Developing a Public Health Quality Tool for Mobile Health Clinics to Assess and Improve Care

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1. The methods describe multiple development stages, consider adding a clearer discussion of how user feedback was systematically analyzed and integrated into each revision cycle.
2. The sample of participating clinics is diverse, however, the manuscript does not explain how representativeness was ensured, or whether certain types of clinics may be over- or under-represented in the pilot and post-COVID implementation.
3. The findings highlight strong usability ratings, but do not present statistical analyses or confidence measures, which would strengthen the validity of claims regarding acceptance and relevance of the PHQTool.
4. The tool’s six quality aims are well justified, but the criteria used to exclude the other three original aims are described narratively rather than analytically; a clearer rationale or decision framework would improve methodological rigor.
5. The results section reports improvement goals selected by clinics, however lacks deeper analysis of whether these goals translated into measurable changes, limiting insight into real-world impact and outcome effectiveness. Consider adding such discussion into the manuscript.
6. The method for evaluating the tool’s effectiveness in supporting quality improvement is not clearly defined, making it difficult to assess whether increased usage correlates with improved clinic performance or only with engagement. Do clarify on this matter.
7. The manuscript discusses wide dissemination, consider including a comparative analysis of usage trends before and after COVID-19, to highlight how external factors influenced uptake and tool relevance.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The paper presents a valuable, evidence-based online tool to support quality assessment and improvement in mobile health clinics (MHCs) serving underserved populations. The manuscript is concise, clearly written, and provides solid historical and conceptual grounding for the tool. Nevertheless, the following points may help strengthen the work.

1. Given the potentially international readership, it would be helpful to clarify whether the MHC model described is specific to the U.S. or whether similar models exist in other countries. If comparable international initiatives or academic efforts exist regarding self-assessment or quality-improvement guidelines for mobile or outreach clinics, citing them would broaden the context. If no such efforts exist, stating this explicitly would highlight the novelty of the PHQTool.

2. Please clarify whether there is any published work documenting the process or results of adapting Honore et al.’s nine quality aims to the six selected for this tool. Providing a reference would improve transparency.

3. The manuscript reports results from the second implementation round in 2015. Given that these data are now a decade old, it would be important to justify their inclusion. A brief explanation of why more recent usage or satisfaction data are not available, or why the 2015 findings remain relevant after COVID-19, would strengthen the rationale.
Additionally, please clarify how many MHCs participated in the 2015 analysis (e.g., 45?).

4. Consider adding a future roadmap for the PHQTool in the Discussion. Indicating planned updates, potential expansion, or refinement would give readers a sense of the tool’s sustainability and future utility.

5. Minor comments.

• Line 25: introduce the abbreviation at first mention, not at line 30.
• Line 49: if “nation” refers to the United States, please name it explicitly for clarity.
• Review references, particularly items 7 and 9, for accuracy and formatting.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors,

Good paper. See the suggestion below

 

Several author affiliations list cities and states but do not include country names, which goes against standard journal requirements for global indexing.
Example: “Boston, MA, 02115, USA” includes USA, but others omit country designation. Some affiliations only show U.S. states without a country reference.

 

There are multiple affiliations per author that are difficult to follow. Some institutions appear duplicated or lack full institutional detail, such as “Mobile Health Care Authority” and “Mission Mobile Medical” without consistent formatting.

 

Abstract

The background states that MHCs lack tools, but does not clearly articulate the research question or aim of this specific study such as development and evaluation of PHQTool.

Terms such as “expert consultation,” “pilot testing,” and “iterative refinement” are mentioned without specifying: Number of experts, Inclusion criteria for clinics, Data collection or assessment methods.

You reports “82 MHCs … reporting high usability” but the lacks numeric result indicators (e.g., response rate, usability scale range), Does not clarify whether improvement goals were achieved.

 

Introduction

The manuscript provides a strong background justification; however, it currently lacks a clearly articulated research question or objective. Please add a concise statement clarifying the aim of the study, such as:
“This study describes the development process and preliminary evaluation results of the PHQTool.”

Lines 58–59: Strengthen the introduction by including recent literature (2022–2024) on mobile clinic quality assessment and evaluation frameworks to provide contemporary context and demonstrate how this work advances current knowledge.

Methods

Please state whether ethical approval or exemption was obtained, particularly since user-generated program data were collected and analyzed. Clarifying the role of human subjects protection is essential for transparency.

Results

Line 122: The statement “96% rated usability as high” should be supported with specific quantitative information, including sample size (n), type of usability instrument or rating scale used, and the range of possible scores. This will allow readers to evaluate the reliability and significance of the reported outcomes.

Discussion

The manuscript would be strengthened by explicitly addressing study limitations, including:

self-selection bias of participating clinics

limited generalizability beyond the current sample

absence of longitudinal data demonstrating quality improvements over time
A dedicated limitations section is advisable.

Conclusion

Please ensure that concluding statements are aligned with the evidence actually presented in the study. Current claims regarding overall improvement and accountability appear aspirational rather than empirically demonstrated. Adding a sentence that acknowledges the need for future validation and formal outcome evaluation would improve balance and accuracy.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

the authors have addressed the comments accordingly.