**Background:** Mixed-immigration status families—households containing undocumented residents, legal immigrants, and/or U.S. citizens—are a large and vulnerable population in the United States, with approximately 20.2 million people living in households with at least one undocumented person as of 2016. The COVID-19 pandemic exacerbated existing disparities for these families, particularly due to anti-immigration policies such as the Public Charge Rule, which stipulates that receiving public benefits can be grounds for inadmissibility for immigrants seeking naturalization. This rule was approved in August 2019 and implemented on February 24, 2020, just before the pandemic was declared. Although the rule was slightly eased during the pandemic, this was not widely advertised, and fear persisted. Federal relief programs like the CARES Act initially excluded undocumented individuals entirely, and even after updates in December 2020, many mixed-status families remained ineligible. This study aimed to understand how the anti-immigrant sociopolitical environment, including fear of Public Charge Rule, impacted mixed-status families' help-seeking behavior during COVID-19 and how these decisions affected their mental health, financial stability, and housing and food security.
**Methods:** The study conducted in-depth semistructured qualitative interviews with 14 adult members of mixed-status families between February and April 2021. Participants were recruited through convenience sampling via digital flyers on Facebook, Instagram, Twitter, and newsletters of the Cross-Cultural Center, Latinx Resource Center, and Dream Center at the University of California, Irvine. Eligibility criteria included being 18 years or older, part of an immediate mixed-status family, and a resident of Southern California. Recruitment was conducted in both Spanish and English. All participants provided informed consent and received a $15 Amazon gift card. Interviews were conducted over Zoom for approximately 45 minutes each, audio recorded, and transcribed. The lead researcher used the constant comparative method (a core component of grounded theory) with Atlas.ti software for coding and analysis, progressing from line-by-line coding to focused coding to develop an overarching theoretical framework.
**Key Results:** Of the 14 participants, 10 identified with she/her/hers pronouns, 2 with he/him/his, and 2 with they/them/their. All lived within the Greater Los Angeles Region and were between ages 19 and 29. Seven major themes emerged: (1) Financial need—every single participant disclosed financial need, stemming from work insecurity as many family members were essential workers earning minimum wage; half depended on a single income producer. Families refinanced homes, sold personal valuables, or took out loans to cover rent, food, and medical expenses. (2) Job insecurity—all participants reported job loss, furlough, or reduced hours, especially early in the pandemic. Undocumented individuals lost "under the table" jobs and struggled to find alternative employment. (3) Housing insecurity—the majority spoke about challenges paying rent, having to move, moving in with family, living in overcrowded housing, and some reported rent increases during the pandemic (e.g., from $1,200 to $1,300 per month). (4) Food insecurity—participants depended on food banks/pantries, rationed food (e.g., reducing from two cups of rice to one cup, using half an onion instead of a whole one), and some used CalFresh (SNAP). (5) Mental health—participants reported heightened stress, anxiety, panic, depression, exhaustion, and isolation, closely tied to financial strain and, in some cases, death of a family member from COVID-19. (6) Distrust of government and health officials—the vast majority expressed distrust, with families avoiding COVID-19 testing, treatment, and vaccines due to fear of being exposed as undocumented. Some participants noted vaccine hesitancy stemming from this distrust. (7) Fear of Public Charge Rule—even participants unfamiliar with the term described fear of being seen as a "burden to the government," which they believed could jeopardize citizenship applications. Families avoided health insurance, health care, and government assistance, with one participant noting their siblings and mother lacked health insurance during the pandemic due to this fear.
**Clinical Implications:** This study provides direct qualitative evidence that anti-immigration policies like Public Charge Rule create a "chilling effect" that prevents mixed-status families from accessing essential health and social services during a public health emergency. The fear of deportation or jeopardizing legal status led families to forgo COVID-19 testing, treatment, and vaccination, as well as routine medical care and mental health services. The interconnected insecurities (financial, housing, food) directly contributed to worsened mental health outcomes. The authors recommend foundational rebuilding of trust between mixed-status families and the government, streamlining the process for gaining legal status, and implementing specific policies to protect and support mixed-status families during public health emergencies. The study is limited by its small sample size (n=14), reliance on virtual recruitment (excluding those without internet access), and the absence of middle-aged and older adult perspectives. Despite these limitations, it provides valuable insights from a hard-to-reach population and highlights how immigration policy is a structural determinant of health that must be addressed to achieve health equity.