Background

Community participation is known as the collective involvement of people in assessing their needs [1]. Prior research suggests that community participation in community services and programming is integral to the health of the community and its sustainability, and such participation can yield positive long-term health outcomes [2]. Community participation in primary and rural health care services has promoted more accessible and relevant services [2, 3], and it can result in higher community-member satisfaction with health services [4]. There is a long tradition of community-member contributions to various health services and preventative health programs [5,6,7].

A Learning Health care System (LHS) is a model that ‘draws from the best scientific evidence while tailoring optimal care to a local health care setting to each patient’ [8, 9]. As technology advances, so does access to clinical and person-specific data that can inform health care decision making [8]. An LHS has three core components: (1) foundational elements; (2) care improvement targets; and (3) a supportive policy environment [9]. Foundational elements include upgrading digital technology to collect data and facilitate data sharing within the health care system. Care improvement targets assist learning and health through clinical decision support tools, patient-centered care, and clinician-community links. A supportive policy environment includes financial incentives that reward high-value care, encourages transparency within the health care system and commitment from leaders. An LHS can lead to many optimal health care characteristics, including engaged patients, appropriate decision supports, aligned governance, and sharing of necessary data; however, adopting an LHS approach has come with an obstacle, to effectively engaging community members to achieve optimum health outcomes.

A Learning Health Care Community (LHCC) model expands on the LHS model by combining the core elements of an LHS with a fourth component: active and continuous stakeholder and community engagement to improve the quality and value of health care within a community [9]. An LHCC focuses on health care beyond a health care system and extends beyond an LHS, which focuses on collaboration in health care. The LHCC uses the best practices of the LHS model with evidence-based approaches to engage community members.

The aims of an LHCC include increasing collaboration between public health and traditional health care providers and intending to address all areas required to achieve optimal impact on health for the community. Collaboration from multiple community sectors and effort from the community is vital to the success of the LHCC. Previous literature has found that engaging community members in meaningful conversations regarding their health care is associated with improved health outcomes, quality of time, and better health care experiences [9].

The LHCC should be trusted and valued by all stakeholders and consist of an economically governable system while being responsive to community needs. Past involvement in discriminatory practices committed against vulnerable and minority populations has impacted community-institution relationships [10]. However, ongoing commitment of investigators and research teams, treating community members as partners, working collaboratively, increasing skills in relationship building, and listening to diverse voices can overcome mistrust by health care providers and researchers [10, 11]. Co-development with communities can assure trustworthy and targeted implementation to address community needs [9].

An LHS model lacks community involvement and fails to consider community-based health care problems [9]. As a result, these communities lack control and power over their health care. An LHCC places the voices of communities at the center of their health care, empowers community members, and increases opportunities for health-related learning [8, 9]. The LHCC framework is relatively new, and, there is limited research on the impact of LHCCs in rural areas. The majority of existing research on LHCCs is completed in urban areas, or it is outcome-focused with less emphasis on the enablers and barriers that enhanced or hindered the implementation process. We sought to address this gap in existing knowledge by summarizing the barriers and enablers across all LHCCs implemented in rural areas. The current review can be used as a guide to develop more targeted and seamless approaches to develop an LHCC and achieve community health outcomes.

Methods

Research aim

The current paper aimed to summarize evidence on the facilitators and barriers that are involved in the LHCC implementation process for rural health care providers, researchers, decision-makers, and community members who wish to implement an LHCC.

Question of interest

What are the barriers and enablers to building a learning health care community in rural areas?

Research design and information sources

We conducted a mixed-methods systematic review. The JBI methodology for mixed-methods systematic reviews was used to inform the entire systematic review. Thematic coding was completed according to the JBI convergent-integrated approach [12].

Eligibility criteria

A search of English peer-reviewed published articles that were rural-based, health-related, and involved the implementation of an LHCC was undertaken. Inclusion criteria included the following:

  • Studies must have been conducted in rural areas. For the purpose of this study, areas were considered rural if they were outside cities [1]. The research team also checked the author’s definition of a rural area used in the included studies.

  • Community participation took place and it was related to improving the health services, health knowledge, or well-being of community members.

  • Studies must have included at least one of the following stakeholders (researcher, health care providers, health system leaders, etc.), as well as a community or patient population.

  • Co-learning took place by community members and stakeholders. Co-learning refers to a bi-directional learning process, where knowledge exchange occurs between those involved [13]. Health care providers, leaders, researchers or investigators learned from the community (e.g., their feedback) and community members learned about a health-related topic or health service from health care providers, leaders, researchers or investigators.

Articles were excluded if they were the format of a letter to the editor, a systematic review, an audit, or an editorial. Studies focused on an urban area or simply on an LHS rather than an LHCC were also excluded. All included studies in the review and articles deemed eligible were assessed and included in the review.

Search strategy

Rural and primary health care experts were consulted to identify keywords and studies on LHCCs, community engagement and health care practitioners. Then, in consultation with a librarian, the search terms were tested and refined. Next, a Public Services Librarian from Memorial University of Newfoundland searched databases including Medline (Ovid), Embase (Embase.com) and The Cumulative Index to Nursing and Allied Health Literature (CINAHL; Ebsco) to identify potentially relevant articles up until May 2, 2023. See Additional File 1 for the search history for Ovid Medline. Results were imported into Endnote X9 for deduplication and then into Covidence for screening.

Study selection and data collection process

Relevant titles and abstracts by database searches resulted in the identification of 8169 articles. After duplicates were removed, 8096 articles remained. Articles were screened independently by two trained authors using Covidence, an online software that streamlines the production of systematic reviews. If an abstract was deemed relevant, a vote of ‘Yes’ was assigned to the article, and if an abstract was deemed irrelevant a vote of ‘No’ was assigned to the article. If both reviewers assigned a vote of ‘Yes’ the article moved into the full-text phase, and if both reviewers voted ‘No’, the article was excluded. Any abstracts that received conflicting votes or were assigned a vote of ‘Maybe’ were discussed and resolved between authors. After a consensus was reached, full texts of the remaining articles were obtained and this process was repeated. A calibration exercise was administered to portray the validity of the research on 10% of the articles in each stage and our approach was adjusted if it was required. For the abstract, 816 articles (10%) were randomly selected, and a third reviewer examined these abstracts. Reference lists and citations within full text articles were checked for eligibility. No additional articles were added using this approach. The same process was used for screening and data extraction. Next, the research team confirmed the included articles following review and conflict resolution. Weekly meetings were executed to discuss the articles. If there were any conflicts in article decisions, a third reviewer was involved in the resolution.

Data synthesis methods

Included articles were moved to data extraction by both independent reviewers. A data extraction tool was developed using Microsoft Excel and pilot tested on 5 articles. Both reviewers independently entered the data to the tool. Columns were included that summarized key information pertaining to the article (i.e. Geographical Setting, Study Objectives, Community Group, Enablers and Barriers, etc.).

Data from each article was compiled into the Microsoft Excel sheet and reviewed by the research team. The compiled articles (n = 25) were reviewed by several team members and discussed during meetings until we reached consensus. Similar text fragments were grouped and categories were identified. Consistent with the JBImixed-methods systematic review convergent-integrated approach [12], categories were identified based on assembled data from both qualitative and quantitative studies. Next, categories were aggregated to form themes relating to the barriers and enablers to building an LHCC. A consensus on the final list of themes was reached through group discussions to reduce bias and ensure consensus was reached.

Enablers and barriers were discussed in relation to the four main components of the LHCC. The Stakeholder and Community Engagement component highlights studies that identified effectively engaging community members to be pivotal to an LHCC success. Infrastructure for health related data-capture was relevant to studies that found harnessing contemporary technology, information sharing through in-person and online interventions, development of educational materials, and health-related data sharing to be vital to patient health. Care Improvement Targets were included as various stakeholders aimed to improve health, disease management, and increase awareness and uptake of prevention interventions within the community. Care Improvement Targets were organized according to the Institute of Medicine’s report: “Crossing the Quality Chasm: A New Health System for the 21st Century” six aims for success (1) safe; (2) effective; (3) timely; (4) patient-centered; (5) efficient; and (6) equitable [14]. A Supportive Policy Environment was included as acquiring proper funding, resources and support was deemed essential to the LHCC.

Quality appraisal

The quality of each study was assessed independently by two authors using the Mixed Methods Appraisal Tool (MMAT) scoring system [15]. The average of each reviewer's assigned score determined the quality of each article. Studies of 75% and above were considered good quality, 50–74% were considered fair, and 50% and below were considered low quality. All studies that met inclusion criteria were included, despite the quality appraisal score.

Results

A literature search identified 8169 articles to screen and assess for eligibility. Following screening and the application of inclusion and exclusion criteria, 25 articles were included (Fig. 1).

Fig. 1
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Prisma flow diagram

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Studies were conducted in the following countries: the United States (n = 15), India (n = 3), Canada (n = 2), Australia (n = 2), Guatemala (n = 1), Thailand (n = 1), and the Republic of Congo (n = 1). The characteristics of included studies are summarized in Table 1. All studies included stakeholder populations (as defined above) that experienced a form of learning health outcome in their community. There were no age-specific studies, and children were not exclusively excluded. Six articles (24% of all articles) were deemed fair, and 19 studies (76% of all articles) were deemed good quality. The studies were a mix of qualitative (n = 14), quantitative (n = 3), quality improvement (n = 2), and mixed methods (n = 6).

Table 1 Characteristics of included studies
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Defining a learning health care community

Descriptions and definitions of LHCCs were extracted from all included articles (Table 2). Most articles did not directly use ‘learning health care community’ terminology; however, all included key LHCC components.

Table 2 Definitions of LHCC and key barriers and enablers as identified in included articles
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All LHCC projects aimed to improve health outcomes, such as disease monitoring, management and prevention, and knowledge sharing with community members. All involved collaboration between stakeholders, co-learning, integration of community feedback, and discussed the community participation process. Additionally, most articles discussed developing rural health services such as online learning or research health networks, community-based intervention workshops, learning health systems, and evidence-synthesis programs.

Enablers and barriers to building an LHCC

Common themes emerged across articles. Theme descriptions were created based on the content of included articles and were reviewed by the research team. A consensus on theme names was reached at team meetings. Meaningfully Engaging Stakeholders referred to the use of tools, activities, or community-specific or creative strategies to grasp the interest of diverse stakeholders to be involved in the LHCC implementation process or to be active members within the LHCC. Stakeholder Collaboration referred to bringing together diverse stakeholders to work together to implement the LHCC or to achieve a common goal as members of the LHCC. Using a Participatory Approach was used to describe recruitment and participation of people who are impacted by the LHCC. Strong Stakeholder Relationships referred to the creation of strong interpersonal and mutually beneficial partnerships between stakeholders. Knowledge Sharing referred to learning about a health topic from in-person or online interventions, through the use or creation of knowledge-translation tools, health-related activities or training sessions, or through the use of technology. A Multidisciplinary Team referred to teams that included at least two different stakeholders with different levels of expertise, skills or experience. For example, certain teams included community members, clinicians, nurses, specific patient groups, or community health workers.

The barrier Obtaining Adequate Funding or Research Support referred to challenges to obtain sufficient funding, technology, or personnel to support the development of the LHCC or to sustain the LHCC. Participant Recruitment was used to describe challenges to recruit community members, family members, patients, or other stakeholders that could assist with the development of the LHCC or who serve as active members within the LHCC. A Lack of Knowledge referred to challenges regarding a lack of knowledge about a health topic or illiteracy within the community. This barrier also described a lack of knowledge of how to effectively engage or recruit stakeholders. Maintaining Stakeholder Commitment was used to describe challenges relating to sustaining involvement of LHCC stakeholders, or underestimating the ongoing effort required to promote long-term commitment from stakeholders.

Competing Demands of Stakeholders was used to describe situations when stakeholders within the LHCC had conflicting priorities and therefore, hindered the progress of the LHCC. This barrier was also used to describe when stakeholders struggled to determine a shared mission of the LHCC. Time Constraints were identified by stakeholders that were either unable to or struggled to meet specific deadlines during the LHCC development process, or those who underestimated the time required to build relationships and effectively engage stakeholders.

See Table 3 for the most frequently noted enablers and barriers and the corresponding number of articles. See Table 2 for more detailed information on the enablers and barriers reported in each article.

Table 3 Most Frequent Enablers and Barriers and the Corresponding Number of Articles
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The most frequently noted enabler that facilitated LHCC implementation included meaningfully engaging stakeholders (n = 15). This finding ‘Stakeholder and Community Engagement’ is one of the four main components of the LHCC framework. One LHCC described by Curtis et al. [26] integrated patient engagement at all stages of their program by ensuring participant voices were heard and incorporated into strategy development. They developed a multidisciplinary team of specialists, Indigenous care providers, patient partners, and policymakers who collectively contributed in the development and implementation process of the LHCC. The LHCC involved shared decision making at all stages and community-member knowledge was leveraged to enhance culturally-safe care.

Other enablers mentioned in four or less articles included having a shared mission, incorporating incremental improvements, demonstrating the value of stakeholder involvement, having strong leadership, prolonging engagement throughout the project, using culturally appropriate research methods, conducting a needs assessment, getting continuous feedback from the community, and providing stakeholders access to their health data.

Allowing patients to engage with their own health data to facilitate participation relates to the ‘Infrastructure for Health-Related Data Capture and Knowledge Sharing’ component of the LHCC model. For example, Arcia et al. [16] used a participatory-design approach where participants completed health surveys on their self-reported health outcomes and anthropometric measures. Data was returned to participants through clinical infographics and all participants effectively provided helpful feedback during design sessions. As a result, the LHCC led to tailored infographic designs that were more engaging, informative, and comprehensible according to participants. See Fig. 2 for quotes from included articles mapped to each enabler.

Fig. 2
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Mapping article quotes to LHCC enablers

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The most frequently mentioned barrier that hindered the success of LHCC implementation included obtaining adequate funding and resources (n = 12). This barrier relates to the ‘Supportive Policy Environment’ component of the LHCC framework. Having adequate funding (i.e. compensation for participants or stakeholders), or needed resources (i.e. technology, supplies, tools, or personnel) to meet LHCC deadlines was deemed essential for specific LHCCs.

Other barriers mentioned in one or two articles included mistrust from the community, achieving effective stakeholder collaboration, a need for flexibility in the research plan, resistance to change, stakeholder burnout, maintaining stakeholder connections, knowledge, and resource dissemination, having limited staff, and time commitment. See Fig. 3 for quotes from included articles mapped to each barrier.

Fig. 3
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Mapping article quotes to LHCC barriers

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Care Improvement Targets involve increased learning through clinician-community links, the use of clinical decision support, patient-centered care and optimizing delivery of health care and community-based resources [9]. Twenty studies (n = 20) reported on care improvement targets. Murray et al. [24] reported on the ‘Autism Speaks Autism Treatment Network’. This network leveraged community-partnerships to transition to an LHCC. The LHCC incorporated a model of co-production of knowledge between families and clinicians that promoted learning of each other’s expertise and values. They provided opportunities to take part in remote and in-person meetings, and participation in workgroups and monthly webinars. The LHCC resulted in growth of enrollment by almost 700 members. Among these studies (n= 20), enablers and barriers were described in alignment with the Institute of Medicine’s six aims of quality care [14].

  • Patient-centered care: Seventeen studies (n = 17) involved the patient or family member involvement to improve patient health or patient-centered care (i.e. by consulting patients and implementing their feedback).

  • Safety: Five studies (n= 5) reported safety of health care or research practices (i.e. the Kidney Check LHCC could increase the use of culturally safe practices in Indigenous communities) [26].

  • Timely: Five studies (n = 5) reported that the LHCC has potential to led to more timely access to interventions, services, and resulted in faster decision-making by health care providers, and decreased wait times for patients.

  • Efficient: It was reported in eleven studies (n= 11) that the LHCC could lead to greater efficiency (i.e. one study connected individuals who frequently use emergency services for non-urgent conditions to more appropriate care, resulting in fewer 911 calls) [18].

  • Effective: Twenty studies (n= 20) reported on the effectiveness of the LHCC (i.e. one study developed a program that led to increased health knowledge and disease management strategies amongst affected populations) [34].

  • Equitable: Seventeen studies (n= 17) reported on the equity of the LHCC. For example, one LHCC offered free health knowledge or exercise classes to vulnerable populations [33].

Discussion

The current review aimed to summarize available evidence on the enablers and barriers of rural LHCC implementation. The review of LHCC studies suggests that LHCC implementation can increase community participation in planning health services and health-related activities. Health-related organizations implemented the LHCC to increase collaboration between community members and stakeholders, integrate community feedback in planning, and increase co-learning to expand knowledge sharing and improve health and services within the community.

Stakeholder engagement and collaboration were crucial enablers to LHCC success. It is unsurprising that stakeholder engagement was identified by multiple authors as active and continuous stakeholder and community engagement is a core component of an LHCC. Osborn & Squires [40] investigated perspectives on patient engagement using a survey in 11 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States of America. They found that across countries patients who were more engaged with their health services, received greater quality care, and reported more positive views on the health care system. When stakeholders understand the value of the project, their involvement are provided with clear direction, and can interact with their data, they are more likely to be engaged. Also, the importance of stakeholder collaboration in health care is reiterated by Mullins et al [9] and supported by the Robert Wood Johnson Culture Health Framework [41]. According to this framework, achieving healthy equitable communities involves collaboration from multiple sectors to have the greatest impact on public and community health [9, 41]. Methods noted to facilitate collaboration include staying connected through various platforms (i.e. online networks, email or text-message), maintaining this contact on a regular basis, and meeting regularly as a group.

Although funding agencies have recognized the value of the LHS and LHCC models, obtaining adequate funding and resources was the greatest barrier identified in included studies [9]. Authors emphasized the challenge to receive robust investments from partner organizations and funding agencies to meet project staffing requirements, compensate participants for their time, and to purchase equipment and materials needed for the LHCC. In order to attract investors, it is important to document the benefits of the LHCC and present this information to organizational leaders and stakeholders. Furthermore, developing a feasible plan and demonstrating how you can sustain innovation can be influential for investors. Participant recruitment was also commonly documented as an obstacle. Particular solutions to address this issue have been noted in the included studies, such as participants being invited by a trusted and recognized expert in the field, putting effort into building relationships with participants, collaborating with them to determine clear goals, determine meeting frequency in advance, and have a clear decision-making process.

LHCCs aimed to either increase learning by community members about health topics (i.e. increase health literacy, interest in preventative health care) from experts within the field, researchers or health care providers, or they aimed to increase learning by stakeholders from the community or a particular community group (i.e. consulting midwives on how to retain them).

The current review outlines some overlap in enablers and barriers to urban or larger scale LHCCs. Similar to rural LHCCs, urban LHCCs also identify stakeholder collaboration, inclusion of multi-disciplinary teams, and knowledge sharing as enablers [42,43,44]. A lack of knowledge, and competing demands of stakeholders were also identified as barriers to implementation of urban LHCC implementation [42, 43]. Enablers specific to urban LHCCs include having access to population health data, access to technology that can analyze large-scale data, and conducting research to make comparisons and pinpoint trends in data [42, 44, 45].

Barriers identified in urban LHCCs included concerns around legal, ethical and policy challenges regarding patient health information and challenges relating to developing technological safeguards to protect the safety and security of patient health information. In addition, language barriers were also identified as a barriers to urban LHCCs [43]. Differences in enablers and barriers between urban–rural areas are related to the differences between rural–urban communities. For example, urban communities consist of much larger more diverse populations with greater access to patient health data and advanced technology.

Additionally, although having a multidisciplinary team is identified in both rural and urban LHCCs as an enabler, this term is defined differently between the communities. Rural LHCCs face challenges to recruit and retain their workforce. For example, only 8% of physicians in Canada work in rural areas [46, 47]. Therefore, rural ‘multidisciplinary teams’ are less likely to include specialists, epidemiologists, data-analysts, health-system leaders or policy-makers compared to urban LHCCs. Further, urban LHCCs place less importance on sustained community engagement. One reason for this may be due to challenges relating to the effort and time required to effectively engage larger populations. The small population size of rural communities may be more practical to engage for longer-periods of time.

Rural populations experience unique challenges compared to their urban counterparts. Rural-areas differ in terms of their geographic location, population size, weather, size of their workforce, and access to financial resources and health care services [48, 49]. Rural communities often have a greater proportion of elderly residents with chronic conditions [50], have limited access to health-information [51], and health care providers [52]. Despite these challenges, rural LHCCs provide an opportunity to address rural health needs. Driven by evidence, rural LHCCs place considerable effort into engaging the community in the LHCC implementation process. Shared-decision-making and co-production of knowledge are priorities of rural LHCCs. Due to workforce shortages, health-related education and training for community members appear to be pivotal in LHCC success. As evidenced by the current review, acquiring adequate funding to support LHCC implementation, meaningfully engaging stakeholders, and fostering collaboration are key components of successful rural LHCCs. Furthermore, LHCCs strive to increase health system transparency and accountability of participating entities to make improvements to health care [9]. By increasing awareness of community health problems, and clinical and financial support, the LHCC has potential to have a positive impact on community health.

The role of the LHCC is to improve the quality and efficiency of health care, therefore the LHCC must not overlook the impact of the social determinants of health (SDOH). Extensive research has emphasized the role of the SDOH on patient and community wellness, despite the quality of health care available [53]. For example, the United States spends an extensive amount of money on health care but is ranked last compared to other developed nations for a multitude of health outcomes, likely due to a lack of public health and social programs [54]. Despite the significance of the SDOH on patient health outcomes, the majority of included articles did not report on the SDOH. Future research should investigate the role an LHCC can play in addressing community and patient social risk factors. In addition, there was a lack of studies that focused on specific patient outcomes following LHCC implementation, and the impact of patient outcomes on the success of the LHCC. There is a need for greater research on LHCCs related to patient groups facing certain health diseases and evaluation of the impact of the LHCC on these health outcomes. Also, included studies did not report on the use of pragmatic clinical trials. Future research should investigate the role of clinical trials on LHCCs in rural areas.

Overall, there was repetition of several enablers and barriers mentioned in the included studies (i.e. effectively engaging stakeholders was mentioned in 15 studies and acquiring adequate funding was mentioned in 12 studies). However, there was also variability in barriers and enablers noted by authors mentioned in only one or two articles. For example, having strong leadership was mentioned as an enabler in two articles, and having limited staff was mentioned as a barrier in one article. One explanation for this could be that certain enablers and barriers were very specific to the LHCC being implemented. Therefore, enablers and barriers can vary based on the approach that is taken by implementers. Further, certain LHCCs may not have had one strong leader helping with implementation, and instead used a committee that struggled to make decisions. In this case, a strong leader would not be noted as an enabler. Nevertheless, this variation indicates that there is a lack of knowledge on the enablers and barriers that facilitate LHCC implementation in rural areas and this is an area for future research.

There were several strengths to the current study. First, this study expands on prior research by collecting the most common enablers and barriers that result from LHCC development and informs implementers of the most common obstacles that may be faced. Second, the approach taken to conduct the current review was closely aligned with recommendations [55]. Third, given the current circumstances of rural medicine and patient engagement, our research team deemed it imperative to conduct a deeper review of how to encourage stakeholders and patients to be involved in a collaborative partnership. This study is the fundamental step to a more thorough environmental scan.

The present study must be considered with limitations in mind. Although a minimum of two researchers and a librarian completed an exhaustive search for articles that met the inclusion criteria, there is a chance that some studies were missed or potentially miscategorized. Additionally, included studies differed across cultural, geographic, sociological, and geo-political boundaries across countries and this may impact the generalizability of our findings in different settings. Searches were limited to those in the English language and published articles. Articles published following the completion of the literature search were not included in this review. Therefore, this review may be subject to publication bias. Further, two studies noted that their findings may have been impacted by selection bias, as despite participation being encouraged in their respective LHCC, some participants did not choose to attend [23, 28]. Additionally, Golden et al. [28] recruited participants based on convenience, subjecting their findings to sampling bias and Gierisch et al. [23] opted to not record their interviews, acknowledging the potential for introducing social desirability bias and confirmatory bias. Although some articles assessed the effect of the LHCC following using pre- and post-implementation assessments, the chosen metrics varied across the studies and approximately half of included studies did not evaluate the impact of the LHCC. Therefore, the current study lacked a systemic approach and analysis of LHCC outcomes.

Ample evidence has shown that rural areas face poorer health outcomes than urban areas, due to a lack of infrastructure, health care providers, screening and medical equipments, and accessibility. The current study can be particularly useful to health care providers, researchers, health-related organizations, policymakers and leaders living in rural areas who want to reduce this health outcome gap, improve health-knowledge, patient engagement in health services planning, and research in their community. The current review summarizes the available evidence on the enablers and barriers to implementing an LHCC in rural communities and it is useful for anyone looking to implement an LHCC. Our findings highlight a clear lack of studies on rural LHCC implementation, as well as a lack of studies that evaluate the effect of the LHCC post-implementation, preventing the opportunity to conduct a meta-analysis. The LHCC model is relatively new, therefore, this review can increase awareness of the many benefits of this model and help to inform approaches to transition to this model.

Conclusion

The LHCC is built collaboratively on a foundation of meaningful use of health data and empowers health care practitioners and patients in informed decision-making. Despite the number of barriers to implementing an LHCC, all studies that did implement LHCCs reported potential for positive outcomes. Although there are a variety of commentary, and perspective papers on LHCC development, this study adds to existing literature by summarizing the essential enablers and experienced barriers to facilitate LHCC implementation. Taken as a whole, an LHCC can be a potential solution to increase community engagement and collaboration between health care providers, researchers, decision makers and community members, and to mobilize resources in rural areas, and thereby lead to improved health services, health-knowledge, and health outcomes in these regions. Further research is needed on evidence-based approaches to effectively engage communities to be involved with their health care as well as the long-term outcomes of LHCC implementation in rural areas.