“This Time, We Were First": From Recipients to Solution Shapers in the Co-Design of a Rehabilitation Service Innovation for Aging in Place in Underserved Rural Appalachia

Abstract Background Community-engaged approaches are increasingly promoted as mechanisms for addressing health inequities in underserved communities. However, relatively little is known about how community members experience participation in service-development processes, particularly within places characterized by longstanding health disparities and histories of disenfranchisement from community and health-service decision-making. Methods We conducted a qualitative-dominant convergent mixed-methods evaluation of a community-engaged co-design of a rehabilitation service innovation supporting aging in place, undertaken in a medically underserved rural Appalachian community in Ohio. The process integrated a participatory regional governance structure (e.g., selecting a county in need and local participants for codesign), codesign toolkit (i.e., access mapping, user personas, and a menu of evidence-based program options with rural adaptations), and structured co-design workshops in the selected county. Participants included a regional Steering Committee (n = 7) and county-level Codesigners (n = 5). Anonymous participants standardized survey data were collected on the acceptability, feasibility, and appropriateness of the process and toolkit. Qualitative data were collected through focus groups and analyzed using inductive, interpretivist thematic analysis, validated by the participants. Results Participants reported highly favorable perceptions of both the co-design process and toolkit. No disagreement responses were observed across survey items. An overarching qualitative theme, “Oh, You Want My Input?”: From Being Consulted to Shaping Solutions , captured participants' experiences. Four themes emerged: (1) “We Already Know the Gaps” ; (2) “This Time, We Were First” ; (3) “They Heard That” ; and (4) “What Began Here Seems So Big.” Together, these themes informed a proposed context-mechanism-outcome (CMO) pathway in which recognition of local expertise, inclusion in shaping priorities, and visible influence over decisions fostered ownership of a locally shaped service innovation and generated momentum for continued engagement and future collaboration. Conclusion Recognition, epistemic legitimacy, decision-making influence, and ownership emerged as potential mechanisms through which participation became meaningful within a historically underserved Appalachian community. Together, the findings informed a preliminary context-mechanism-outcome pathway suggesting how community engagement may translate into ownership, sustained participation, and future collective action.