Trust is essential for healthy, reciprocal relationships; creating safe environments; engaging in transparent interactions; successfully negotiating power differentials; supporting equity and putting trauma informed approaches into practice. Less is known, however, about the ways that trust-building may be at the forefront of consideration during community capacity building efforts, what trust-building elements are perceived as essential for optimally engaging communities, and what practices might support these efforts.The present study examines an evolving understanding of trust-building over the course of 3 years, from qualitative data derived during interviews with nine agency leads from a large and diverse urban community, who are spearheading community-based partnerships to create more trauma-informed communities and foster resiliency.meeting people “where they are at” and creating safe spaces), 2) Embodying core values of trustworthiness , and 3) Sharing decision-making, championing autonomy, and addressing barriers to trust . These trust-building elements are presented in the Community Circle of Trust-Building, which provides an accessible, visual format that can facilitate capacity building efforts within organizations and with the broader community; guide the selection of training opportunities that support healthy interpersonal relationships; and aid in the identification of relevant, supporting frameworks .Data reflected fourteen trust-building elements, captured by three themes: 1) Building relationships and engagement (e.g., behavioral practices such as Community engagement and trust are essential for overall health and well-being, increasing equitable access to resources, and supporting an effective and connected citizenry. These data shed light on opportunities for trust-building and thoughtful engagement among agencies working directly with community members in large urban areas.The online version contains supplementary material available at 10.1186/s12889-023-15860-z. The focus of the baseline interviews was twofold: 1) to understand adaptations that agency leads made as they implemented their strategies following a delay in funding that required them to rethink the needs of their communities and which partners would best serve the strategies and communities associated with the initiative, and 2) to explore the nuts and bolts of such a complex undertaking . We specifically queried: 1) how they created a common language among partnership members and the community through shared definitions relevant to the project, 2) the trauma-types experienced by community members and what supports were most needed in their region; 3) partnership and strategy development and adaptation; 4) communication; and 5) learning and reflections about project implementation. Example questions included: “meeting people in the community where they are at”), 2) trauma informed approaches to community capacity building ; 3) establishing collaborative goals with community members and meeting their needs in light of COVID-19 and civil unrest; and 4) the project’s impact and sustainability . Example questions included: What are the biggest barriers to safety and trust in your community now? Which Innovation 2 project goals are most aligned with your community’s needs in response to COVID-19 and civil unrest? In what way has the Innovations 2 outreach changed how your community talks about trauma, adversity  and their most pressing needs? How do you involve community members in conversations about sustaining trauma-informed community capacity building after Innovations 2?The midpoint interview was conducted via Zoom (November and December of 2020) and addressed the project pivots that were occurring due to COVID-19 and shutdown orders, as well as changes in economic and resource availability, increased food insecurity/residential instability and discrimination-related civil unrest. The midpoint interview reflected on: 1) key themes that emerged organically during the baseline interview , Promatores de Salud , and Community Ambassadors , forming a network to educate the community about public health issues  and connect community members to services. Agency leads were also asked in what ways their project experiences changed their concept of mental health services and/or community health and well-being. Example questions included: How do you define trust? What do you think are the key elements of trust-building within your (a) agency/organization, (b) partnership and (c) community? How has the concept of resiliency or the Community Resiliency Model changed your thinking about the community and how you connect with your community? What would you recommend to others as the key elements of capacity building and successful community engagement?The Final Interview was conducted via Zoom (November 2021) and asked agency leads to reflect on Innovations 2. Reflections focused on the impact of: 1) embracing a learning-based project culture; 2) adverse childhood experiences and trauma-informed practices ; 3) strength-based approaches (resiliency focused) and the Community Resiliency Model; and 4) direct community involvement in ‘First Cycle’ coding methods, two to four Team members  created relevant codes for the question topics and categories, guided by theoretical considerations and emergent themes in the interview content. For each annual interview set, qualitative data from 36–40% of the interviews were initially open coded by multiple team members using First Cycle Coding Elemental Methods , along with Focused Coding to develop and illustrate salient categories (given the semi-structured nature of the interviews) and follow-up Memo Coding in the form of shared written comments, impressions and ideas among team members  making ourselves accessible to all members of the community. [N]ot just once they come in our doors, but really being out there at the parks, at the churches, at the flea markets, and not just being out there, but engaging with people. We don’t sit behind the table and the tablecloth that says “services” and just check our phone, right? We are in front of the table passing out the flyers, getting people to know who we are and engaging in different small talks, and saying ‘hi’ to their kids or [noticing] they have a puppy, all those things that are engaging. [B]ecause, if we do that consistently enough, we become part of that [community].”First, all but one agency lead described implicit ways that the seeds of trust were planted by meeting community members “where they are at was linked to creating safe spaces and providing support, which in turn were conducive to community members willingness to express their needs:“[A] top-down approach is not going to work for really getting the voices of folks, but it's like: ‘are you open to sitting down next to this person and hearing them out and hearing what they're going through? [A]re you creating that space that's going to be comfortable for them to share that with you?’ Because, once you do that, then you can effectively be their partner….”Meeting community members demonstrating relevant expertise and competence, demonstrating integrity), championing autonomy , voice and choice and recognizing and addressing existing distrust.“[W]e'll have to build trust and rapport…but it's also [about] being able to adequately address the needs that will come up with community members.”“[T]he goal would be to really truly have wellness within our community, but that also means learning to be trustful with the organizations that are here, because a lot of the community is not trustful. You have to [have] their trust before you can actually start implementing a lot of different things. So that would be our goal, to really increase [our] trustworthiness….“[Y]ou have to look at the whole person.… [W]e understand that the relationship piece is the most important piece, like building that trust with the young people so that they feel comfortable to keep coming back and then to engage further in services.”Second, direct trust-building was explicitly referenced by the majority of agency leads as both demonstrating relationship-building skills and embodying core values and traits related to being trustworthy. These reflect central practices related to “Embodying Core Values of Trustworthiness.” Explicit trust-related themes arose in response to questions a-c above as well as questions about the biggest challenges faced in building community capacities, and what elements were necessary for community members to be empowered to ask directly for what they need. Explicit trust-building was described in terms of an ongoing process that fosters trust by being trustworthy  were the key elements of how partnerships approached implementing the initiative’s community capacity building strategies. These practices also aligned with the initiative’s use of a trauma informed lens  .meeting people where they are at”, trust-building through embodying core values  and addressing barriers to trust. Importantly, being appreciative and patient emerged as a key ingredient to community capacity building work and applied equally to partnership members. When agency leads were asked about how they intentionally addressed trust with their community, the need for their own patience emerged as an important skill that included an element of gratitude :“…to develop those trusting relationships takes time, and there’s often a frustration that comes, because there’s this feeling of, ‘I’m not doing anything.’ Yet some of the most powerful things you can do is maybe break bread with someone or just be available or do something that’s totally unrelated.”During our midpoint interview, we asked how safety and trust continued to factor into the partnerships’ work with their communities and queried other key trauma informed principles. The three central themes of trust-building from our baseline interview were articulated. Agency leads reiterated the importance of “Demonstrating integrity, reliability and consistency were necessary for fostering trust, and for creating safe and nonjudgmental spaces where community members were free to open-up about their needs:“I think we’ve done everything we can to keep our word. We’re not promising something that we can’t deliver on, because that really creates a rift. I’m trying to [create] a space where folks feel welcome. They feel seen. They feel heard. They feel like we’re not going to judge them.”being authentic, genuine and personal was by including community-facing staff who had lived experience similar to the experiences of the community being served :“I’ve seen how the Promotoras are able to connect with our community members, because they’ve either lived it themselves at some point…or have that level of empathy and compassion.”One important way to put into practice the embodied value of integrity as well as keep the importance of addressing systemic distrust and sticking to commitments at the forefront of partnerships’ awareness and practices:“[W]e're on an uphill battle in terms of getting people to trust systems, that's why [Community Ambassador Network] organizations, and even myself, as a community worker, I'm mindful of the systemic injustices that have taken place. So, I try to be particularly mindful about not over-promising, not being just yet another institution that lets folks down.”Incorporating staff with lived experience (consistent with the trauma-informed principle of peer support), and having staff embedded within the community, was noted to increase trustworthiness and reflect “I think barriers to safety and trust sometimes [are about] messaging in terms of probably how we communicate things, the timing [of when] we communicate. Sometimes it’s beyond our control. And change only happens at the speed of trust. [A]s we expand the partnership, the messaging around what…we’re trying to do and [how we are] supporting the community [is critical].”Several potential barriers to building relationships, being viewed as trustworthy, and collaboratively working within partnerships and with the community also emerged during the midpoint interviews. Specifically, communication-related challenges  were recognized as potential barriers to safety and trust within partnerships that needed to be acknowledged and addressed:demonstrating trust); embody core values of trustworthiness  and share responsibility in more collaborative work that acknowledges historic distrust (address existing distrust and systemic inequities). In other words, there is a need for funding agencies to recognize that community agencies and partnerships are not the sole source of trustworthiness – it must be embodied at every level of the service system, starting with the funding agency and its representatives:“…DMH is improving, to some extent, but historically [they have] left it to the community agencies to be the outreach trust-building entity. They’re behind the clinic seeing patients and providing psychiatric services. [But] there’s not a huge arm of trust-building, per se. It’s the community agencies that are out there doing the work and [building] the trust, right? So, when DMH says ‘go and do concrete supports, there's no limit, we don’t want one person going hungry, we don’t want one person losing their house, go, do it at all, you need more, why haven’t you spent this more, why haven’t you done all this stuff?’ And then they say, ‘oh well, actually, next month is the last month of [funding]. So, call back all your community partners and let them know [to] stop referring, because we're not doing that [anymore].’ It's us, the organizations, that have to say that to the community, not DMH.”Finally, agency leads described the double bind of being tasked by the funding agency (DMH) to build relationships with, and engage, the community, yet they were not in control of the work, timing, or funding. The disconnections among funding sources, service delivery and community relations highlight the central importance of funding agencies also learning lessons from their own initiatives and community, including their partners. Specifically, there is a need for funding agencies to build healthy relationship  so that communities understood that agencies had their best interests in mind (embodying benevolence):When I think of trust in the Innovation 2 project, I think of having a foundation of a relationship where you come to have some type of expectation that is satisfied overtime: [K]nowing when we’ll be in a specific place offering resources, know[ing] that those resources are valuable, and know[ing] that we have your best interests at heart.The three central trust-related themes that emerged in the first 2 years of the initiative were again echoed in interviews with agency leads as they embarked on their final year of the initiative. Agency leads recognized that an essential part of maintaining the relationships they had built over time required delivering on their promises , core values  and more collaborative goals .[I]n general when we’re dealing with a crisis with a student or a member, we're very open and transparent, if we need to have them go to the hospital we have that open conversation of, ‘Here’s where we’re at. But we have choices. So how do we want to move forward, do you want to go this way or do we need to call in support?’ And again, that has to do with safety, being transparent, when you have an open conversation and kind of put the power back in the hands of the folks that you're serving, that safety kind of takes care of itself.”“Responses continued to reflect a combination of intentional relationship-building skills  skills in their interactions with the community emerged as important aspects of trust-building, specifically characterized by  and “Embodying Core Values of Trustworthiness” . Reflective supervision was reported as a particularly useful skill set:“[R]eflective supervision…[is] a great way to have that trust with your colleagues and your partners… checking in with them, making sure that they’re okay and…[that] it’s okay to say that ‘it’s not okay,’ We’re checking [in], we’re doing self-care.”“One part of orientation that I always have when a new member comes on board is the commitments that I will make as a supervisor, and then the commitments that I will make as a community ambassador. [A]lot of that is around safety and empowering themselves, and making sure that we’re doing self-care and checking in with boundaries... I think that through the reflective supervision, we’re able to build on that trust because I am not just their supervisor or they’re not just a [Community Ambassador]…if they’re not feeling well or there’s a problem or a challenge with either one of our committees or a school that we’re working with, that we will have the support of our peers to continue empowering.”Reflective supervision is an approach comprised of several practices related to “Building Relationships” “It’s being able to like to rely on someone, being able to be candid with no judgement… I want to say that with my team, I have that trust and I think during this pandemic, it’s definitely elevated for us to be trustworthy because we’re working from home, trusting our peers that we’re completing a task, completing the projects that we’re working on and same with our partners, where we check in and we reach out to them and…also having that trust established with our community members and reaching out to them.”“One of the things that we're really big on with [Transition Age Youth] is being transparent not just with each other, but also with the folks that we're serving, not trying to create this dynamic of ‘We're here and you're there,’ but really kind of normalizing and making a human relationship connection with the folks that we're serving.”Finally, trust behaviors were seen as essential for navigating ongoing challenges due to the COVID-19 pandemic within the agency and partnership, including delivering on obligations to foster trust with colleagues, being transparent and working collaboratively with the community. Again, the little things were important: reaching out and making human connections.Taken together, the three waves of interviews, spanning the initiative implementation until its final year, provided a contextual and theoretical roadmap for trust-building within partnerships, as well as between partnerships and community members in a large urban setting. Figure There are other, broadly available, circles, or pillars, of trust and authenticity with various elements of trust and trust-building –58, but creating safe spaces at the emotional, physical and health levels, and providing support, such as skill training, resource access and peer support within the organization and with community members  were seen as central elements for capacity building from a trauma informed perspective. Second, listening well, creating a common language, and engaging in mutual conversations were essential for effective communication internally (within agencies), across partnership members, with community members who were directly incorporated “into the work”  and with the broader community. Third, meeting people where they are at, being flexible and open, and embracing diversity were necessary ingredients for effectively engaging the community and staff. Fourth, conveying empathy; valuing and respecting others; and being appreciative and patient fostered mutuality and set the stage for collaboration. Fifth, demonstrating vulnerability furthered a sense of safety and openness to sharing. Sixth, demonstrating trust to foster trust in others emerged as central to mutuality amongst staff and community members, providing a foundation for identifying self-assessed needs and providing appropriate resources (community members) and training (staff).The first overarching theme “Building Relationships and Engagement,” includes six core trust-building behavioral practices. First, being consistent/sticking to commitments, and demonstrating integrity, reliability and consistency; 2) being authentic, genuine, and personal; 3) being transparent and honest; 4) demonstrating relevant expertise and competence and 5) embodying benevolence. Taken together, these facets of trust-building represent the core elements of trustworthiness that have also been identified in the broader, cross-disciplinary literature on trust: transparency and honesty; “ability” ; “character” which is typically reported to be composed of integrity and benevolence, and “consistency”  [having shared goals and vision and sharing decision-making; 2) bolstering resiliency and hope, championing autonomy, voice and choice; and 3) addressing existing distrust and systemic inequities with cultural competence and humility. All themes and trust-building elements are captured by the exemplary quotes above and documented in Tables The second overarching theme, “Embodying Core Values of Trustworthiness” captured five core values or traits that are foundational to a trusting relationship and reflect trustworthiness: 1) mitment) , 59–63. where they are at” physically within the community, emotionally, and in terms of their interests); 2) embodying core values of trustworthiness , and 3) sharing goals and decision-making; championing autonomy, voice and choice; and addressing existing distrust and existing systemic inequities . Each of the trust-building elements that fell under these three themes were described as an ongoing process that included relationships at all levels of stakeholders: the funding agency, the partnership, and the community. The practices that emerged as examples of these themes, were also important reflections at the individual level . As we followed this relationship-building thread over 3 years, valuable across-partnership lessons on the importance of trust-building at every stage of the initiative emerged: from inception, to navigating a pandemic and finally re-aligning with the initiative’s original strategies as the pandemic became more manageable with the availability of vaccines and reduced restrictions. For ease of reference, Fig. The present study captures an ongoing dialogue, in the form of three longitudinal waves of interviews with agency leads that spanned a community capacity building initiative in Los Angeles County from implementation to project conclusion. What emerged were common but central themes about the importance of 1) building relationships , when embedded meaningfully and consistently at all levels of an organizational culture, are useful for humility , 85. Whihumility , 87 thatFinally, equity initiatives may be especially informative for supporting the collaborative practices that emerged in the present study. Resources include frameworks to promote shared decision-making, reflection practices that result in action, tools to address institutional distrust, and measures to assess outcomes in Community Based Participatory Research  trust-building must be incorporated both within organizational cultures and across partnership interactions with community; 2) establishing trust takes time and patience – it cannot be rushed and must be continually earned; 3) trust-building requires mindful, intentional actions from funding agencies, leadership, supervisors and staff; 4) historical distrust must be addressed directly; and 5) building trust is an important, specific impact, independent of an organization’s mission, programming, or services.Trust-building likely played a role in these partnerships’ ability to pivot from their specific, funded strategies, to providing for basic needs  and establishing online technology and capabilities for families and students during COVID-19. As previously reported, these same partnerships made 14,000 service referral linkages for community members during the first 2 years of the initiative: 85% of community members followed through with their partnership-provided service referrals pre-Covid-19 compared to 87% follow-though during the pandemic . These rOf note, one in eight individuals globally experienced mental illness in 2019 but there was a worldwide 26% increase in anxiety, and 28% increase in depression, during the first year of the pandemic alone, with women and young people most severely impacted . CoupledAdditional file 1.


This article offers a novel, intimate view of historical return migration as a more complex and discursive process. The case study is Italian American migrants at the turn of the twentieth century, one of the groups which – according to historical statistics – was most actively engaged in Transatlantic remigration; more recent readings, however, show that many of these returnees eventually re-emigrated to the US. Using for the first time immigrant newspapers against the baseline of the Italian public discourse, the article analyzes Italian migrants’ own accounts of remigration as a way to access the more subjective dimension of migration. The integration of text mining and Critical Discourse Analysis will show that migrants were experiencing migration as a sense of identity crisis manifested through feelings of being misunderstood, rejected and unappreciated. These results indicate a less material reading of (re)migration, that is beyond economic reasons, and that for many individuals remigration was a bi-directional movement, only fully concluded when they were no longer experiencing a sense of identity crisis, be it in their homeland or the host society. The article will argue that this was the visible outward sign of a much more profound issue: the Italian Government’s view of (r)emigration –mainly through the lens of domestic economic advantage –deeply underestimated the complexity of migration as a social phenomenon and as a profoundly changing psychological experience. In the long run, this error of judgment deeply damaged Italy as many of those  More recently, why they returned. In other words, historical analyzes that focus on the inner voice of migrants and on how they perceived returning beyond the reasons for returning remain comparatively rare. The reasons for that are complex but on the whole scarcity of primary sources may be at the root of the gap. Moreover, for the most part remigration is rigidly envisioned as a one-way movement from the host country to the country of origin and, perhaps even more critically, as the final stage of the migration experience.As this brief literature review shows, these important contributions all acknowledge the relevance of integrating the study of return migration with a more comprehensive analysis of the cognitive and subjective aspects of the migratory experience. Methodologically however, these works reflect a general tendency to either take a macro approach based on the analysis of historical events, statistics and socio-economic indicators or to adopt a zoom-in perspective based on a limited amount of small case studies. There seems to be a frustrating lack of large-scale investigations that would devote attention to the cultural perception of return migration –both by the country of origin and by migrants themselves –as an alternative entry point to the question of ChroniclItaly 3.0  are always built on justification and legitimation  as well as moral values and fluctuate with the development of economic needs and political agendas . The immThe second hypothesis is that remigration is a movement both from the host country to the country of origin and vice versa. Historical scholarship of migration has widely acknowledged the phenomenon of the so-called “birds of passage,” that is temporary migration of mostly young males who traveled back and forth depending on the accumulated capital when abroad. This pattern is shared by many, if not all national groups, including of course Italy. This means that the final decision of settling in America or returning to the home country was often the result of several transatlantic trips, sometimes in the span of years during which these individuals, whilst living through larger historical changes, learned from the experience and were profoundly changed by it. Within this framework, the displacement process of remigration, it is argued here, can equally be conceptualized as a crisis of identity, in both collective and personal identities. This is justified by the fact that social processes of displacement and transformation deeply affect people’s inner notions of identity and belonging. For example, in the context of Italian Transatlantic migration, historical statistics show that Italians were one of the groups most actively engaged in Transatlantic remigration but more recent readings indicate that many of these returnees eventually re-emigrated to the US . Indeed,For example, according to ChroniclItaly 3.0, the archive used for the investigations, contains 21,454,455 words, therefore using close reading methods alone would not allow us to make full use of the record. The proposed methodology will first provide a comprehensive, zoom-out overview of how words are distributed in the newspapers and second, will identify relevant narratives. CDA will then be used as the applied theory for the analysis of the narratives of (r)emigration. Despite the ever-large amount of available digital sources, particularly for historical research, to my knowledge only two studies exist to date that have conducted digital discourse-based analysis of remigration on large quantities of textual data  in the years 1905–1906 (I Ritornati (the returnees), as they were called, were about 40%, they were predominantly males (90%), young (between 14 and 44), uneducated and unskilled. Women were less likely to return because they would typically emigrate to join their husbands who had already decided to settle abroad. Although certainly valuable, these data suffer from severe limitations; above all, they exclude from the count the returnees entering Italy through ports other than Genoa, Naples, Palermo, and Messina, or by railroads.For the period of mass migrations (1860–1920), official statistics indicate that about 40% of all European migrants eventually returned. More recent studies, however, evidence that due to differences in how the data were gathered between sending and receiving countries and several errors in how individuals were counted, the return migration rate from the host country to the country of origin may have in fact been as high as 70% . As for 905–1906 . The surIn the United States, data on return migration were gathered from 1907 to 1908 by the Commissioner of Immigration. As noted by non-emigrant aliens, that is non-US individuals who had declared that they would return to the United States within a year. These figures show a steady decreasing trend therefore suggesting that most returnees intended to resettle permanently in Italy  as it was called, soon became the government’s top priority, therefore dominating the public debate  had dramatically worsened the already critical economic situation of the South, making the task of creating a nationally integrated economy virtually impossible . The rapc debate . HoweverQuestione meridionale (It is in these years that discourses on migration (both emigration and return migration) entered the public debate. Emigration was generally considered as a negative phenomenon, seen as a disruption of the social and moral order, a drain of capital, and a side-effect of the process of national integration which ultimately made Italy look bad abroad . Accordiidionale  and moreidionale . ConcurrIt is important to state that at the turn of the twentieth century, within the national debate of emigration Italian migrants were expected to return. This expectation was in line with the general European trend for which migrants were indeed returning. The argument was that for as long as emigration was necessary, Italians would continue to leave but these migrants would alternate on a rotating basis every three to 5 years. In other words, virtually every migrant would have eventually come back . MoreoveAs the debate was shifting more towards emigration as being beneficial for Italy, the role of the Government became at the centre of the discourse. One of the main arguments was that the Government had the obligation to regulate emigration so that its benefits could be maximized, and its disrupting effects contained. In other words, regulation of emigration was in the national interest , 1878. TCommissariato Generale dell’ Emigrazione. Remittances would also start to be regulated. With this law, the Government officially gave the Banco di Napoli the task to collect, protect, save, and transfer migrants’ remittances from all over the world to Italy  with the more pleasant title lavoratore italiano all’estero . Along with the same narrative, in 1927 the Commissariato Generale dell’ Emigrazione was abolished. But for more than three decades prior to fascism, the national discourse had praised migration, return migration, and remittances for single-handedly being able to achieve what decades of governmental measures had failed to accomplish. The reason behind such a naïve and opportunistic vision of (r)emigration and the hype about remittances as a miracle cure may be found precisely in the failure of all previous governmental programs. The 1901 law remained practically the same until fascism when the regime firmly rejected emigration as weak and unpatriotic . FascismChroniclItaly 3.0-unsilence the voice of migrants.One of this study’s most distinctive features is the use of immigrant newspapers  and by far, the one that covers the longest timespan (1897–1919)  see . The titCronaca sovversiva, a sovversivi newspaper, is the second largest title in ChroniclItaly 3.0; it includes 771 issues from 1903 to 1919. It was founded by the anarchist Luigi Galleani in 1903 who had escaped extradition a few years before and had settled in Barre, Vermont, where an Italian community of stonemasons was living. Galleani published the anarchist newsletter for 15 years until the United States government forced him to stop under the Sedition Act of 1918. Cronaca Sovversiva typically discussed a variety of radical topics, including arguments against the existence of God and against historical and contemporary establishment. Like all radical press, Cronaca sovversiva not only served as the main means of communication for the sovversivi’s community but it acted as the movement’s financial centre  was rapidly growing. The paper claimed to be independent and voiced support for socialism, striking laborers, and the International Workers of the World . La Tribuna del Connecticut published reflections on America by Russian writer Maxim Gorky; gave prominent coverage to notable socialist intellectuals visiting Bridgeport, like Italian editor Carlo Tresca; and responded to articles and ideas then being discussed in Italian socialist newspapers. It also informed the Italian community about dances, concerts and other social activities. Of note is that La Tribuna del Connecticut also served Danbury, Connecticut and Port Chester, New York; it also had a wide network of stable regional correspondents who were located in more than a dozen cities in the Nutmeg and Empire States (Connecticut and New York). In 1913 Altieri became the editor of La Sentinella.L’Indipendente includes 48 issues from 1907 to 1936. It began publication as a weekly in 1904. It was headquartered in Wooster Square, one of two neighborhoods  which housed New Haven’s large Italian immigrant community. It claimed to be the “first and only Italian daily in New England.” Its aim all was to support and protect Italians in New Haven. Although it claimed to be pro working classes, the tone of the coverage was pro-capitalist and pro-American which was not uncommon in the early 20th century Italian American press.L’Indipendente overtly opposed the Italian colonial invasion of Ethiopia of 1936.ChroniclItaly 3.0 also features the whole 40 issues of La Ragione from 25 April to 23 August 1917, as this newspaper only survived eight editions. It was published in Philadelphia and its main aim was to expose corrupted personalities within the Italian community such as prominenti and dishonest bankers (banchisti). La Rassegna was also a short-lived newspaper published in Philadelphia in 1917. The archive includes 25 issues from 7 April to 25 August 1917. It focused on issues affecting Italian immigrants in Philadelphia and chronicled major historical events such as World War I and Italy’s nationalistic claims to Dalmatia. In addition to defending prominenti, La Rassegna encouraged Italian immigrants to seek naturalization.ChroniclItaly 3.0 is the existence of a complete, or largely complete, microfilm “object of record” with priority given to higher-quality microfilms . Collocations and ngrams are used to identify relevant articles and passages in the corpus. Collocations are words that appear frequently within a certain distance of the search term and provide a picture of which words co-occur with other words in a corpus; ngrams are a contiguous sequence of two or more (n) items in a text. Ngram language models are probabilistic models –known as Markov chain  –for preGuided by CDA theory, the narratives of remigration are analyzed in identified excerpts. Specific attention is given to how retuned migrants are discursively represented in the diasporic media and through which communicative strategies their identity is constructed. As in any crisis, crisis of identity are also always attempts at maintaining power . For exaThis section shows the results of the analysis following the described methodology; in particular, the first section shows the results of the ngrams analysis while the second one analyzes identified excerpts using CDA.emigrazione (emigration), emigrant (emigrants), rimpatriare (to repatriate), ritornare (to return), rimesse (remittances) in all possible morphological combinations . The results are displayed in Ngrams  are computed for salient words so as to gain insights on their semantic distributions in the corpus. The used words are A few interesting considerations can already be drawn from the results. First, ngrams containing the word ‘emigranti’ (emigrants) or ‘emigrati’ (emigrated) have the highest frequency of occurrence whereas ngrams in combination with ‘rimpatriare’ (to repatriate) occur much less frequently. This would suggest that the topic of emigration was discussed much more frequently than the topic of returning in turn suggesting that Italian migrants were more preoccupied with matters concerning their migratory experience rather than with returning to Italy. The finding indicates a contrast with the Italian public debate of migration which almost exclusively focused on the economic contribution migrants would provide to Italy upon return and on solving the southern question through remittances (here with the lowest rate of occurrence – ‘rimesse’).ChroniclItaly 3.0 is L’Italia, a prominenti newspaper with the longest record of publication. L’Italia frontpage of 25 December 1909. The mission statement can be found right below the date. In the years 1909–1910, L’Italia’s mission statement was the following (emphasis mine):Second, ngrams containing ‘emigranti’ are almost always in combination with ‘sentimento’ (sentiment) and ‘patria’ (homeland). As it was custom at the time, ethnic newspapers’ front page often reported their mission statement; this would change periodically depending on the newspaper’s political orientation or indeed the historical moment. One of the newspapers in emigranti un sentimento di dignità collettiva Italiana, educando la coscienza loro alla grandezza e virtù della razza Italiana, alle glorie nazionali del passato, al virile e civile risveglio del presente, alle liete e ragionevoli speranze nell’ avvenire.In questa terra cosmopolita, dove insieme col popolo americano vivono popoli di ogni razza e d’ogni paese; Qui, dove lo spirito di nazionalità si acuisce fortemente nella gara del lavoro tra i figli di tutte le Patrie europee e americane: Qui, il giornale L’ ITALIA vive e lotta a difesa del nome Italiano, per tener vivi ed alti l'amore e l’attaccamento verso la Madre Patria, per suscitare nel nostri L’Italia’s mission statement reflects this struggle to negotiate inclusion in the host society and it shows how this formed a substantial part of the Italian migratory experience.The mission statement pushes a narrative aiming at empowering the Italian migrant community by resorting to the cardinal concepts of an Italian heritage of civilization and a glorious past of grandeur. As it has been pointed out in the academic discussion , such exThird, ngrams containing the word “rimpatriare” (to repatriate) score rather low in the corpus; again, this would suggest that the topic of resettling in Italy was not frequently discussed by the immigrant press. Even more interestingly, “rimpatriare” is found in combination with “dovendo” (being forced to), “servizio” (service), and “biglietto” (ticket). This could indicate that contrary to the national discourse of migration in Italy for which migrants were expected to return, in the immigrant press repatriation was framed as a forced, rather than a voluntary decision to return. It would also indicate that immigrant newspapers were mostly discussing remigration in the context of giving the Italian community practical information about returning to Italy. The CDA of selected excerpts in the next section will offer a finer grained picture of the different narratives in the repository.L’Italia on 18 August 1904 (emphasis mine).Collocations lists are generated from the same search terms used to identify salient ngrams and relevant excerpts are retrieved from these lists. CDA is then applied to analyze these linguistic data as discursive “events” , that istanto lenta quanto è imbecille, non frapponga inciampi e ostacoli all’esecuzione di disegni e di proposte, mercè cui la difesa della emigrazione e la sua tutela contro le male arti delle arpie nazionali e straniere esca dal regno della retorica, e diventi realtà immanente ed efficace. […] Non dimentichino in Italia che la popolazione Italiana del Nord America si accosta al milione e che, specialmente nel Mezzogiorno della Penisola, se interi paesi pagano le tasse o non muoiono di fame é in virtù delle rimesse degli emigranti!È da augurarsi che la burocrazia degli uffici ministeriali as slow as it is idiotic, will not create hurdles and obstacles interfering with bills and proposals, and that the defense of emigration and its protection against the evils of national and foreign sharks will leave the kingdom of rhetoric to soon become an efficient reality. […] May Italy not forget that the Italians in Northern America are about one million and that, especially in the Mezzoggiorno, if entire towns are able to pay the taxes or not starve is by virtue of the emigrants’ remittances!Let us all hope that the bureaucracy of the ministerial offices, Commissariato Generale per l’Emigrazione. The passage above refers precisely to a visit to the United States by Adolfo Rossi, Inspector of the general commissariat for emigration at the time. The purpose of the visit was to assess the conditions of the Italian colonies, especially outside of the biggest cities, to explore the possibility of establishing employment offices that would give Italian migrants accurate job information and protect their interests on their behalf. Indeed, like millions other migrants, Italians were often exploited as cheap labor and forced to work in extremely poor conditions. The argument in favor of the law had claimed that the reform would have assisted migrants in all stages of their migratory experience, including providing support in the host countries. But in reality, changes had been slow to implement. The passage highlights how Italian Americans were disillusioned by the moderate impact of these reforms and how they were feeling neglected and essentially misunderstood.More than 3 years after the law on emigration was passed, migrants’ conditions had not improved much. Excerpt 1 shows a feeling of frustration, resentment, and powerlessness by the Italian American community towards the Italian Government about the lack of progress towards effective reforms. One of the main novelties introduced by the law had been the centralization of all matters regarding emigration through the establishment of the The reference to remittances is also significant; it shows that the Italian diasporic community felt exploited by the Italian Government. Emigrants thought that they were significantly contributing to the Italian national economy by sending remittances to their families in Italy. Yet despite their important contribution –perhaps exaggerated in the article –their efforts were not appreciated by the Government which was lost in rhetoric and slow bureaucracy.L’Italia 2 years after, 14 November 1906 (emphasis mine).Excerpt 2 is taken from an issue published by povertà che esiste fra i nostri connazionali in ragione diretta delle loro rimesse postali e che da queste viene tragicamente mascherata.L’intensità e l’eccesso del lavoro imposti dalla poverty on our fellow Italians is directly due to their remittances and by them is tragically concealed.The intensity and excess of work imposed by The excerpt above provides a sad account of the harsh living conditions of Italian Americans in the period of mass migrations; it also gives a more bitter view on remittances than the exalted narrative the national discourse was spreading. The passage shatters the illusion that migrants were becoming rich and that they were supposedly able to save large amounts of money easily and without sacrifices. Migrants knew that this fabricated belief tragically concealed a much darker reality. The pressure of saving as much money as possible to send remittances to Italy forced them to work excessively and to live in extreme poverty. The sharp contrast with the national discourse suggests that Italian migrants felt their struggles were minimized or even denied and that their experiences were misunderstood.La Tribuna del Connecticut of 27 April 1907 describes the constant tension of the migrant’s condition, the longing for a beloved, yet resented country that negates them everything and forces them to leave. This ambivalence remains sustained even when, crushed by nostalgia, the migrant decides to return (emphasis mine).The following excerpt taken from Tutto gli ha negato la patria! Il lavoro, il pane, il tugurio, il vestito! Ed egli segue la corrente, che fuori della patria trascina tante preziose esistenze, che toglie alla patria i migliori dei suoi figli! Parte per raggiungere l’ignoto, pieno di fiducia, di speranza, perche’ ha inteso che la’, lontano, lontano, oltre l’oceano, c’e’ una terra dove l’oro si guadagna a palate. E parte … Mentre il piroscafo solca le onde, […] guarda, e protende minaccioso il pugno verso l’ingrata che gli ha negato il pane! Il povero emigrante si volta ancora, non vede più’ quel punto, che […] adesso gli e’ caro; e il ricordo […] gli da’ il capogiro, il cuore palpita, le lagrime gli fanno velo agli occhi. […] E guardando sempre scorge finalmente la terra, e’ l’America! L’America, la meta agognata, la terra che gli deve procurare quello che la patria gli ha negato. Arriva, sbarca, lavora, accumula capitali, spedisce denaro ai suoi, ha il benessere, ha tutto. Ma… un punto oscuro e’ sempre nella sua mente, il suo cuore ha un palpito perenne’. Egli dovrebbe esser contento e’ non lo e’! […] E’ il ricordo della terra natia. […] Ma che m’importa della terra natia, egli dice […] E’ la lontananza dei miei cari. Se li avessi vicino a me ritornerebbe la calma. E spinto da una repentina risoluzione s’imbarca e inaspettato tocca la terra natia. Rivede i suoi cari, e al suo cuore ritorna la calma. Ma la patria e’ sempre quell’ingrata, ed egli insieme ai suoi ritorna in America. Ora li ha tutti vicini a se, ora é tranquillo. Ma egli s’inganna, egli mente a se’ stesso, sente sempre dentro di se qualcosa che lo conturba. La malinconia l’invade sempre. Lo perseguita il ricordo della terra natia […] Non può’ più mentire a sé stesso. E’ la patria lontana, è la nostalgia.Poverino!. His homeland denied him everything! Work, bread, hovel, clothes! And he follows the current, which carries so many precious lives out of the homeland, which takes away its best children! He leaves to reach the unknown, full of trust, of hope, because he has understood that over there, far, far away, beyond the ocean, there is a land where gold can be earned by the shovelful. And he leaves … While the steamer cuts through the waves, every now and then he looks back […] and holds out his fist threateningly towards the ungrateful land who denied him bread! […] The poor emigrant turns around again, he no longer sees that point, which […] is now dear to him; and the memory […] makes him dizzy, his heart flutters, the tears veil his eyes. […] As he keeps looking, he finally sees the land, it’s America! America, the craved land, the land that will give him what his homeland denied him. He arrives, he disembarks, he works, he accumulates capital, he sends money to his family, he lives well, he has everything. But a dark thought is always on his mind, his heart flutters perpetually. He should be happy and he’s not! […] It is the memory of the native land. […] But what do I care about my native land, he says […] It’s the distance from my loved ones. If I had them close to me, I’d be at peace. And driven by a sudden resolution he embarks and unexpectedly reaches his native land. He sees his loved ones again, and calm returns to his heart. But the homeland is always ungrateful, and he and his family return to America. Now he has them all close to him, now he is calm. But he deceives himself, he lies to himself, he always feels something inside that disturbs him. Melancholy always invades him. The memory of his native land haunts him […] He can no longer lie to himself. It’s the distant homeland, it’s nostalgia.Poor thing! return, but this time to America.The passage above well exemplifies the tormented condition of the migrant, the perennial crisis of identity that does not allow them to fully enjoy even a wealthy life. The migrant adores the native country but at the same time, they resent it, they feel rejected by it, their country “denied them everything.” As they leave, they are overwhelmed by these two conflicting feelings. This tension is also conveyed linguistically in the text. Whereas America is expressly mentioned, Italy is always referred to as “the homeland.” This not only highlights a more intimate relationship with the home country, but also a clear opposition with the host country. This narrative thread is sustained throughout the entire passage: the homeland is “ungrateful,” America is ‘craved’; the homeland denies the migrant everything, America is the promise of gold. When the migrant returns, they sadly discover that the homeland has not changed at all, it has remained “ungrateful.” They must leave again, they must This passage illustrates the second hypothesis of this study, that migration experience did not end with repatriation. The migrant described in the excerpt may well be the migrant of investment , the oneL’Italia of 16 November 1908 (emphasis mine).Excerpt 4 is taken from italiano ritornato in patria, di regola è praticamente male avvezzato. Egli ha perduto le sue buone qualità italiane, guadagnando le cattive americane, conservando sempre le peggiori, e non le migliori qualità dei due paesi.L’ Italians who return home have normally bad habits. They have lost their good Italian qualities and learned the bad American ones, always keeping the worst, and not the best qualities of both countries.The excerpt describes repatriated Italians as having been worsened by migration, especially morally. The narrative is built along the ‘Us vs. Them’ paradigm synthesized in the culturalized images of country-specific qualities, which are positive if referred to the in-group and negative when referred to the Other. This discourse path highlights the differences between the two groups, rejects the values of the Other, and builds confidence in the “us” group. But the passage shows another interesting phenomenon: in the context of return migration, the returnees become themselves “the Other.” Because they have lost what indeed made them Italian  in favor of ‘bad’ American habits, now their right to belong is contested. The “us” vs. “them” narrative emphasizes the in-group identity which in fact refers to the Italians who never left. The process of transformation migrants have gone through is oversimplified and reduced to a linear, binary opposition: Italian = good; American = bad. This description of how returnees were perceived in Italy suggests that their process of social inclusion was complex even within their community of origin. Within this discourse frame, Italians who left were no longer considered Italian, suggesting that once returned, migrants struggled again with their identity negotiation.L’Italia of 19 July 1912 (emphasis mine).Excerpt 5 is taken from non aver ancora pagato iI proprio tributo all’emigrazione. Quando molti si domandano se l’emigrazione sia un bene o un male, si puo’ rispondere paradossalmente — ma non meno veracemente — che l’emigrazione è un bene per la patria, ma un male per i suoi figli. È l’individuo che si sacrifica per la collettività. Le vittime dell’emigrazione in tempo di pace sono assai piu’ numerose delle vittime della guerra.Facendosi l’esame di coscienza, l’Italia deve confessare di not having paid its dues to emigration yet. When many ask if emigration is good or bad, one can answer paradoxically-but not less sincerely –that emigration is good for the country, but bad for its children. It is the individuals that sacrifice themselves for the sake of the collectivity. The victims of emigration in peacetime far outnumber war victims.If Italy examined its own conscience it should confess to ibid.). Those who would survive, however, would become a liability both for national and local governments as they represented an economic burden and a threat to national health security. Their families also considered them as a failure as they had become reason for embarrassment in the community .Excerpt 6 is taken from fare o rifare le proprie finanze e rimpatriare. […] Fra gli italiani d’America il fine del rimpatrio è, salvo le eccezioni, cessato, per necessità di cose, per logica e diritto di famiglia. […] Qui non vi sono più, e non vi possono essere “italiani d’America, “ma v’è un Gruppo italo-americano, che ha trovato inevitabile costituirsi parte integrante della popolazione “at large,” composta di altri sessantasette gruppi di razza. La nostra italianità, quindi, è divenuta un sentimento, un fenomeno, più ampio. Noi praticamente non siamo più italiani da un punto di vista nazionale, ma dal punto di vista della razza, che comprende la nazionalità. I nostri figli, nati in America, sono già più numerosi di noi, e poiché, come dice il Diritto Romano, che, in fondo, sanziona un sentimento naturale, “amor descendit, “nazionalmente noi ci sentiamo attaccati più alla terra dei nostri figli che a quella dei nostri padri.Un carattere precipuo distingue gl’italiani immigrati in America dagl’italiani emigrati altrove. All’inizio erano tutti accomunati da una sola speranza: to raise their finances and repatriate. […] Among Italian Americans the purpose of repatriating has, with a few exceptions, ceased, because of necessity, logic and family law. […] Here there are no longer, and there can no longer be “Italians from America, “but there is an Italian-American group, which found it inevitable to form an integral part of the population “at large,” made up of sixty-seven other groups of race. Our Italianness, therefore, has become a broader feeling, a phenomenon. We practically are no longer Italians from a national point of view, but from the point of view of race, which includes nationality. Our children, born in America, are already more numerous than us, and since, as Roman Law says “amor descendit, “after all sanctioning a natural feeling, nationally we feel more attached to the land of our children than to that of our fathers.A specific character distinguishes Italians who immigrated to America from Italians who emigrated elsewhere. At the beginning they all had one hope in common: The excerpt illustrates the identity negotiation struggle of Italian migrants. After a few years in America, migrants’ sense of identity has been changed by the migratory experience. They are no longer ‘Italians who live in America’; the sentence highlights the opposition between Italy intended as manifestation of a cultural identity  and America, intended as a place. The process of transformation has deeply affected their Italianness which has transformed into something bigger. Now migrants’ identity incorporates American identity too  and this allows them to negotiate inclusion within the wider American society . It is interesting to notice how the process of identity negotiation also affected migrants’ decision to repatriate. Initially they all wanted to return to Italy, but now this path is chosen only by a few exceptions. This new identity is also passed to the new generations, thus strengthening a ‘natural feeling’. This discourse frame abandons the “us” vs. “them” narrative of the previous years. In this passage, there is no opposition between the in-group and the out-group identity; the complex process of social inclusion is mediated by a newly formed identity which is no longer in crisis.emigrazione, emigranti, rimpatriare, ritornare, rimesse suggested that in the ethnic press, repatriation was less frequently discussed than matters of emigration and life in America. Ngrams containing the word ‘remittances’ scored low in the corpus suggesting a contrasting trend with the Italian public debate of migration in which remittances were at the centre. Moreover, these are found in combination with words such as ‘service’ or ‘ticket’ which could indicate an emphasis on practical information and advice in relation to repatriation. This would suggest a stronger preoccupation with the enormous social challenges migrants had to face in America rather than with repatriating. Migrants often struggled to navigate the complexities of a constantly evolving migration landscape, both in Italy  and the United States. The finding would therefore also be in line with the historical mission of the ethnic press: primarily to help Italians cope with life in the host country whilst maintaining a bond with their heritage.The combination of text mining and CDA allowed for the identification of recurring themes and characteristics in how the experience of migration and remigration was perceived by Italian American migrants. The ngrams analysis of the semantic distribution of salient words such as The CDA allowed for the triangulation of linguistic data within their social contexts and concurrent socio-historical events. The analysis of excerpts provided deeper insights into how the Italian diasporic community in the United States was narrating its own migratory experience. Specifically, it showed a common pattern of a sense of crisis and identity negotiation manifested through feelings of being misunderstood, rejected and unappreciated and constructed around three main themes: 1) the Italian Government was profiting from emigration; this narrative was found in reference to remittances; 2) Italian migrants were heroes who were sacrificing themselves for the greater good; this narrative was found in reference to the struggles in the host country, including poverty and tuberculosis, and 3) Italian migrants had changed; this narrative was found in reference to returnees or returning to Italy. Generally, the adopted discourse strategy was constructed around an “us” vs. “them” narrative, i.e., Italian migrants vs. the Italian Government but also Italians vs. Americans (particularly in early years) and Italian migrants vs. Italians. The criticism of Italy and the Italian Government as Other-identity was found to be a common communicative device used by Italian migrants to position themselves as the ‘sacrificial victims’, the heroes who were singlehandedly rescuing the country. Therefore, if in the national debate migrants and emigration were framed as beneficial for the country and migration was oversimplified as an easy way to make money, in the ethnic press the same frame is used to criticize such praises as plainly rhetorical, to characterize migration as an extremely painful process for the individual, and the Italian Government as being unable to factually demonstrate appreciation for the migrants’ sacrifice.The analysis also highlighted how migrants were struggling with processes of inclusion and identity when returning to Italy. Returnees were framed as having lost their ‘italianness’ and as having been worsened by the migratory experience. They were described as hybrid creatures made up of the worse traits of the two countries. The derogatory image polarizes differences between Italian and American values first and between the so-transformed Italians and Italians after. This narrative is once again in contrast with the national discourse for which repatriated migrants were believed to being improved by the migratory experience and in turn praised for improving Italy. Migrants also described themselves as feeling rejected by the society of origin when returning. The homeland was characterized as ungrateful, again not appreciative of the migrants’ sacrifices and feelings. Returnees were on the contrary represented as ‘foreign’, suggesting that upon return, migrants faced new, great challenges and that these individuals may have experienced remigration as a second crisis of identity. It also supports the second hypothesis of this study, that for many individuals remigration was a bi-directional movement which often did not stop with repatriation.Processes of identity negotiation and inclusion were found to be a constant preoccupation of the migratory experience. References to Italian and American identity, Italianness, and Italian American identity indicate a continuous search for acceptance and suggest a less material reading of the reasons behind migration, that is beyond economic reasons. Ethnic newspapers revealed that from a cognitive point of view, what made the displacement process particularly painful for the migrant –even when they could enjoy good social and living conditions –was a constant sense of identity crisis, a feeling of rejection, be it from their homeland or the host society. It is only when the migrant made peace with this feeling, only when they finally embraced a new identity that they were no longer in crisis and migration –intended as a painful process –was finally concluded.At the turn of the twentieth century, the national debate of migration in Italy became entangled with the so-called Southern Question, that is the economic integration of the South. The predominant –though not exclusive –view was that mass emigration was fatalistically necessary to relieve the South from unemployment; moreover, thanks to remittances, emigration was beneficial for the country, as well as remigration, since returning migrants were coming back with money and skills. The exaggerated value of remittances became at the centre of the discourse, almost creating the myth that remittances alone would solve all Italy’s problems. This article offered a novel perspective of the migratory experience of Italian migrants by using for the first time ethnic newspapers to compare migrants’ discourse of emigration, remigration, and remittances against the national debate of emigration and remigration in Italy. This insider’s perspective showed that while the Italian public discourse praised and actively encouraged remigration as positive for the country, both economically and socially, Italian Americans’ views were more complex and ambivalent. This more inner perspective –though still mediated –unveiled the identity construction mechanisms part of those strategies which, historically, were implemented by the Italian diasporic community to construct identity, negotiate inclusion, and maintain power in a hostile environment, may this have been the host or the country of origin. In this way, the study provided a more nuanced and discursive conceptualization of return migration as a bidirectional phenomenon deeply entrenched in identity negotiation processes.The study also offered a methodological contribution to digital migration studies. A mixed-method approach of distant (ngrams and collocations) and close reading (CDA) was used to explore how migrants themselves were experiencing migration, how their positioning was constructed in relation to the homeland, and how they coped with identity negotiation struggles. Text mining and semantic modeling methods facilitated a more immediate identification of relevant passages, whereas the semantic similarity clustering (ngrams) allowed for a general overview of the distribution of salient words in the corpus. Finally, CDA allowed for a finer-grained analysis of the narratives.ritornati felt misunderstood, rejected, and disillusioned and crossed the Atlantic again, this time never to return.The findings of this study provided a comprehensive understanding of the dynamics, motivations, and challenges associated with migrants returning to their home countries. This knowledge may contribute to effective migration management and policy development, to ensure the well-being of both migrants and the societies they return to, making it highly relevant in the EU and the broader context of global migration. In this respect, the study demonstrated the value of the ethnic press as a novel source that can add an intimate dimension to the study of migration of the past century, of the migratory experiences of those migrant communities and their process of identity negotiation. It highlighted the considerable discrepancy between the exalted domestic discourse about remigration and the more nuanced experience of Italian migrants. Such discrepancy, the article argued, may be seen as an indication that the Italian Government’s view of remigration –mainly through the lens of domestic economic advantage –deeply underestimated the complexity of migration as a social phenomenon and as a profoundly changing psychological experience, also for the Italians who never migrated. In the long run, this error of judgment deeply damaged Italy as many of those https://zenodo.org/record/4596345.Publicly available datasets were analyzed in this study. This data can be found at: The author confirms being the sole contributor of this work and has approved it for publication.


Deimplementation, the removal or reduction of potentially hazardous approaches to care, is key to progressing social equity in health. While the benefits of opioid agonist treatment (OAT) are well-evidenced, wide variability in the provision of treatment attenuates positive outcomes. During the COVID-19 pandemic, OAT services deimplemented aspects of provision which had long been central to treatment in Australia; supervised dosing, urine drug screening, and frequent in-person attendance for review. This analysis explored how providers considered social inequity in health of patients in the deimplementation of restrictive OAT provision during the COVID-19 pandemic.Between August and December 2020, semi-structured interviews were conducted with 29 OAT providers in Australia. Codes relating to the social determinants of client retention in OAT were clustered according to how providers considered deimplementation in relation to social inequities. Normalisation Process Theory was then used to analyse the clusters in relation to how providers understood their work during the COVID-19 pandemic as responding to systemic issues that condition OAT access.We explored four overarching themes based on constructs from Normalisation Process Theory: adaptive execution, cognitive participation, normative restructuring, and sustainment. Accounts of adaptive execution demonstrated tensions between providers’ conceptions of equity and patient autonomy. Cognitive participation and normative restructuring were integral to the workability of rapid and drastic changes within the OAT services. Key transformative actors included communities of practice and “thought leaders” who had long supported deimplementation for more humane care. At this early stage of the pandemic, providers had already begun to consider how this period could inform sustainment of deimplementation. When considering a future, post-pandemic period, several providers expressed discomfort at operating with “evidence-enough” and called for narrowly defined types of data on adverse events (e.g. overdose) and expert consensus on takeaway doses.The possibilities for achieving social equity in health are limited by the divergent treatment goals of providers and people receiving OAT. Sustained and equitable deimplementation of obtrusive aspects of OAT provision require co-created treatment goals, patient-centred monitoring and evaluation, and access to a supportive community of practice for providers. Contributions to the literatureThe removal of potentially hazardous approaches to healthcare is key to achieving social equity in health, yet deimplementation processes can risk widening inequitiesThis analysis demonstrates that constructs drawn from Normalisation Process Theory  are useful to explore deimplementation work to understand how it can produce more equitable outcomesThe findings have implications for opioid agonist treatment programs which have changed drastically across the world since the beginning of the COVID-19 pandemic, but also for other settings where rapid deimplementation risks entrenching social inequities in healthPeople who use illicit drugs are vulnerable to an unregulated drug market and lack of safe supply . Opioid In Australia, there are significant variations in OAT provision between jurisdictions due to decentralised funding of health services and the varied historical contexts across the country . In someTowards the end of the first year of the COVID-19 pandemic, at the end of 2020, Australia was maintaining a rate of around 0.5 cases per million people per day while countries in Europe experienced new peaks  . Within Studies investigating increased flexibilities in OAT provision during the COVID-19 pandemic period have not found an associated increase in opioid overdose –17; theroveruse to achieve equity, such as reducing use of preventive care and screening which delivers no benefits  turn up in the right week at the right time for their appointments. Who also don’t have a telephone. So there’s some clients that need sort of fairly flexible care who we’re seeing in person, essentially, when they turn up.Providers suggested that “one size fits all” deimplementation would be harmful to some patients, and adaptive execution was evident in several accounts. Such adaptive execution allowed providers to tailor the deimplementation to what they perceived were the needs of subpopulations. P01 described overcoming the challenges of reducing in-person appointments for people for whom telehealth was not appropriate. The adaptive execution of deimplementation allowed more equitable care to be provided to people with comorbidities.P08: We would never have been in a position where we had anywhere near the staffing capacity to actually [deliver OAT to homes]. Plus, we felt that the alternative, which was get mum or uncle, or brother, or somebody to go and pick it up for you, we felt that was an appropriate way around that.For people who were isolating with a COVID-19 diagnosis or isolating because of comorbidities which increased vulnerability to COVID-19 transmission, home delivery was offered at some sites. P08 described the adaptive execution when home delivery was not feasible, through flexible OAT pick-up practices to ensure continuity of care.P20: Sometimes patients who are having hepatitis treatment provided at the clinic were kept a bit longer [on supervised dosing] as well, to make sure that they could continue the hepatitis treatment, knowing that some of those patients weren’t taking their dose, if they weren’t at the clinic, being supervised and helped by taking that. So … I think they were the primary patients that were kept at the clinic.Accounts of adaptive execution demonstrated the tensions between providers’ treatment goals and the equitable provision of care, particularly when other services were being provided alongside OAT. P21 reported that in-person reviews allowed for people with “mild or moderate psychotic symptoms… to be scheduled or encouraged to voluntarily go into the mental health unit”. In P20’s clinic, increased flexibilities in OAT provision were withheld to achieve hepatitis C treatment completion.P14: I understand why [the service] had to stick to generalised rules for everyone because otherwise the lines get a bit grey. I sometimes wish [the rules] were a bit more black and white because you do find, looking after 60 clients, one person will say, “Well, how come Dave got this?” And you’re like, “Well, because of the situation.” They’re like, “That doesn’t feel a bit fair.”One nurse felt the workarounds risked damaging patient-practitioner relationships. The different treatment of patients which is inherent in equitable care was seen as problematic when treating a relatively closed community of people attending the service.P15: I mean, if someone had had a one-off use of [methamphetamine] and had told you about it, that’s not really going to affect the take-away status. So you’ve got to look at things in their entirety. And [our service] is a harm minimisation program. We don’t promise a cure. So some people will use occasionally and that’s a reality. But the program has helped them limit their use and improve their life, so you’ve got to look at all things, not just one thing in isolation.The entrenched rigidity of OAT restrictions in Australia was a challenge to deimplementation. Communities of practice to support deimplementation, were more easily formed when providers within a service deemed deimplementation to be coherent with the existing organisation ethos. This sense-making process was most visible where providers situated their work within the principles of harm reduction, indicating the service’s prioritisation of equitable provision of care over abstinence and treatment cessation.P03: As a public clinic, we probably always err on the side of caution with takeaways and we’re much, much more likely to stick to the state guidelines than many of the private prescribers. But I think as long as you’ve got a good clinical rationale for what you’re doing we can really sort of push for ourselves to be a little bit more flexible. So, in that regard, it’s a real positive I think.Where deimplementation was carried out without evident support from a community of practice, the providers expressed confidence in their own decision-making. Although P03 acknowledged the limits of the setting (public clinic vs private), they also felt assured in grounding their decisions in “clinical rationale”.P27: I had my sort of resistance movement in the corner just to the extent that I could as a [senior staff member]. I write my own rule book. You’d convince a few people along the way that this was better medicine and more humane whereas now you’ve got an axe that’s gone right through the whole thing, and everybody realises, “Oh, you can give people all these take-aways and you don’t have a rash of overdoses. And we may be even improving the outcomes.”In some instances, the common experience of the COVID-19 pandemic encouraged the establishment of a community of practice, which some providers used to mobilise efforts towards sustained deimplementation. Communities of practice are an opportunity for the clinicians who are driving deimplementation to support others who are lagging behind. P23 reported using the period of rapid change to gain the support of hospital staff, by providing education on the benefits of flexible OAT provision based on their own experience. Providers who extolled deimplementation to achieve social equity in health were previously advocating to individual clinicians but found that COVID-19 had broadened interest to a wider community of clinicians. For P27, who had long been advocating for more flexibility in OAT provision, deimplementation during COVID-19 was an opportunity to change from incremental change to a more drastic shift towards “humane” care that P27 had long supported.P08: Mental health services are set up quite nicely around the regions [and there is potential for them to deliver] depot buprenorphine which we think will be a simpler way of delivering pharmacotherapy, but people aren’t terribly interested. The response, generally, is, “Look, we’re really busy. We’re just not going to take that on”.There was a recognised need for communities of practice which incorporated health services beyond drug treatment, but these were stymied by siloed healthcare systems. P08 felt deimplementation processes could be smoothed through collaboration between addiction medicine and mental health. Consistent with prior literature , 51, breP30: For example, home dosing [could be a possibility] not just for things like COVID but for people that are maybe very, very ill or terminally ill, you know, that can now be [considered]. Initially, as a health professional, I was very scared. So, if I’m very honest, home dosing wasn’t something that I wanted to do, initially. I have pre-existing conditions myself so [I was thinking about] whether […] I would be more impacted if I got infected [with COVID]. And also […] we are delivering an S8 drug [drugs that are subject to tight restrictions] and sometimes to homes that are in suburbs or areas that are not very safe.After decades of OAT provision with little innovation or change, the normative restructuring required for deimplementation is a key area to address in the normalisation process. The work involved in deimplementation for the COVID-19 period provoked reflection on the norms around OAT provision and caused providers to question their own motivations as well as wider treatment motivations. The tasks that were involved in deimplementation challenged P30 to consider their identity as a health worker, despite being initially scared of an increased threat of COVID-19 and changes to the handling of methadone and buprenorphine.P26: The caseworkers, you know, nurses, social workers, psychologists, are probably a bit more instrumental in delivering care or being responsible for organising and co-ordinating care. I think previously, because we’ve got a predominantly pharmacotherapy-based service, it became quite medical. And there was [previously] a lot of opportunity for clients to circumvent their case-management processes because, really, all they want is a script. So, if all I want is a script, all I need to do is go and see the doctor for my script review. So there’s been a slight shift in focus towards case management.Strategies to meet the needs of certain groups of patients included forming communities of practice across other services or with clinic staff who were not OAT providers. P13 described their service’s successes in “bridging the gap” to more equitable care for Aboriginal people through sessions at an Indigenous Health Service. P26 highlighted the increased importance of case managers during the COVID-19 pandemic which improved care coordination but also supported the transition from a “medical”, “pharmacotherapy-based service” to one which could support people’s broader needs. Although there is no standard definition of a case manager (it does not preclude being an OAT provider), they broadly work with the patient on issues beyond treatment which may impact a person’s ability to engage in OAT.P18: Many of our patients experience stigma and discrimination but sometimes they fear stigma and discrimination. And, and I think a lot of them found that, when they did go to the pharmacy, the stigma and discrimination that they might have been expecting didn’t, in fact, occur or occurred to a lesser degree. And, you know, the, the comfort that they had with our nurses was then transferred into comfort that they had with their community pharmacies. And so, having sort of made the leap, they then realised that some of the fears that they had about it previously were not so founded and became comfortable in their new environment.While community pharmacies constitute the majority of dosing points in Australia, the COVID-19 pandemic saw their increased use in OAT delivery as OAT clinics moved people to pharmacy in order to receive takeaways. P18 indicates normative restructuring was required among people receiving OAT, to allow pharmacies to perform this role in deimplementation. P18 highlights that established relationships with a provider in the clinic could make people receiving OAT, who often experience stigma, reticent to attend pharmacy. Ensuring that all health services, including pharmacy, provide non-stigmatising care is paramount to achieving deimplementation and equitable care.Some norms relating to OAT restrictiveness remained unchallenged and could present a barrier to deimplementation. Drug treatment is notable because the evaluation of a patient’s success based on “good behaviour” or compliance with an explicit or implicit set of rules. P23 reported that in-person attendance was necessary to assess if the person was “drowsy”, “dishevelled’, or “well-kempt”, underscoring the breadth of criteria beyond the official guidelines which providers apply when assessing a patient’s engagement in treatment. P22 reported that looking for signs of ongoing drug use such as “hobbling in because they have an infection in their groin”, was part of a risk management strategy and stated that using “that leverage to bring them back in [for more frequent in-person dosing] is all about safety; nothing else”. These criteria based on appearance, of which the person receiving treatment may not be aware of, creates a “black box” of clinical decision-making and prevents people engaged in treatment from advocating for their own care. The tacit criteria described above highlight the many ways by which a provider might consider somebody “unsuccessful” in treatment. Basing treatment decision-making on superficial or non-clinical indicators, without first discussing needs and a corresponding treatment plan with the person who is in treatment, risks exacerbating the social and structural determinants of poor health.P02: [I would recommend that people attend in person if] their English language skills aren’t that good. That’s nearly impossible to do on the phone or by telehealth. So, I ask them to come in because I think anything on the phone would be so cursory and superficial it would be a waste of time. At least face-to-face when there’s a language barrier… I can use Google Translate and there’s all sorts of things I can do which I can’t do otherwise.Despite the study taking place during the first year of the COVID-19 pandemic, providers were already beginning to reflect on the service in a “post-COVID-19 world” and they highlighted several barriers to normalisation. There was a sense that reduced in-person appointments were not suitable for everyone and would inherently result in inequities in provision of care. P02 felt that the service was not equipped to offer telehealth to people who had lower levels of English, excluding them from more flexible care.P16: I like to be able to sit down with the patient and negotiate an acceptable number of take-aways based on their current situation, and what I perceive to be the safe, safeness of the situation according to the guidelines. But I don’t feel that a formal documentation helps me particularly… I’d like to go back to the more restrictive practice mainly to protect myself more than anything else. From the medico-legal point of view.Providers were concerned that COVID-19 exceptionalism would not last long and any adverse events (such as overdose) that might be attributed to increased access to OAT takeaways could provoke legal consequences. In P16’s view, this limited the possibilities for sustained deimplementation, despite being generally supportive of the process during the pandemic.P11: My simple understanding of that is that, when there’s that sort of disparity between two jurisdictions for something that is medically supervised, the evidence probably is limited as to what works and what doesn’t work. Otherwise, we’d be following whatever evidence was available, I would have thought. And, in the absence of evidence, my understanding is that the next step to look at in terms of guidance about an issue in medicine is expert consensus. The difference is quite marked in terms of supervision of OAT between those two jurisdictions [in Australia].P11 highlighted the ongoing issue that jurisdictions differ in their OAT guidelines and regulations. P11 calls for different types of evidence to be drawn upon in order to shape sustained deimplementation, suggesting that “expert consensus” could play a key role given the perceived lack of other evidence.By investigating change in the provision of OAT during COVID-19, this analysis from the CHOICE Study provides useful insights for future work around deimplementation and equity beyond the OAT setting. Deimplementation in OAT provision presents an opportunity to reduce burden of treatment for patients, reduce resource outlay in clinics, and improve patient and provider satisfaction. Deimplementation which prioritises equity in health and maximises efficient use of resources [The typical decision-making processes of healthcare providers were disrupted by the pandemic, where the quickly evolving situation challenged evidence-based medicine paradigms . ProvideTo reduce social inequities in health, deimplementation needs appropriate, non-stigmatising healthcare outside of the OAT setting. One participant noted that people may be reticent to change dosing point, supporting literature on potential stigma produced through negotiating treatment in unfamiliar territory . There iThere were concerns raised about the unequal treatment of patients, which is inherent to equitable healthcare, and its impact on patient-practitioner relationships. Community dynamics give people the information and tools to advocate for their own access to OAT using the knowledge and experiences shared with peers. This may benefit people who have stronger social networks or are linked to community organisations, possibly producing inequities with people outside of these networks. While there is evidence on the importance of social networks in OAT outcomes , there iNormalisation of deimplementation requires “thought leaders” and communities of practice to disrupt self-identities of prescribers who are more reticent to adopt. Diffusion of innovation theory  has beenThere are several limitations to the study. The initial OAT providers who participated in the study were contacted because they currently or previously participated in research, which could result in a sample already interested in patient-centred care. Participants were recruited via public clinics which limited the opportunities of reaching providers working in the private sector. There were two jurisdictions  where providers were not recruited. The interviews took place over a period of four months at the end of 2020 and given the rapidly changing COVID-19 case numbers, restrictions and differences in state response, the time of enrolment and location of participant may have influenced participants’ responses.The findings from this analysis indicate a number of key areas for policy change. Deimplementation has the potential to improve equitable outcomes in health, but only if the patients’ treatment goals are centred in the provision of OAT without compromising access to flexible care. Discussions with the person receiving OAT about their treatment goals should inform treatment initiation and any ongoing reviews of treatment. Models of “open access”, which prioritise the removal of barriers to care to ensure rapid initiation onto OAT, can help guide service planning . GloballIn this account of deimplementation, providers linked social equity in health to their work despite equity not being embedded in the planning stage. Provider norms and OAT regulations prevent an equitable, flexible, system of OAT provision from being actualised. The flexibilities introduced during COVID-19 provoked OAT providers to consider the cost of overly restrictive treatment programs. The providers reflected on their understanding of the balance between hazard and safety, in the context of peripheral threats to health and wellbeing generated from restrictive OAT provision. This analysis demonstrates the importance of centring social equity in health in the planning of deimplementation strategies. Normalisation Process Theory is useful to explore potential problems in the deimplementation process which could prevent normalisation.