Consultorios móviles para la atención de la salud en mujeres y niños
Resumen
Antecedentes
La accesibilidad a los servicios sanitarios es un factor importante que afecta los resultados de salud de las poblaciones. Un consultorio móvil presta una variedad amplia de servicios, pero en la mayoría de los países el centro de interés principal son los servicios sanitarios para las mujeres y los niños. Se prevé que la mejoría en la accesibilidad de los servicios sanitarios mediante los consultorios móviles mejorará la salud de las mujeres y los niños.
Objetivos
Evaluar la repercusión de los servicios con consultorios móviles sobre la salud de las mujeres y los niños.
Métodos de búsqueda
Para obtener revisiones sistemáticas relacionadas, se hicieron búsquedas en la Database of Abstracts of Reviews of Effectiveness (DARE), CRD; Health Technology Assessment Database (HTA), CRD; NHS Economic Evaluation Database (NHS EED), CRD (búsqueda 20 febrero 2014).
Para los estudios primarios se buscaron en ISI Web of Science los estudios que citaron los estudios incluidos en esta revisión (búsqueda 18 enero 2016); WHO ICTRP, y en ClinicalTrials.gov (búsqueda 23 mayo 2016); Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials)(CENTRAL), parte deThe Cochrane Library. www.cochranelibrary.com (incluyendo el registro especializado del Grupo Cochrane para una Práctica y Organización Sanitaria Efectivas [Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register]) (búsqueda 7 abril 2015); MEDLINE, OvidSP (búsqueda 7 abril 2015); Embase, OvidSP (búsqueda 7 abril 2015); CINAHL, EbscoHost (búsqueda 7 abril 2015); Global Health, OvidSP (búsqueda 8 abril 2015); POPLINE, K4Health (búsqueda 8 abril 2015); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (búsqueda 8 abril 2015); Global Health Library, WHO (búsqueda 8 abril 2015); PAHO, VHL (búsqueda 8 abril 2015); WHOLIS, WHO (búsqueda 8 abril 2015); LILACS, VHL (búsqueda 9 abril 2015);
Criterios de selección
Se incluyeron los ensayos controlados asignados al azar de forma grupal e individual (ECA) y los ensayos controlados no aleatorios. Se incluyeron los estudios controlados tipo antes y después (before‐and‐after studies) (ECAD) que tuvieron al menos dos sitios de intervención y dos sitios control. También se incluyeron las series de tiempo interrumpido (STI) si había un punto temporal claramente definido de cuándo se realizó la intervención, y al menos tres momentos de toma de datos antes y tres después de la intervención. La intervención de un consultorio móvil se definió como un vehículo consultorio con un profesional sanitario (con o sin personal de enfermería) y un conductor que visitó las áreas de forma sistemática. Los participantes fueron mujeres (18 años o más) y niños (menores de 18 años de edad) de países de ingresos altos, medios y bajos.
Obtención y análisis de los datos
Dos autores de la revisión, de forma independiente, examinaron los títulos y resúmenes de los estudios identificados mediante la estrategia de búsqueda, extrajeron los datos de los estudios incluidos mediante un formulario de extracción de datos especialmente diseñado en base a la lista de verificación de obtención de datos del Grupo Cochrane EPOC y se evaluó la elegibilidad de los artículos de texto completo. Todos los autores realizaron los análisis, las evaluaciones del "Riesgo de sesgo", y evaluaron la calidad de las pruebas mediante el enfoque GRADE (Grading of Recommendations Assessment, Development and Evaluation).
Resultados principales
Dos ECA grupales cumplieron los criterios de inclusión de esta revisión. Ambos estudios se realizaron en EE.UU.
Un estudio evaluó si ofrecer la mamografía móvil en el terreno combinada con educación sanitaria fue más efectivo para el aumento de las tasas de cribado para el cáncer de mama que ofrecer educación sanitaria sola, que incluyó recordatorios para asistir a un consultorio estático para la mamografía. Las mujeres del grupo al que se les ofreció mamografía móvil y educación sanitaria pueden tener mayores probabilidades de someterse a la mamografía en el transcurso de tres meses de la intervención que las del grupo de comparación (55% versus 40%; odds ratio [OR] 1,83; IC del 95%: 1,22 a 2,74; pruebas poco confiables).
El análisis de la costo‐efectividad de las unidades de mamografía móviles versus estáticas encontró que el costo total por paciente cribada puede ser mayor para las unidades móviles que para las unidades estáticas. Los costos graduales por paciente cribada en una unidad móvil comparada con una unidad estacionaria fueron USD 61 y USD 45 para una unidad móvil completamente digital y una unidad móvil de películas respectivamente.
El segundo estudio comparó los resultados del asma en niños de dos hasta seis años de edad que recibieron atención para el asma en un consultorio móvil de asma y niños que recibieron atención estándar para el asma en un centro de atención primaria habitual (estático). Los niños que recibieron atención para el asma en un consultorio móvil de asma pueden presentar poca o ninguna diferencia en los días libres de síntomas, el uso de atención urgente y el consumo de la medicación informado por el cuidador en comparación con los niños que recibieron atención en su centro de atención primaria habitual. Todas las pruebas tuvieron una confiabilidad baja.
Conclusiones de los autores
La escasez de pruebas y el rango restringido de contextos de los que hubo pruebas disponibles dificultar establecer conclusiones sobre las repercusiones de los consultorios móviles sobre la salud de las mujeres y los niños en comparación con los consultorios estáticos. Se necesitan estudios rigurosos adicionales en los países de ingresos altos, medios y bajos para evaluar las repercusiones de los consultorios móviles en la salud de las mujeres y los niños.
PICO
Resumen en términos sencillos
Consultorios móviles para la atención de la salud en mujeres y niños
¿Cuál era el objetivo de esta revisión?
El objetivo de esta revisión Cochrane fue evaluar los efectos de los consultorios móviles sobre la salud de las mujeres y los niños. Los investigadores Cochrane buscaron y analizaron todos los estudios relevantes para responder esta pregunta.
Mensajes clave
La revisión sólo incluyó dos estudios. Un estudio incluido mostró que los consultorios móviles pueden aumentar el número de pacientes que utilizan los servicios de mamografía, aunque el costo del cribado con mamografía puede ser mayor. El otro estudio mostró que los consultorios móviles pueden lograr poco o ningún cambio en los síntomas de asma de los niños, el consumo de medicación y la atención urgente o la calidad de vida de los cuidadores. Se necesitan más estudios, incluidos los que midan el efecto de los consultorios móviles sobre el costo y sobre el acceso de las personas a la asistencia sanitaria, la satisfacción, la salud y el bienestar.
¿Qué se estudió en la revisión?
En muchos contextos las personas tienen un acceso limitado a los servicios de asistencia sanitaria porque viven en zonas remotas o de difícil acceso. Las mujeres y los niños pueden tener un acceso muy difícil a los servicios de salud debido a las circunstancias económicas o sociales.
Una manera de aumentar el acceso de las personas a los servicios de asistencia sanitaria es proporcionar consultorios móviles. Un consultorio móvil es un vehículo con un conductor y un equipamiento clínico, y provisto de un profesional sanitario como un médico o personal de enfermería, que visita las áreas regularmente para proporcionar servicios sanitarios.
Los consultorios móviles se utilizan en muchos países y a menudo ofrecen servicios sanitarios a mujeres y niños como atención prenatal, inmunización de la niñez, servicios de planificación familiar y cribado del cáncer de mama.
Al llevar los servicios sanitarios a la comunidad mediante consultorios móviles, los gobiernos esperan aumentar el uso de estos servicios y mejorar la salud de las personas. Esta revisión Cochrane tuvo como objetivo explorar el efecto de los consultorios móviles sobre el acceso de las personas al uso de la asistencia sanitaria y sobre su satisfacción, salud y bienestar, así como su costo y costo‐efectividad, en comparación con los consultorios permanentes.
¿Cuáles son los principales resultados de la revisión?
Los autores de la revisión incluyeron dos estudios, procedentes de los EE.UU.
En el primer estudio, a las mujeres se les brindó educación sanitaria y cribado con mamografía en consultorios móviles o educación sanitaria sola, que incluyó recordatorios para asistir a un consultorio permanente que ofrecía el cribado con mamografía. El estudio mostró que:
· las mujeres a las que se les ofreció la mamografía en los consultorios móviles pueden tener mayores probabilidades de someterse a la mamografía (pruebas de confiabilidad baja);
· el costo del cribado por mujer puede ser mayor con los consultorios móviles que con los consultorios permanentes (pruebas de confiabilidad baja).
Este estudio no evaluó el efecto de los consultorios móviles sobre la salud y el bienestar de la paciente, el acceso a los servicios o la satisfacción con estos servicios.
En el segundo estudio, a los niños se les ofreció la atención para el asma en consultorios móviles o en su centro de atención primaria habitual. Este estudio mostró que los consultorios móviles:
· pueden lograr poco o ningún cambio en los días libres de síntomas de asma en los niños o en el uso de la atención urgente y el consumo de la medicación (pruebas de confiabilidad baja);
· pueden lograr poco o ningún cambio en la calidad de vida de los cuidadores de los niños (pruebas de confiabilidad baja).
El estudio no evaluó el efecto de los consultorios móviles sobre el acceso de los niños a los servicios o su satisfacción con estos servicios, ni en el coste y la coste‐efectividad de utilizar los consultorios móviles.
¿Cómo de actualizada está esta revisión?
Los autores de la revisión buscaron estudios que se habían publicado hasta abril de 2015.
Authors' conclusions
Summary of findings
| Immediate onsite mobile mammography with health education versus health education only (including reminders to attend a static clinic service for mammography) | |||||
| Participant or population: women aged 60 to 84 years at study entry. (Age of participants matches our selection criteria) | |||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of participants | Certainty of the evidence | |
| Assumed risk | Corresponding risk | ||||
| Static clinic | Mobile clinic | ||||
| Health status and well‐being | The study did not assess this outcome | ||||
| Health behaviour: self‐reported mammography uptake | Study population | OR 1.83 | 473 | ⊕⊕⊖⊖ Low 2 | |
| 382 per 1000 | 531 per 1000 | ||||
| Utilisation, coverage or access | The study did not assess this outcome | ||||
| Resource use: total cost per patient receiving mammography screening | The total cost per patient screened may be higher for mobile units than for stationary units (USD 41 for a stationary full digital screening unit; USD 102 for a mobile full digital screening unit; and USD 86 for mobile film screening unit). This evidence was of low certainty (⊕⊕⊖⊖)2 | ||||
| Satisfaction with care among healthcare recipients | The study did not assess this outcome | ||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence High certainty: this research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different3 is low. | |||||
| 1Naeim 2009. | |||||
| Mobile clinics compared with standard 'static' services for childhood asthma care | |||
| Paticipannt or population: children aged 2 to 6 years with persistent asthma and their caregivers. (Age of participants matches our selection criteria) Settings: High income country; USA (Baltimore) Intervention: mobile asthma clinic delivering screening, evaluation, and treatment services Comparison: static services comprising standard asthma care from the usual primary care provider | |||
| Outcomes | Impact | No of participants | Certainty of the evidence |
| Health status and well‐being (follow‐up: 12 months) | Children who receive asthma care from a mobile asthma clinic may experience little or no difference in symptom‐free days and urgent care use, compared to children who receive standard asthma care. There may be little or no difference in quality of life among caregivers of children who receive asthma care from a mobile asthma clinic, compared to caregivers of children who receive standard asthma care. | 322 (1)1 | Low 2 ⊕⊕⊖⊖ |
| Health behaviour (follow‐up: 12 months) | There may be little or no difference in caregiver‐reported medication use among children who receive asthma care from a mobile asthma clinic compared to children who receive standard asthma care. | 322 (1)1 | Low 2 ⊕⊕⊖⊖ |
| Utilisation, coverage or access | The study did not assess this outcome | ||
| Resource use | The study did not assess this outcome | ||
| Satisfaction with care among health care recipients | The study did not assess this outcome | ||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||
| GRADE Working Group grades of evidence High certainty: this research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different3 is low. | |||
| 1Eakin 2012. | |||
Background
Description of the condition
The accessibility of health services is an important factor that affects the health outcomes of populations. Several approaches have been employed to increase geographical healthcare coverage and utilisation, including building new facilities and use of outreach clinical services.
However, in many settings the building of new health centres and other facilities is not always feasible and does not necessarily result in more people receiving better services. For example, initiatives by governments, non‐governmental organisations (NGOs), and community self‐help schemes have often led to an increase in the building of health facilities. However, a study in Zimbabwe concluded that in some circumstances it was more economical to bring health staff to patients than vice versa, and that choosing geographically more optimal sites (i.e. further away from static clinics) would increase the cost‐effectiveness of outreach clinics (Vos 1990). Community‐based distribution programmes and mobile clinics are the most common outreach clinical services globally. Mobile clinics are used in a wide range of low‐ and middle‐income countries, e.g. in Nigeria (Onyia 1981), Thailand (Sriamporn 2006), Indonesia (Molyneaux 1988), and Egypt (El‐Zanaty 2001).
Description of the intervention
Mobile clinics have been widely used worldwide for many years. These clinics provide a wide range of services but their main focus in most countries is on health services for women and children. A mobile clinic is a clinic vehicle with a healthcare provider, such as a doctor or nurse, and a driver that visits areas on a regular basis (e.g. weekly, biweekly, or monthly) to provide health services.
Such services can enhance accessibility by providing services to underserved populations; they may therefore increase the potential to reach women and children who are underserved by static health services (ACCP 2004). For example, expanding access to contraceptives through mobile clinics can contribute to improving health by helping to reduce rates of unintended pregnancy and its associated morbidity and mortality (Welsh 2006).
In the USA, mobile clinics are used for screening for sexually transmitted diseases (STDs), human immunodeficiency virus (HIV) counselling (Ellen 2003), prenatal care (Edgerley 2007), and breast cancer screening (Skinner 1995). In Nigeria, mobile under‐fives clinics (clinics for children under five years old) provide health education, immunisation, malarial chemoprophylaxis, and regular weight monitoring (Onyia 1981). In Egypt, it was planned that mobile clinics should offer family planning services, antenatal care services, and counselling, examination, and investigation for some diseases, e.g. hepatitis B, HIV/autoimmune deficiency syndrome (AIDS), and health care for menopausal women. However, the main services offered by mobile clinics for the last 10 years have been restricted to family planning, antenatal care, and, occasionally, immunisation (El‐Zanaty 2001).
How the intervention might work
Mobile clinics could tackle some barriers of access proposed by various frameworks especially availability, geographic accessibility (distance between service location and households), and utilisation of health services (Jacobs 2012). It is anticipated that improvement of access would have a positive impact on the health of specific groups. For example, increased accessibility to family planning services for women may increase the use of effective contraceptive methods and reduce the number of unwanted pregnancies and illegal abortions. Similarly, increased accessibility to antenatal care may result in earlier diagnosis and referral of high‐risk pregnancies and better care for women with normal pregnancies, and so decrease the risk of having low birthweight babies (O'Connell 2010). Mobile clinics also could play a vital role in increasing utilisation of cervical cancer screening and raising awareness among women about importance of early detection of cervical cancer (Swaddiwudhipong 1995). For children, increased vaccination coverage and regular nutritional assessment may result in decreased infant and child morbidity and mortality in the long term.
Why it is important to do this review
Mobile clinics play an important role in offering services to vulnerable groups (i.e. women and children) living in remote or difficult‐to‐access areas where their access to health services is poor. Previous studies have suggested that mobile clinics may have the potential to increase access to antenatal care (Edgerley 2007; O'Connell 2010), immunisation, malaria chemoprophylaxis, and regular monitoring of weight (Onyia 1981), and may also have the potential to increase utilisation of breast cancer screening (Skinner 1995), cervical cancer screening (Swaddiwudhipong 1995), and screening for STDs and HIV counselling (Ellen 2003).
However, despite the wide use of mobile clinics across a range of settings, there is ongoing debate regarding their use compared to static clinics (Mercer 2005). For example, in Thailand mobile services were more heavily utilised than static services, which may be because these mobile services were more accessible and acceptable to women (ACCP 2004). In contrast, in rural areas of other countries, such as Bangladesh (Mercer 2005), and Egypt (El‐Gibaly 2008), static clinics were preferred by women to satellite clinics. In Bangladesh, women who were dissatisfied with the mobile clinics reported lack of medicines and unavailability of some services. In Egypt, static clinics were preferred because women perceived that the quality of family planning services offered by the static clinics is better than that offered by mobile clinics. In addition, continuity of care offered in the static clinics and availability of health provider on a daily basis were other causes for static clinic preferences (El‐Gibaly 2008). In Egypt, a national strategic plan has been adopted for the period 2007 to 2017 and includes provision of fee‐waiver family planning/reproductive health services using mobile clinics. The intention of this plan is to make these services accessible in areas not served by static clinics (El‐Zanaty 2001). Women and children are vulnerable and high risk groups. They may, in some low‐ and middle‐income countries, have limited mobility and therefore have difficulties accessing health services. Bringing the service to them may therefore have a greater impact on their health than on the health of other population groups, such as men, in the same countries.
In addition, the inclusion of economic evaluation has become an increasingly accepted component of health policy and planning. A number of country experiences have shown that information on the cost‐effectiveness of health interventions can be used alongside other types of information to inform different policy decisions (Hutubessy 2003). Also, information about cost‐effectiveness can guide policy makers to make the right judgements and address inequities based on the evidence presented from cost‐effectiveness studies about the pros and cons of the different policies and programmes (Oxman 2009). This is of particular importance in countries where health care demand exceeds supply and where resources for healthcare provision are very limited. For example, in Egypt the cost per client at a mobile clinic is lower than that at static clinics. However, reproductive health services offered by mobile clinics were used by only 6% of the target communities (women living in remote rural areas), which may reduce their cost‐effectiveness (El‐Gibaly 2008).
Objectives
To evaluate the impact of mobile clinic services on women's and children's health.
Methods
Criteria for considering studies for this review
Types of studies
We included the following study designs:
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individual‐ and cluster‐randomised controlled trials (RCTs);
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individual and cluster non‐randomised studies;
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controlled before‐and‐after (CBA) studies that included at least two intervention sites and two control sites;
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interrupted time series (ITS) studies with a clearly defined point in time; when the intervention occurred and at least three data points before and three after the intervention.
Types of participants
We included women (defined as aged 18 years or more) and children (from birth until the age of 18 years) in low‐, middle‐, and high‐income countries.
Types of interventions
A mobile clinic is a clinic vehicle (with a healthcare provider) that visits areas on a regular basis (e.g. weekly, every two weeks , or monthly) to provide health services. We assessed mobile clinics for their effectiveness in providing services to women and children. These services include promotive, preventive, and curative care for women and children, and might involve antenatal care, postnatal care, screening for sexually transmitted diseases (STDs), screening for breast and cervical cancer, screening for osteoporosis, human immunodeficiency virus (HIV) counselling, family planning, vaccination of children, and regular weight monitoring of children.
We compared:
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mobile clinic services versus no services;
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mobile clinic services versus static clinics;
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combined mobile and static clinic services versus static clinics.
We excluded mobile clinics that provided services exclusively to men over the age of 18 years (since the interventions and outcomes of interest were related only to women and to children under the age of 18 years) and mobile clinics used in emergencies (such as in earthquakes). We didn't include outreach workers that used other means of transportation (e.g. bikes) to deliver e.g. family planning methods. This was because a mobile clinic is able to offer a different, and generally wider, range of services in a different way, compared to using a bike to reach a particular areas to deliver care. For example, the structure of a mobile clinic is often similar to that of a static clinic, and the mobile facility is usually staffed by a health professional trained to deliver a range of curative, promotive, and preventive services and with access in the mobile clinic to the equipment needed to undertake these activities (e.g. an ultrasound machine, instruments for examination, etc). In contrast, outreach workers who use other forms of transportation generally do not have access to this range of equipment and supplies. Also, we excluded a temporary clinic structure that was not mobile, but whose health workers only visited once a week (for example) to provide services to a particular community. Moreover, other types of outreach services are dealt with in other reviews, e.g. the Gruen 2003 review on specialist outreach clinics in primary care and rural hospital settings.
Types of outcome measures
Primary outcomes
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Health outcomes: participant outcomes were:
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health status and well‐being, including number of cases diagnosed, treated, or referred for treatment, including cases of STDs, high‐risk pregnancies, malnutrition among children and infectious diseases among children;
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health behaviour: any measure of the extent to which service users adhered to recommended care plans. For example, for women, whether they attended for the recommended number of antenatal visits, and for children, whether they completed the vaccination schedule at the designated time;
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utilisation, coverage, or access: we used coverage and service utilisation as proxies for the impact of health services on the health of women and children. Measures included:
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contraceptive prevalence;
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vaccination coverage among children;
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use of other services provided by mobile clinics (e.g. osteoporosis screening, antenatal care, postnatal care, screening for STDs, screening for breast and cervical cancer, HIV counselling, regular weight monitoring of children etc.);
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resource use, including:
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cost‐effectiveness of services offered by the mobile clinics in comparison to static clinics.
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Secondary outcomes
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Satisfaction (assessed in any way) of healthcare recipients with care.
Search methods for identification of studies
Electronic searches
We searched the following databases for related systematic reviews:
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Database of Abstracts of Reviews of Effectiveness (DARE), Centre for Reviews and Dissemination (CRD) (searched 20 February 2014)
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Health Technology Assessment Database (HTA), Centre for Reviews and Dissemination (CRD) (searched 20 February 2014)
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NHS Economic Evaluation Database (NHS EED), Centre for Reviews and Dissemination (CRD) (searched 20 February 2014)
We searched the following databases, with no language or date restrictions, for primary studies:
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Cochrane Central Register of Controlled Trials (CENTRAL) 2015, Issue 3, part of The Cochrane Library.www.cochranelibrary.com (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 7 April 2015)
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MEDLINE In‐Process & Other Non‐Indexed Citations, MEDLINE Daily, MEDLINE and OLDMEDLINE 1946 to Present, OvidSP (searched 7 April 2015)
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Embase 1980 to 2015 Week 14, OvidSP (searched 7 April 2015)
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CINAHL 1980 to present, EbscoHost (searched 7 April 2015)
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Global Health 1973 to 2015 Week 13, OvidSP (searched 8 April 2015)
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POPLINE, K4Health (searched 8 April 2015)
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Science Citation Index and Social Sciences Citation Index 1975 to present, ISI Web of Science (searched 8 April 2015)
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Global Health Library (GHL), Regional Indexes, Word Health Organization (WHO) (searched 8 April 2015)
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Pan American Health Organization database (PAHO), Virtual Health Library (VHL) (searched 8 April 2015)
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World Health Organization Library Information System (WHOLIS), WHO (searched 8 April 2015)
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Latin American and Caribbean Health Sciences database (LILACS), Virtual Health Library (VHL) (searched 9 April 2015)
Searching other resources
Trial registries
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International Clinical Trials Registry Platform (ICTRP), Word Health Organization (WHO): www.who.int/ictrp/en (searched 23 May 2016)
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ClinicalTrials.gov, US National Institutes of Health (NIH): clinicaltrials.gov (searched 23 May 2016)
Other sources
We also:
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reviewed the reference lists of relevant systematic reviews and studies
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conducted a cited reference search for all included studies using Science Citation Index and Social Sciences Citation Index 1975 to present, and Emerging Sources Citation Index 2015 to present, ISI Web of Science (searched 18 January 2016)
See Appendix 1 for the search strategies we used.
Data collection and analysis
Selection of studies
Two review authors independently screened the titles and abstracts of studies identified by the search strategy to assess which studies met the inclusion criteria. We obtained the full‐text articles of potentially eligible studies. Two review authors (AF and GS) assessed the full‐text articles against the inclusion criteria of this review. Whenever there was uncertainty or disagreement, we reached consensus by discussion among the review authors (HAA). All full‐text articles that were excluded after full‐text assessment are listed in the 'Characteristics of excluded studies' table.
Data extraction and management
Two review authors independently extracted details of study design, population, intervention, and comparison, and outcome data from included articles using a specially‐designed data extraction form based on the Cochrane EPOC Group data collection sheet.
The extracted data included:
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participant characteristics (age, gender, education, ethnicity, health issues, etc.) and number of participants included in the study;
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intervention characteristics (description of the mobile clinic including staffing, drugs, equipment, number of visits to the target area etc.) and comparison static clinic characteristics in the same terms. These descriptions also included the characteristics of the healthcare providers in both types of clinics (age, gender, profession, level of training, etc.) whenever reported in the included studies;
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the setting (urban/rural) and description of other services provided in the served communities;
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the country (low‐, middle‐, or high‐income);
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description of the outcomes, timing of outcome assessment, and outcome data.
Assessment of risk of bias in included studies
Two review authors independently assessed the risk of bias of each included study using the nine standard Cochrane EPOC criteria and the seven standard criteria for ITS studies (EPOC 2015; Appendix 1). Judgements on the overall risk of bias took into account the likely magnitude and direction of the bias and whether we considered that the bias impacted on the findings. We assessed studies to be at high risk of bias if they scored 'high risk' in one or more of the following domains: sequence generation; allocation concealment; or selective outcome reporting (based on growing empirical evidence that these three factors are the most important in influencing risk of bias) (Higgins 2011). We judged the overall risk of bias as low if we assessed these key domains as at low risk of bias; unclear if one or more key domains were at unclear risk of bias; and high if one or more key domains were at high risk of bias.
Measures of treatment effect
For dichotomous outcomes, we had planned to use risk ratios (relative risk). For continuous outcomes measured in the same way, we had planned to use the mean difference. We had planned to use the standardised mean difference to combine the data from trials that measured the same outcome using different methods.
Unit of analysis issues
We used the odds ratio (OR) of the non‐randomised studies because it accounted for clustering in data. For example, in Reuben 2002, the primary analysis adjusted for correlation of observations within sites (cluster effect) using the Huber method (inflating the standard errors), which is a non‐parametric correction independent of observations when estimating the sample variance.
However, Eakin 2012 used a generalised estimating equation (GEE) to estimate the group population average for each outcome over time to control for the correlation among longitudinal measures within an individual, while adjusting for baseline level of each outcome.
In future updates, we may need to re‐analyse cluster‐RCTs if clusters were not taken into consideration during analysis. We will re‐analyse each study if it is possible to extract the following information from the trial report:
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the number of clusters (or groups) randomised to each intervention group, or the average (mean) size of each cluster;
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the outcome data ignoring the cluster design for the total number of individuals (e.g. number or proportion of individuals with events, or means and standard deviations (SDs));
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an estimate of the intracluster (or intraclass) correlation coefficient (ICC).
We will present the point estimate of effect without any measure of uncertainty, and will note the presence of unit of analysis errors.
Dealing with missing data
We assumed that data were missing at random (as judged by the authors of each included study, i.e. missing due to refusal, or dropout). Therefore we analysed the available data only (and ignored the missing data).
In future updates, if we assume that data were not missing at random (as judged from the sociodemographic characters of the study participants compared to the outcome results in the same paper and the authors' justification for selecting a certain group versus another), whenever possible we will contact the original study investigator for missing data. In case of missing summary statistics (e.g. SDs), we will look for other statistics within each study to calculate the SD.
Assessment of heterogeneity
We were unable to assess heterogeneity as only two studies (three articles) met the inclusion criteria of this review. In future updates, we will assess clinical heterogeneity across the non‐randomised studies based on differences in populations, interventions, comparisons, and outcomes.
We will assess statistical heterogeneity using the T² value, the I² statistic, and the Chi² test and also using visual interpretation of forest plots. We will consider heterogeneity substantial where the T² value is greater than zero, and either the I² statistic is greater than 50% or there is a low P value (less than 0.10) in the Chi² test for heterogeneity. We will explore any heterogeneity (see the 'Subgroup analysis and investigation of heterogeneity' section below).
Assessment of reporting biases
We were unable to assess publication bias as only two studies (three articles) met the inclusion criteria. In future updates of this Cochrane review, we will assess publication bias using a funnel plot provided that there are 10 or more studies included in an analysis. We will judge publication bias to exist when we detect asymmetry in the funnel plot.
We assessed selective outcome reporting bias in each included study by comparing the outcomes reported in the results to those previously specified in the methodology section. Also we assessed this by checking whether the outcomes reported included those expected to have been measured in the study, based on the research question if the study protocol was unavailable.
In future updates, and provided that the study protocols are available, we will assess reporting bias by comparing if all of the prespecified (primary and secondary) outcomes list in the protocol are also reported in the published study. Where study protocols are unavailable, we will assess selective outcome reporting as above.
Data synthesis
Due to the small number of included studies and different outcomes reported, we were unable to perform data synthesis. In future updates of this review, we will group and compare studies according to similar outcome measures, e.g. non‐randomised studies that report contraceptive prevalence rate, vaccination coverage, percentage of breast cancer screened women, percentage of women with osteoporosis, etc. We will use a random‐effects model for meta‐analysis, based on the assumption that the true effects measured across non‐randomised studies are related but not the same due to differences in population, intervention, and setting. If studies are not sufficiently homogeneous to combine in a meta‐analysis, we will present the results of included studies in a forest plot but will not present the pooled estimate.
Subgroup analysis and investigation of heterogeneity
In future updates, we will investigate heterogeneity even if there is no statistically significant heterogeneity. We plan to perform the following subgroup analyses:
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gender of the health care provider(s) that offers services to women included in the study, as the gender of the healthcare provider may affect the acceptability of the service and seeking of health care;
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whether the study was conducted in a low‐, middle‐, or high‐income country as the socioeconomic level within the country may affect the quality and level of services offered by the mobile clinics;
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the geographical setting of the study as living in a rural or urban area may affect the accessibility of the mobile clinic and may also affect quality.
Sensitivity analysis
In future updates of this review, we will conduct sensitivity analyses based upon the following to determine how robust and consistent the results are:
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exclusion of all non‐RCTs;
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exclusion of studies at high risk of bias (assessed using the Cochrane 'Risk of bias' tool described above);
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exclusion of studies where we have obtained additional data from the study investigators;
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variation of the ICC used to re‐analyse data from cluster‐RCTs
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exclusion of data from studies that were re‐analysed.
'Summary of findings' tables
We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence related to each of the key outcomes. We created 'Summary of findings' tables using the GRADEpro Guideline Development Tool (GDT) (available from www.gradepro.org). As we only had the complete information from one included study (Reuben 2002), we assessed the quality of the evidence for this study only and included it in the 'Summary of findings' table.
Results
Description of studies
Results of the search
The search retrieved 9516 records. There were 6910 after we removed duplicates. We screened 6910 records by title and abstract, and excluded 6820 articles. We assessed 90 full‐text articles for eligibility. We excluded 84 studies and three studies are awaiting classification while 3 articles (constitute 2 studies) were included. The reasons for exclusion: studies had an ineligible study design (n = 63); used an ineligible interventions (n = 16); were reviews rather than primary studies (n =5) (see Characteristics of excluded studies). We have presented this information in the study flow diagram in Figure 1.
Study flow diagram.
Included studies
Two studies met the inclusion criteria of this review (Reuben 2002; Eakin 2012). Another published paper, Naeim 2009, was a cost‐effectiveness analysis and a secondary analysis of data collected in Reuben 2002. It focused on the cost‐effectiveness of the intervention.
Reuben 2002 is a cluster‐randomised controlled trial (RCT) that tested whether the offer of immediate, onsite, mobile mammography combined with health education was effective at increasing breast cancer screening rates versus health education alone, including encouragement to have a mammogram at the typical static clinic. The study randomised 60 community‐based meal sites, senior centres, and clubs in California, USA to either health education only or health education plus onsite mobile mammography over a two‐year period. There were 463 female participants (aged 60 to 84 years at study entry): 235 were offered health education and onsite mobile mammography and 228 received health education only.
The exclusion criteria of this study included recent mammography (within the past year), no telephone, inability to speak English or Spanish, and limited cognitive capacity to participate in the study (based on failure to be oriented to the date and day of the week, and inability to place numbers appropriately on an outline of a clock). The study assessed self‐reported mammography after three months through telephone interviews.
A secondary analysis, Naeim 2009, examined the cost‐effectiveness of mammography at mobile versus static (stationary) units.
The second included study was a cluster‐RCT that evaluated whether a 'Breathmobile' clinic would improve asthma outcomes compared to standard care, a static clinic (Eakin 2012). 'Head Start' programme sites in Baltimore, USA (66 sites in total) were the units of randomisation, while children were the unit of analysis. The Breathmobile is a mobile asthma clinic that delivers asthma screening, evaluation, and treatment services directly to inner city children at their schools or at the Head Start sites. A specially trained nurse practitioner, allergist, nurse, and driver/patient assistant provide care on the Breathmobile. The study included 322 children aged two to six years of age with persistent asthma. Eligibility criteria included caregiver reported physician diagnosed asthma or reactive airways disease and at least one of the following:
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use of short acting beta agonist in the past four weeks;
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asthma symptoms in the past four weeks; or
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treated in the emergency department (ED) for asthma in past six months.
The study included both male and female children, and most participants were African‐American (more than 97%) in the two trial arms relevant to this review. Most children belonged to low‐income families.
Eakin 2012 included the following outcome measures:
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symptom‐free days (SFD). This primary outcome was calculated by subtracting the number of days, or nights, or both, with asthma symptoms (i.e. cough, wheeze, shortness of breath) in the past 30 days, as reported by caregivers;
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acute care and medication use. This measure included caregiver reports of ED visits, hospitalisations, prescribed asthma controller medication regimen (e.g. inhaled corticosteroid and leukotriene modifiers), and courses of oral corticosteroids in the previous six months;
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caregiver quality of life. The study used the Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ), which is a 13‐item measure of activity limitations (four items) and emotional function (nine items) experienced by caregivers of asthmatic children. Responses on the PACQLQ are given on a 7‐point scale where 1 represents severe impairment and 7 represents non‐impairment. Higher scores indicate higher quality of life.
Excluded studies
We excluded 82 articles due to ineligible study design (n = 62); failure to meet our intervention definition (n = 16), or because they were not primary studies (n = 4) (see the 'Characteristics of excluded studies' table).
Risk of bias in included studies
We have presented a summary of the 'Risk of bias' assessments in Figure 2 and Figure 3, and provided the detailed assessments in the 'Characteristics of included studies' tables. Overall, we assessed the two included studies as at moderate risk of bias.
'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies.
'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study.
Allocation
We assessed Reuben 2002 as at low risk of selection bias. Eakin 2012 was at unclear risk of bias as the study did not report adequately on how sequence generation was determined.
Blinding
In Reuben 2002 blinding of the participants and research associates was not possible (high risk of bias). The study reported that "on the day of the program, the presence or absence of the mobile mammography van revealed to participants which intervention group they had been assigned. For the same reason, the research associates administering the interventions also were aware of participants intervention status. While blinding was assured for outcome assessment since the outcomes assessor was unaware of the intervention group status of all participants”. The study used telephone interviews to ask women whether they had undergone mammography.
In Eakin 2012, blinding of the participants to the intervention could not be assured (high risk of bias); the study reports that the Breathmobile was present only at those Head Start sites assigned the Breathmobile. However, outcome assessment was blinded since the research assistants that conducted follow‐up telephone surveys were unaware of participants' group assignment.
Incomplete outcome data
We assessed the risk of attrition bias as low in both studies since the proportion of missing data was similar in the intervention and control groups.
Selective reporting
Selective reporting bias was unclear in both included studies. Although the studies reported all outcomes listed in the methods section in the results section, we were unable to assess the study protocols (unavailable).
Other potential sources of bias
For cluster‐RCTs, we assessed the following potential sources of bias.
Recruitment bias
Individuals were most likely recruited to the trial after the clusters had been randomised in both studies, but this was unclear for Eakin 2012.
Baseline characteristics
We assessed this as low risk as baseline characteristics were similar across intervention and control in the two included studies.
Loss of clusters
There was no evidence of loss of clusters in either study.
Incorrect analysis
We assessed Reuben 2002 as at low risk of bias as the study authors took clustering into consideration during the analysis using the Huber method (inflating standard errors). Eakin 2012 was unclear regarding this risk of bias item as the study authors used generalised estimating equations (GEE) but did not discuss adjustment for clustering explicitly.
Effects of interventions
See: Summary of findings for the main comparison Mobile clinics versus static clinics for mammography screening; Summary of findings 2 Mobile clinics versus standard static services for childhood asthma care
Primary outcomes
1. Health outcomes
1.1 Health status and well‐being
One study, Eakin 2012, showed that children who receive asthma care from a mobile asthma clinic may experience little or no difference in symptom‐free days up to 12 months following the intervention versus children who receive standard asthma care from their primary care provider (low certainty evidence) (summary of findings Table 2).
Eakin 2012 showed that children who receive asthma care from a mobile asthma clinic may experience little or no difference in urgent care use (including both emergency room use and hospitalisations) up to 12 months following the intervention versus children who receive standard asthma care from their primary care provider (low certainty evidence).
Eakin 2012 also assessed caregiver quality of life, and showed that there may be little or no difference in this measure at 12 months among caregivers of children who receive asthma care from a mobile asthma clinic compared to caregivers of children who receive standard asthma care from their primary care provider (low certainty evidence).
1.2 Health behaviour
One study, Reuben 2002, showed that women offered immediate, mobile onsite mammography and health education may be more likely than those offered health education only (including encouragement to have a mammogram at any usual static clinic) to report undergoing mammography within three months of the intervention (55% versus 40%; OR 1.83, 95% CI 1.22 to 2.74; low certainty evidence) (Analysis 1.1; unadjusted data only) (summary of findings Table for the main comparison).
The second included study, Eakin 2012, showed that there may be little or no difference in caregiver‐reported medication use at 12 months (including courses of oral steroids and prescriptions of inhaled corticosteroids) among children who receive asthma care from a mobile asthma clinic compared to children who receive standard asthma care from their primary care provider (low certainty evidence) (summary of findings Table 2).
2. Utilisation, coverage, or access
None of the included studies assessed this outcome.
3. Resource use
Naeim 2009 reported a secondary cost‐effectiveness analysis of the data from Reuben 2002. This evaluation compared three types of screening program: stationary mammography units (with full digital film), mobile mammography with screen‐film, and mobile mammography with full digital film. The study included the following cost items: costs of equipment, mobile van, personnel, operating costs, processing and printing, and real estate costs. The study found that the total cost per patient screened was USD 41 for a stationary full digital unit, USD 102 for a mobile full digital unit, and USD 86 for mobile film unit. The study calculated the incremental cost per patient as the cost per mobile screening minus the cost per stationary screening. For mobile screening compared to screening at a stationary unit, the incremental cost per patient was USD 61 for a mobile full digital unit and USD 45 for a mobile film unit. For a mobile compared to a stationary unit, the incremental cost per screening was USD 264 for a mobile full digital unit and USD 207 for a mobile film unit. This evidence was of low certainty (summary of findings Table for the main comparison).
Secondary outcomes
1. Satisfaction with care among healthcare recipients
None of the included studies assessed this outcome.
Discussion
Summary of main results
This Cochrane review aimed to assess the impact of mobile clinics that delivered services on any aspect of women's and children's health. However only two studies met the inclusion criteria. Reuben 2002 focused on mammography screening for women, and Eakin 2012 focused on care for children with asthma. Women who are offered mobile onsite mammography and health education may be more likely than those offered health education only to report undergoing mammography within three months of the intervention. However, the total cost per participant screened may be higher for mobile units than for stationary units. Children who receive asthma care from a mobile asthma clinic may experience little or no difference in symptom‐free days, urgent care use, and caregiver‐reported medication use versus children who receive standard asthma care from their usual primary care provider. In addition, there may be little or no difference in quality of life among caregivers of children who receive asthma care from a mobile asthma clinic compared to caregivers of children who receive standard asthma care. The certainty of the evidence was low for each of these outcomes.
Overall completeness and applicability of evidence
This Cochrane review aimed to evaluate the impact of mobile clinic services on women's and children's health. However, the available evidence was limited, and both included studies were conducted in a high‐income country among quite specific populations (children aged two to six years with persistent asthma and older women who might be eligible for mammography screening). This limits the applicability of the evidence to low‐ and middle‐income country settings, as well as to other populations. Mobile clinic utilisation and impact may be influenced by a various number of factors, including the reasons for using mobile services (e.g. improving geographical access to a package of health services or increasing coverage of targeted interventions to a targeted population) and the context in which these services operate.
For a number of review outcomes, including utilisation, coverage, or access and satisfaction with care among healthcare recipients, little or no data were available. For other outcomes, the data available were sparse. Further rigorous studies are needed that both cover a range of settings, populations, and health issues and that assess a wide range of outcomes relevant to understanding the effects of mobile clinics.
This review considered studies with a wide range of designs for inclusion and is based on comprehensive searches, without language or publication status restrictions. We searched for randomised controlled trials (RCTs), non‐randomised studies, controlled before‐and‐after (CBA) studies, and interrupted time series (ITS) studies. We included this range of designs as randomisation may not be feasible for some mobile clinic interventions. However, non‐randomised studies, CBA, and ITS studies are not as well indexed as RCTs in electronic databases and it is possible that we may have missed some studies.
Certainty of the evidence
The 'Summary of findings' tables for the main comparisons summarise the certainty of the evidence for the key outcomes (summary of findings Table for the main comparison; summary of findings Table 2).
Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the certainty of the evidence as low. We judged both included studies as at moderate risk of bias overall and there was some imprecision around the estimate of effect (Reuben 2002; Eakin 2012). This suggests that the likelihood that the effect will be substantially different (i.e. the difference may be large enough to affect a decision) from that reported in the studies is high.
Potential biases in the review process
Identifying studies of mobile clinic interventions in electronic data base is challenging. However, our literature searches included many synonyms (mobile unit, mobile centres, mobile facilities, etc.) and we also searched a number of grey literature sources. Widening the scope of the eligible studies to include those carried out in high, middle or low income countries was an advantage to draw the attention to the absence of experimental studies evaluating the role of mobile clinics compared to the static clinics in low middle income countries.On the other hand, among the limitations which could be out of our control, is the possibility that we did not identify all eligible studies.The unpublished data were not obtained. Moreover, few outcomes were identified in the review compared to the proposed outcomes planned in the protocol. Many published papers evaluated the role of mobile clinic in offering maternal and child health services, however, because we limited our selection criteria to experimental designs only, none of the observational studies were included in this review. Another potential bias is that we excluded studies involving services offered to men which could have helped in better understanding the role played by the mobile clinics in improving health within communities and overcoming access barrier. However, we did exclude those studies because we were more interested in understanding mobile services offered to vulnerable populations (women and children) most.
Agreements and disagreements with other studies or reviews
Two other systematic reviews have explored the effects of mobile clinics. Mdege 2014 examined evidence on the use of mobile clinics to bring antiretroviral therapy closer to end users. The review did not identify any eligible studies on this topic. A second review, Vashishtha 2014, examined the use of mobile dental units. While Vashishtha 2014 identified a number of studies, none of these studies were eligible for inclusion in this Cochrane review as they did not meet our study design criteria.
We identified two other studies that evaluated the effects of mobile clinics for women's and child health but they did not use designs that were eligible for inclusion in this review (see the 'Characteristics of excluded studies' table). One cohort study, O'Connell 2010, evaluated the difference in prenatal care utilisation and birth outcomes among demographically similar women who used, or did not use, a mobile van (on a regular schedule and equipped to deliver services for women) for prenatal care in Florida, USA. This study suggested that adequate prenatal care was higher for mothers that utilised a mobile van compared to those who did not. One ITS study evaluated the use of mobile clinics for cervical cancer screening in rural Thailand (Swaddiwudhipong 1995), but did not meet our ITS study eligibility criteria. This study suggested that knowledge about cervical cancer and cervical cancer screening, as well as ever being screened for cervical cancer, increased after implementation of the mobile clinic intervention. The findings of both of these studies should be viewed with caution as these studies used designs that are at high risk of bias.
The inclusion of an economic perspective in the evaluation of health and health care has become an increasingly accepted component of health policy and planning. A number of country experiences have shown that cost‐effectiveness information can be used alongside other types of information to guide policy makers who address inequities and make evidence‐based decisions (Oxman 2009), and thus aid different policy decisions (Hutubessy 2003). In this Cochrane review, one study included a cost‐effectiveness analysis (Reuben 2002). Although mobile mammography was more effective, the costs per screen were much higher in the mobile units compared with stationary units. Incremental cost per patient for a mobile over a stationary unit was USD 61 for a mobile full digital unit and USD 45 for a mobile film unit. Other studies have suggested that mobile clinics might be most cost effective in rural and remote areas. For example, a cost‐effectiveness analysis of mobile clinics used for screening for cervical cancer in Japan showed that these had the highest benefit‐cost ratio (1.20) and were more suitable for rural areas compared to a detection centre and a private physician program (Takenaga 1985). A cross‐sectional study from Tunisia also showed that a mobile clinic service was cost‐effective in delivering family planing services to remote rural areas (Coeytaux 1989). This study highlights that clinic output was positively associated with literacy of the population, the number of centres served by a unit, and the frequency with which centres were served in a month. These factors may be important considerations for future evaluations.
Study flow diagram.
'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies.
'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study.
Comparison 1 Mobile versus static clinic for mammography, Outcome 1 Mammography within 3 months of the intervention: unadjusted.
| Immediate onsite mobile mammography with health education versus health education only (including reminders to attend a static clinic service for mammography) | |||||
| Participant or population: women aged 60 to 84 years at study entry. (Age of participants matches our selection criteria) | |||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of participants | Certainty of the evidence | |
| Assumed risk | Corresponding risk | ||||
| Static clinic | Mobile clinic | ||||
| Health status and well‐being | The study did not assess this outcome | ||||
| Health behaviour: self‐reported mammography uptake | Study population | OR 1.83 | 473 | ⊕⊕⊖⊖ Low 2 | |
| 382 per 1000 | 531 per 1000 | ||||
| Utilisation, coverage or access | The study did not assess this outcome | ||||
| Resource use: total cost per patient receiving mammography screening | The total cost per patient screened may be higher for mobile units than for stationary units (USD 41 for a stationary full digital screening unit; USD 102 for a mobile full digital screening unit; and USD 86 for mobile film screening unit). This evidence was of low certainty (⊕⊕⊖⊖)2 | ||||
| Satisfaction with care among healthcare recipients | The study did not assess this outcome | ||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence High certainty: this research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different3 is low. | |||||
| 1Naeim 2009. | |||||
| Mobile clinics compared with standard 'static' services for childhood asthma care | |||
| Paticipannt or population: children aged 2 to 6 years with persistent asthma and their caregivers. (Age of participants matches our selection criteria) Settings: High income country; USA (Baltimore) Intervention: mobile asthma clinic delivering screening, evaluation, and treatment services Comparison: static services comprising standard asthma care from the usual primary care provider | |||
| Outcomes | Impact | No of participants | Certainty of the evidence |
| Health status and well‐being (follow‐up: 12 months) | Children who receive asthma care from a mobile asthma clinic may experience little or no difference in symptom‐free days and urgent care use, compared to children who receive standard asthma care. There may be little or no difference in quality of life among caregivers of children who receive asthma care from a mobile asthma clinic, compared to caregivers of children who receive standard asthma care. | 322 (1)1 | Low 2 ⊕⊕⊖⊖ |
| Health behaviour (follow‐up: 12 months) | There may be little or no difference in caregiver‐reported medication use among children who receive asthma care from a mobile asthma clinic compared to children who receive standard asthma care. | 322 (1)1 | Low 2 ⊕⊕⊖⊖ |
| Utilisation, coverage or access | The study did not assess this outcome | ||
| Resource use | The study did not assess this outcome | ||
| Satisfaction with care among health care recipients | The study did not assess this outcome | ||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||
| GRADE Working Group grades of evidence High certainty: this research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different3 is low. | |||
| 1Eakin 2012. | |||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Mammography within 3 months of the intervention: unadjusted Show forest plot | 1 | 463 | Odds Ratio (M‐H, Fixed, 95% CI) | 1.83 [1.27, 2.65] |
