More than 10.7 million undocumented immigrants and 8 million citizens with at least 1 undocumented family member live in the US.1 Evidence shows that immigrants are at increased risk for COVID-19 infection2-4 and have high levels of distrust in public systems.5 Contact tracing is an effective way to mitigate disease transmission but requires trust and cooperation among infected persons and their contacts. Using the Centers for Disease Control and Prevention sample contact tracing script as a framework, we describe undocumented immigrants’ attitudes about contact tracing and challenges that may be a factor in their ability to follow contact tracing and public health guidelines.
This qualitative study used data from 20 in-depth interviews conducted between June and October 2020 to examine the social, economic, and health implications of COVID-19 for undocumented immigrants. We used snowball sampling to recruit a purposive sample of 20 undocumented immigrants representing equal proportions of male and female Asian and Latinx people, who self-reported their race and ethnicity. All participants provided verbal informed consent and were virtually interviewed using a semistructured interview guide codeveloped by a community advisory board that included undocumented immigrants and subject matter experts. Specific questions regarding contact tracing were integrated after the fourth interview based on community reports about challenges engaging immigrants in contact tracing. To assess potential differences in attitudes based on inclusion in the Deferred Action for Childhood Arrivals (DACA) program—a federal program that provides temporary work authorization and protection from deportation to eligible undocumented immigrants—we ascertained participants’ DACA status by asking, “Are you currently a DACA recipient?” Using grounded theory, 1 of us (H.Y.C.) and a research assistant developed a codebook and analyzed all transcripts between October 2020 and February 2021. Subheadings in the Centers for Disease Control and Prevention’s Contact Tracer’s Interview Tool: Notifying People About an Exposure to COVID-196 were used as larger domains to organize participant quotes. This study was approved by the University of California, Los Angeles Institutional Review Board and follows the Standards for Reporting Qualitative Research (SRQR) reporting guideline.
Of 20 participants (mean [SD] age, 27 [3.7] years; 10 men and 10 women) included in the sample, 16 (80.0%) were asked about their familiarity with contact tracing, and 6 (37.5%) had never heard of contact tracing before the interview. Among 10 participants (62.5%) with some awareness of the process, 2 (20%) reported ever speaking with a contact tracer. After learning about the principles of contact tracing, including privacy and confidentiality as well as select contact tracing prompts (ie, home address, work address, names of cohabitants), 13 of 20 participants (65.0%) worried about disclosing information, and of those, 10 (76.9%) specifically cited immigration-related concerns.
We found that numerous questions in the Centers for Disease Control and Prevention’s sample contact tracing script have the potential to elicit fear, discomfort, inaccuracies, or nonresponse among undocumented immigrants based on participant concerns about breach of information, protecting undocumented parents from deportation and language discrimination, and distrust in government agencies (Table 1). For example, both Asian and Latinx participants doubted the quality of language access that could be offered to their parents and said their parents’ lack of DACA status, and thus greater vulnerability to deportation, made them reluctant to share information on their parents’ behalf.
Participants also described a lack of resources to follow referrals or recommendations to access health care, quarantine, and negotiate work-based leave policies with employers. For example, when asked about informing employers about incident COVID-19 symptoms, participants mentioned they were denied sick leave or were immediately fired and felt financial pressure to keep working. We found considerable discordance between public health guidelines and undocumented immigrants’ retrospective or prospective abilities to follow the guidelines because of lack of access to immigrant-friendly health care, limited space to quarantine, low neighborhood assets, job insecurity, and lack of employee benefits and workplace protections (Table 2).
This qualitative study found that undocumented immigrants contend with unique challenges that may have implications for the ability of contact tracing programs to reach this population, including fears associated with policies that target undocumented immigrants (eg, immigration enforcement and eligibility rules for individuals in the DACA program and health coverage), language discrimination, and distrust of government agencies. These concerns were more salient among participants who indicated the need to protect their undocumented parents, revealing differential vulnerabilities and opportunities to engage immigrants in contact tracing.
The study is limited in terms of the generalizability of the findings because of the small, nonrepresentative snowball sample used. However, there is a critical lack of data among this population. We highlight important considerations for implementing contact tracing programs among undocumented immigrant populations.
Nationally, more than 16.7 million people in the US live with families with mixed immigration status or at least 1 family member with undocumented immigration status.1 Therefore, more research about the association between inclusive or restrictive immigration policies and the ability to follow public health strategies is needed to mitigate the health and social implications of COVID-19 for immigrant communities and beyond.
Accepted for Publication: October 12, 2021.
Published: December 8, 2021. doi:10.1001/jamanetworkopen.2021.37719
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Choi HY et al. JAMA Network Open.
Corresponding Author: Hye Young Choi, MPH, Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 (hyeyoungchoi@hsph.harvard.edu).
Author Contributions: Ms Choi and Dr Sudhinaraset had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Choi.
Obtained funding: Sudhinaraset.
Administrative, technical, or material support: Sudhinaraset.
Supervision: Sudhinaraset.
Conflict of Interest Disclosures: Dr Sudhinaraset reported receiving grants from the University of California Office of the President to collect data during the conduct of the study and grants from the Bill & Melinda Gates Foundation, the Society of Family Planning, and the National Institute on Minority Health and Health Disparities outside the submitted work. No other disclosures were reported.
Additional Contributions: We thank Fernanda Gutierrez Matos, MPH, CHES, Department of Population Health Sciences, Virginia Tech, for providing insightful discussions about public health surveillance. She received compensation for her contributions. We also thank undergraduate assistant Catherine Kim, University of California, Los Angeles, for her assistance in coding. She did not receive compensation for her contributions to this article.