services in rural areas, several pathways for service
improvement have been identified too. For example, in response to the issue of poor accessibility
to health services in the rural areas, mobile medical clinics can be used to improve the provision
of existing health care services in rural areas. Strategies like rapid maintenance process and
service quality assessment can be done to optimize service provision. Mobile medical clinics can
take the responsibility to maintain continuity of health care services by implementing a quick
maintenance process. Based on rural localities, extra mobile clinic can also be kept so that it
could replace the other clinic when under maintenance particularly while providing services to
challenging geographic terrain (Aljasir and Alghamdi 2010).
The systematic review also revealed accessibility challenges in delivery mobile medical
services to rural regions. Phillips et al. (2017) indicated deployment of small scale mobile clinics
to address health accessibility issues and increase health coverage Haiti. However, as Phillips et
al. (2017) used a large scale mobile clinic program, the result cannot be generalized to all parts
of Haiti region. The process of adaptation may vary in different regions. The study selected
contradicted with the idea that accessibility of healthcare services through nearby locations were
the only determining factor for repetitive patient visits to the MMUs. However as mentioned by
Gibsonet al. (2014), there were a number of other factors which affected the patient visits to the

29MEDICAL MOBILE CLINIC
healthcare units. Ryan et al. (2015) puts forward that although the mobile health units have
increased the rate of yield of the symptoms screening for the several infectious diseases however
they have failed to establish the linkage. The study also stated that the weekend clinic and the
after-hour clinic might gradually become a barrier in the path of accessing care from these
mobile healthcare units. It was found that the patient living within a range of less than 5 miles
and greater than 50 miles which mainly comprised the outskirts of the city were of ethnic
minority origin. Hence, some of these people would not readily access the mobile medical units
owing to cultural issues. Additionally, language also serves as a barrier in most cases as the
ethnic minority groups often find it difficult to communicate in any other language. As argued by
Gibsonet al. (2014), the cultural paradoxes and faiths possessed by an individual often restricted
their healthcare choices. Additionally, the study fails to take into consideration factors such as
language differences often prevented the ethnic and minority communities from approaching the
nearby medical units. Addressing language barrier may help to promote health of multicultural
societies. Clayman et al. (2010) argues that health communication is critical to promote health
and impact of language on service utilization should be made a priority.
The systematic review also presented the utility of mobile medical clinics in fulfilling
health care needs of pregnant women and new mothers. In India, mobile medical clinic was
found as a feasible model to improve service provisions for pregnant women living in rural areas.
Kojima et al. (2017) was able to achieve high attendance for mobile medical clinicians because
of the integration of the mobile medical clinics with antenatal care. The strength of the study was
that while implementing mobile medical clinics in rural areas, the researcher shifted from
traditional norms and encouraged job-market mobility by including women in the project too.
Another advantage of hiring women was that these women could also provide pregnant women

30MEDICAL MOBILE CLINIC
vital information related to their experience with pregnant. However, operational challenges in
the process included high turnover of physicians compared to nurse turnover. The main reason
for this was higher pay options in urban areas compared to rural regions. In contrast, the
implementation of same type of mobile medical clinics in Haiti revealed poor quality of lab
examinations as an issue (Phillips et al. 2017). However, the positive aspect of the
implementation process was that low consultation cost was found to improve patient’s perception
related to quality care. Hence, the comparison of implementation process in two countries
revealed that adapting unique strategies during implementation process yields positive outcome
for the health of the population. In a study it was argued that there is lack of evidence to support
the fact that the mobile health units are effective in providing care to the individuals especially
those who are suffering from non-communicable diseases (Salazar et al. 2016). Cooperation
with traditional health care clinic is essential proper integration and continuity of health services
for people in need (Brownson 2017).
The systematic review and identification of challenges related to the implementation of
mobile medical clinics also signifies areas which have little attention during the implementation
process and ignorance of these factors have affected the service utilization rate of services.
Mobile medical clinics were found to be developed in large numbers to provide health screening
and health prevention services. Implementation of the new model of care in this area is a positive
trend as current health care providers are overburdened by the rising prevalence of chronic
disease and coordination with mobile testing unit can provide new solutions to overcome work
burden related challenges in disease screening process (Steinhubl, Muse and Topol 2013). The
positive aspect of the study by Govindasamy et al. (2013) was that it revealed that by the
implementation of multiple diseases screening through a mobile unit, high number of newly

31MEDICAL MOBILE CLINIC
diagnosed cases of HIV were identified. The study also provided solutions to address time
related barriers during utilization of mobile health services. This included delivery of mobile
health services in other times apart from traditional service. Integration of various types of
screening program also provides the scope to reach out to vulnerable population in a timely
manner.
Despite several gaps found in implementing mobile medical clinics for different purpose
in rural regions, the review of research literatures signified various benefits of mobile medical
services too. Many studies were done in rural areas with underserved population. Morishita et al.
(2017) gave evidence regarding the potential of mobile health clinic to reduce health care cost
and disparities associated with care delivery. The Family Van reached large number of people at
risk of chronic disease. Accessibility issue is found in tradition health care because of financial
difficulties and Hill et al. (2012) argues that mobile van can mitigate financial barriers such as
long waiting times, remoteness and logistical constraints in health care delivery. As per the
recommendation of Lie et al. (2011), focusing on consistency of service provision, staff diversity
and cultural competence training can enhance the quality of care provided through mobile
medical vans.
It was also found that lack of health insurance and stable housing conditions also affected
the rate of visits to the mobile healthcare units. The perceived need of the people was another
factor which governed the rate of reception of the mobile healthcare services. For instance the
ones in use of constant drug support such as injection and opoids for pain management and other
chronic illnesses have been seen to have higher number of repetitive visits to the clinic. The
majority of the ethnic minority communities were lacking effective employment sources.

32MEDICAL MOBILE CLINIC
Therefore, the provision of free medical services would have benefitted them to a major extent.
As mentioned by Duprayet al. (2016), implementation of MMC can help in reducing the stigma
attached with availing the mental healthcare services. As mentioned by Gibsonet al. (2014), the
delivery of effective mental healthcare services in resources limited settings have been
highlighted over here.
The reason behind the low adherence to the clinical guidelines was short duration of
consultations (Phillips et al. 2017). It could be attributed to large volume of women and women
who seek antenatal care. It was found that the women in fixed clinics would spend higher
amount of time answering the questions which were thrown at them. Some of these questions
helped in detailed interpretation of the conditions of the patients visiting the clinic. However, the
slightly higher level of intake questions were not followed by at length physical examinations;
the duration of which was same for both the mobile medical clinics and the fixed clinics. The
difference in time of consultation could be attributed to the different level of knowledge and
expertise possessed by the healthcare providers (Prabhakaran et al. 2014).
The beneficiaries of the mobile healthcare services reported high satisfaction as well as
the healthcare service providers also highlighted some of the major benefits provided by the
mobile medical clinics, such as teamwork involved and making the services accessible to each
and every individual residing in the rural community. Through the mobile clinics 30% antenatal
coverage of the pregnant women were achieved. However, lower rates were secured elsewhere
and could be attributed to difference of cultural perspectives. As mentioned by Peterset al.
(2013), the cultural paradoxes often prevented an individual from reaching out to the relevant
healthcare channels. Some of the loopholes which were found within the current design were
lack of privacy, long waiting hours and lack of guidance on follow up care. Some of these could

33MEDICAL MOBILE CLINIC
be attributed to the level of skills or knowledge possessed by the healthcare workers.
Additionally, the huge rush of patients puts a pressure upon the makeshift clinical setup (Dressler
et al. 2017). The data collected points towards the scope of improvement of the services.
Performance based financing mechanisms to improve the quality of care.
The services users have attached positive values with the services delivered by the mobile
medical clinics, low pay associated with rural healthcare setups have been seen to act as a de-
motivating factor. It covered some of the essential services like immunization and antenatal
care. As mentioned by Peterset al. (2013), the mobile medical clinic served as a perfect model
for the delivery of primary healthcare services. However, the study failed to provide an economic
analysis of the cost benefits attached with mobile medical clinics. In this context, the study
followed both survey methods and interview questions for the purpose of data collection.
Therefore, it belonged to level 3 of the evidence based table.
The current study places importance on telehealth for the delivery of health and support
care services in rural areas. There is a misnomer regarding the delivery of the mobile healthcare
services. For instance, the mobile healthcare services also cover the aspect of telehealth. In
telehealth mobile phones are used to extend equitable healthcare services to the vulnerable
population. As mentioned by Marcolinoet al. (2018), the telehealth services helped in the
delivery of support and healthcare in much real time. The process of telehealth made continued
healthcare services easy where the patients continue to share their medical details with their
doctors even after visiting the mobile medical clinics. This particularly helps in following up
with the improvements in health of the patient. One of the basic limitations which have been
found with the mobile medical units is that they are often restricted in expertise and

34MEDICAL MOBILE CLINIC
infrastructure. Therefore, the delivery of quality health care is often challenged over here. In the
context of chronic illness, referrals could be made easy through implementation of telehealth
services. As mentioned by Fernandezet al. (2017), the telehealth services provides a digital
platform for review of important medical records of patients by physicians who may be located
at distance, which facilitates effective care planning and decision making. As argued by Brown-
Connolly et al. (2014), technologies developed for the mobile health have the capability to
transform the quality and nature of medical research on a global scale. With the development of
the mobile technologies, several barriers can be overcome like the distance factor. Similarly as
mentioned by Marcolinoet al. (2018), the mobile health units are of great help in terms of
delivering health care to the individuals who are displaced after the occurrence of a natural
disaster. These individuals provide psychological services and are involved in the evaluation of
the strategies for the timely retreat of these health units.
Conclusion:
The main purpose of the systematic review was to understand the effectiveness of mobile
medical clinics by looking at the implementation process and outcome of mobile medical
services implemented in rural areas of developing countries. Research in this area was
considered because of the potential of mobile medical clinic in addressing disparities in health
outcomes and health care service accessibility in rural areas (Lien et al. 2014). For people living
in rural areas and unserved regions, distance is an issue and lack of health literacy also presents
new challenges in maintaining health and well-being. Although distance related barrier could be
addressed with mobile medical clinics, however it is not clear whether clear whether mobile
medical clinics can significantly influence health of the rural population or not.. Other objectives
of the systematic review was to understand the potential of mobile clinics in reducing burden of

35MEDICAL MOBILE CLINIC
disease, evaluate the acceptability of services and its impact on staffing issues. A total of 28
articles were found relevant to address the research question and meet study objectives. The
inclusion of primary research designs revealed six types of health care services provided through
mobile health units in rural areas. These included HIV testing services, disaster relief, mental
health, intensive care, child care, prenatal care and disease screening services. Hence, systematic
review of research literature was done to assess delivery of mobile medical clinics in rural areas
and identify challenges in delivery of such model of care in rural areas of various countries. The
systematic review presented many positive and negative aspects of mobile medical clinics in
rural areas.
The positive outcome from the review was that mobile medical clinics were found to be
accepted by rural population and such clinic was feasible to be implemented in underserved
areas. However, challenges or gaps in services were found because of funding issues and
implementation related errors such as lack of diagnosis based on laboratory findings. The
primary purpose of mobile medical clinic is to maintain continuity of health services. However,
research studies revealed continuity issues because of lack of steps taken to evaluate the
performance of mobile medical clinic on a regular basis. In response these issues, it is
recommended that rapid maintenance process should be implemented in rural areas so that
performance assessment and need for optimization of resource can be done periodically. For
delivery of mobile medical services in geographically challenging terrains, keeping the provision
of extra mobile clinics can significantly improve the health of the rural population.
The systematic review also revealed the utility of mobile medical clinics in improving
disease screening process and identifying individual at risk of chronic disease at an early stage.
Research evidence by Morishita et al. (2017) and Jiménez-Ramírez et al. (2015) presented the

36MEDICAL MOBILE CLINIC
effectiveness of mobile screening unit in active case findings for disease like tuberculosis and
diabetes retinopathy respectively. Jiménez-Ramírez et al. (2015) suggest that community
pharmacy should coordinate with mobile screening units so that active screening and early
treatment for diseases could be done. Research evidence also indicates about challenges in
screening through mobile medical units because of false positive results and over-diagnosis.
Hence, careful assessment and recruitment of highly skilful epidemiologist or clinician is
recommended while delivery mobile screening process. To eliminate racial and ethnic disparities
in delivery of mobile medical clinics in rural areas, it is essential that community health workers
be recruited in mobile screening program after providing cultural competence training. This
would help in providing centred care and maintaining consistency of service provision within
community. Therefore, by taking lessons related to challenges encountered while implementing
mobile medical clinics in rural areas, health care leaders can develop understanding regarding the
vital resources and implementation tactics that is needed to enhance the success of the mobile
medical clinics in rural. Correct implementation process would open new pathways for
promoting health equity and addressing health disparities for people living in rural areas and
remote locations.
Limitations
Limitations exist in terms of selection bias has been found in some research literature
during the survey and lack of analysis of socio-economic measures is some significant
limitations of cost based analysis studies. This imposes a disadvantage to the study as these
information would have given new insights about the reason for unequal mobile clinics
utilization in rural areas. The study cannot be applied to all conditions and is specific in nature,
hence this can be viewed as a limitation along with its small sample size.

37MEDICAL MOBILE CLINIC
Scope of future work
Future works can be carried out in this field in order to address the existing limitations of
the study. Studies can also be done in order to eliminate the biasness which will help to increase
the efficacy and credibility of the results. More amount of quantitative and qualitative data can
be done to promote a widespread integration of the MMC into the infrastructure of the health
services. Future studies can be performed using larger sample size along with factors, so that the
study can be implemented not only in one condition.
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