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Background: Community engagement is seen as key to citizen‐centred and sustainable healthcare systems as involving citizens in the designing, implementation and improvement of services and policies is thought to tailor these more closely to communities' own needs and experiences. Organizations have struggled to reach out to and involve disadvantaged citizens. This paper examines how if, why, and when low‐income citizens wish to be involved. Methods: For this qualitative realist case‐study, 19 interviews (one dyad) were held with (20) low‐income citizens in two Dutch municipalities. Additionally, the results were discussed with a reference panel consisting of professionals and citizens to enrich the results and to ensure the results had face validity. Results: The results showed four different ways in which low‐income citizens wished to be involved: (a) in a practical/volunteer way; (b) as a buddy; (c) as a lay expert; (d) not involved at all. The factors affecting citizens' interest and capacity to participate include citizens' own experiences of the services they access and their personal situations, e.g. their mental or physical health, extent of financial crisis, family situation, home environment. None of the interviewees was currently involved, but all had ideas for improving health(care) services and policies. Citizens' experiences of the services they accessed acted as a motivator for some to be involved as they wanted to ensure others would not have the same struggles, while for others their own needs and an apathetic system remained too high a barrier. To enable involvement, citizens need continued support for their own health(care) and financial situation, better communication and accessibility from services, practical support (e.g., training and bus passes) and recognition for their input (e.g., monetary compensation). Conclusion: The study shows that citizens' experiences of the services they accessed influenced if and how they wanted to be involved with health and care services. Despite the fact that all participants had shared solid ideas for improving services and policies, they were hindered by a bureaucratic, impersonal and inaccessible system. Organizations seem to underestimate the required investments to reach out to low‐income citizens and the support required to ensure their involvement. Patient and Public Involvement (PPI) in Study: Citizens as well as PPI organizations were members of the reference panel who helped formulate the research questions and recruitment strategy. The local reference panel also helped to interpret and refine the initial findings. [ABSTRACT FROM AUTHOR]

In pursuing person-centredness and cost containment in long-term care, policy makers and academics stress the importance of public participation and co-production with communities. When citizen involvement is interpreted as increasing their ownership over local care arrangements - either meant literally or as a sense of being in control - it potentially affects the roles of professional and community actors beyond a mere redistribution of responsibilities. While the issue has become a core concern in both policy and academic debates, not much is known about what it means for professional care organizations when profound strategic influence of citizens is pursued. This paper draws on 18 months of ethnographic field work, studying representatives of a professional care organization negotiating the design and delivery of services with inhabitants of a small town in the north of the Netherlands. Looking at attempts to transform a 'traditional' professional care home into a joint initiative of professional and community actors, I focus on how the various actors involved draw different symbolic boundaries between what they see as 'professional' and 'community' domains and their corresponding roles. As such notions are malleable and change over time, I explore how their evolving meaning affects - and is affected by - the degree of actual ownership that citizens experience over local care service delivery. The case study reveals some of the complexities of attempting to achieve higher levels of community ownership over activities traditionally dominated by professional organizations. On one hand, a substantial boundary shift took place by opening up space for citizens to negotiate issues that were initially decided for them. Still, it was a common reflex for organizational representatives to impose barriers when citizens actually tried to exert influence. Although boundaries seemed to be shifting, they did not disappear; professional actors struggled to reconcile 'letting go' to enable meaningful participation, with 'staying in control' to meet organizational requirements. Some dealt with this tension by clearly demarcating the domain in which citizen involvement was deemed possible and desirable. Others instead engaged in blurring organizational boundaries by - actively or passively - involving citizens in adjusting 'internal' policies and processes to accommodate local needs or preferences. These two approaches resembled different ways in which the organization's relation to citizens was characterized. When emphasizing citizens' role as client-consumer or volunteer _for_ the organization, they were granted less strategic agency than when portraying them as 'equal partners' in designing and delivering local care services. This study sheds light on how different perspectives on community engagement evolve and interact when attempting to transform the relationship between professional care organizations and the communities they work with. It shows how such attempts can potentially lead to fundamental questions about who defines the boundaries of the professional organization and how far citizens' strategic agency can go. Whereas the current paper focuses on how actors redraw and give meaning to such boundaries during the start-up of a joint initiative, future research is required for investigating how such dynamics evolve as the initiative matures. [ABSTRACT FROM AUTHOR]