The impact of COVID-19 on service delivery systems: evidence from a survey of United States refugee resettlement agencies
BMC Health Services Research volume 22, Article number: 535 (2022)
Key to the US refugee resettlement effort is the role of non-governmental organizations (NGOs) who receive, place, and provide transitional programs and referrals to new and recently resettled refugees. Yet only one rapid assessment study thus far examined the impact of COVID-19 on service delivery systems of US refugee resettlement agencies. This exploratory study describes the capability and preparedness of US refugee resettlement agencies to provide services and care to clients during the COVID-19 pandemic.
Using both telephone interviews and an internet survey, we assessed the impact of COVID-19 on service delivery, agency capacity, and preparedness of 101 US refugee resettlement agencies. Descriptive statistics were used to describe the dataset, while chi-square (χ2) tests were used to examine relationships by resettlement agency size (number of employees in each agency).
Despite a temporary pause on refugee admissions, restrictive stay-at-home orders, and refugee travel restrictions, the majority of responding US refugee resettlement agencies continued to provide specialized services and care to resettled refugees and other immigrants. Among the more important findings was that agencies that continued to provide refugee services and care onsite in their existing facilities or office rather than moving such services offsite differed by agency size [χ2 (9.494, n = 101), p < 0.05]. Almost all agencies (93.1%) strongly agreed or agreed that staff have timely access to COVID-19 information. Most of the refugee services were provided offsite (n = 72 agencies, some with multiple offices across the US).
US refugee resettlement agencies continued to perform admirably despite a lack of funding. Future research is underway to obtain a more balanced understanding of the impact of COVID-19 on practice or operations.
Key to the US refugee resettlement effort is the role of non-governmental organizations (NGOs)  who receive, place, and provide transitional programs and referrals to new and recently resettled refugees. These agencies operate under the US Department of State’s standard cooperative agreement which, in turn, specifies the services that must be provided, such as housing, employment services, and assistance in applying for social security. However, the stay-at-home order necessitated by the pandemic affected the delivery of and access to healthcare not only globally [2,3,4], but also across the US (beginning March 21, 2020). In US healthcare, for example , the most affected service delivery systems include those that focus on children’s welfare , psychiatric care , community outreach and behavioral health [8,9,10], and arbovirus surveillance programs . In Ohio, COVID-19 caused a disruption of health and social services systems, and a decrease in volunteer availability for volunteer-dependent agencies . Elsewhere, clinicians have reported challenges with the provision of services and care to refugees , while some agencies permanently or temporarily closed their doors . Combined, these findings suggest a need to assess and monitor the impact of COVID-19 on US service delivery systems.
Aspects of service delivery affected by COVID-19 include environmental factors (e.g., work conditions), direct factors (e.g., workforce absenteeism, stress, and quarantines), and indirect factors (e.g., changes to how services are delivered and increased healthcare costs) [12, 15, 16]. For refugee resettlement agencies, service delivery systems were not only affected by the stay-at-home order but also by the Trump administration’s limit on the number of refugee arrivals, and the United Nations High Commissioner for Refugees (UNHCR)‘s suspension of refugee resettlement departures due to COVID-19. Collectively, these factors had an impact on many agencies who, in part, rely on federal funding; such funding is disbursed only when refugees arrive . This has raised questions as to how social service programs should be managed during health crises or natural disasters . So far, however, with the exception of a recent rapid assessment , the impacts of COVID-19 on US refugee services provision remain understudied in the US.
This exploratory study describes the capability and preparedness of US refugee resettlement agencies to provide services to recently resettled clients during the COVID-19 pandemic. This study was completed when the most restrictive stay-at-home orders were in place . The findings below shed light on the needs of refugee resettlement programs and will help to inform needed program and policy changes that support the delivery of high-quality services to refugees during the current COVID-19 pandemic and during future health crises such as natural disasters or disease outbreaks.
This cross-sectional study used both telephone interviews and an internet survey to examine the capabilities and preparedness of US refugee resettlement agencies to provide services to clients during the COVID-19 pandemic. Respondents were given a choice concerning the mode by which they wished to complete the study.
Agencies of interest included those providing services and care to refugees as they arrive in the US and those responsible for placing refugees with one of their local affiliates. We found 280 resettlement agencies nationwide through internet searches. The information from these searches was verified with each respondent. Data collection occurred in May–July 2020, and targeted agency representatives (e.g., directors, executives, and any staff who was familiar with the agency’s operations). The survey was conducted at a time when the most restrictive stay-at-home orders were in effect in many states, and some states were beginning phased re-opening . Trained undergraduate students in the Department of Geography Immigrant and Refugee Health course at the University of Miami conducted the telephone surveys.
The questionnaire consisted of 31 questions divided into three sections: organizational characteristics questions (11 questions), COVID-19 and staff capacity questions (11 questions) and demographics (9 questions). Questions were multiple choice, categorical, dichotomous, open-ended, and Likert-type questions with five-point rating scales. Surveyed agencies included religious organizations, non-governmental agencies, and cultural community groups. Excluded were government facilities (e.g., detention centers and US Immigration and Customs Enforcement (ICE) facilities) because they were unable to complete a survey of this nature without time-consuming approvals.
To increase the response rate and because the study was conducted at a time when most states had stay-at-home orders, multiple contacts were made (e.g., telephone, email, Facebook, Instagram, and organization websites). Reminder notices were sent on various days of the week and at different times of the day to increase the likelihood of reaching a prospective survey respondent. Those who preferred to complete the survey online were emailed a link to the online version of the survey. The survey closed on July 10, 2020.
Descriptive statistical analysis was performed using IBM SPSS Statistics, version 26 . Ninety-five percent confidence intervals (CIs) were developed for each percentage. Chi-square (χ2) tests were used to examine relationships by resettlement agency size based on the number of employees - microenterprise, 0–9; small enterprise, 10–49, medium enterprise, 50–249, and large enterprise, 250 or more). Respondents were asked to have their organizational chart with them as they respondent to the survey. Also examined were the resettlement agencies’ staff capacity and preparedness at a time when the most restrictive stay-at-home orders were in effect. Fifteen agencies did not respond to the organization type question.
The final sample included 280 agencies. Organizations that worked with legal services and social services rather than resettlement services were excluded. Also omitted were programs that had closed permanently, and ICE detention facilities centers and jails due to non-response caused by legal restrictions. Excluded from the analysis were organizations that housed or detained refugees (n = 14) and questionnaires that lacked responses to critical questions (n = 11). This resulted in a final usable sample size of 101 (Fig. 1). Of the refugee resettlement agencies recruited for the study, 126 completed the survey (a 46.1% response rate). In addition, 8 respondents had incomplete responses to survey questions, 15 declined to complete the survey, and 128 could not be reached. The cooperation rate was 85%. That is, of the respondents that were reached, 85% completed the survey.
Table 1 presents the main characteristics of the responding refugee resettlement agencies. An important finding is that 95.1% of refugee resettlement agencies reported continuing to provide services either onsite (71%) or offsite (24%) to clients at a time when the most restrictive stay-at-home orders were in place. Only 5% discontinued services, but we suspect that many of our non-responding agencies had either closed temporarily or permanently. Closer inspection of the table shows that almost all agencies (98.8%) had guidelines in place for preventing the spread of COVID-19, while 15 agencies reported 1–4 employees as having missed work in the preceding 30 days. Over half (57.0%) of the agencies were privately run (for profit or not for profit), 33.7% were faith-based (with a religious organization, and only 9.3% were publicly run (federally or state run).
Table 2 shows that refugee resettlement agencies are split evenly when asked whether staffing levels are adequate to assist clients with COVID-19: 33.3% “strongly agree” or “agree”, 33.3% “strongly disagree” or “disagree”, and 33.3% indicated that the question does not apply. In contrast, 56.9% (n = 41) “strongly agree” or “agree” that staff are appropriately trained, 78.9% “strongly agree” or “agree” that their agency is practicing social distancing within their offices (n = 56), and 93.1% “strongly agree” or “agree” that staff are capable of interpreting guidelines issued by the CDC (n = 67). In addition, the majority “strongly agree” or “agree” that staff have timely access to COVID-19 information (93.1%, n = 67) and that their supervisor “believes that CDC guidelines are critical for mitigating COVID-19 in their agency” (84.5%, n = 60).
Table 3 shows wide variation in service provision mode based on refugee resettlement agency size, type, and length in operation (Table 3). Small (n = 22, 72.3%) to medium (n = 22, 95.7%) enterprises were more likely to continue providing services to client offsite as well as onsite. Of those that continued to provide services offsite, most were faith-based organizations, and most had been in operation for more than 20 years.
This paper offers a unique exploration of the impact of COVID-19 on service delivery systems experienced by US refugee resettlement agencies during the early months of the COVID-19 pandemic. Understanding this impact is vital, as these agencies are typically the first agencies to engage with refugees upon arrival, and can support refugees who, like minority populations, may be at higher risk for COVID-19 . In addition, in the early resettlement period, refugees encounter multiple potential stressors and competing priorities (e.g., adjusting to a new country, finding employment, learning a new language, and navigating complex, unfamiliar healthcare systems) . Our findings, collected via cross-sectional analysis, facilitated this understanding as the impact of COVID-19 on service delivery systems were identified directly by agencies experiencing and working to address them.
While refugee resettlement agencies are split almost evenly on whether staffing levels are adequate to assist clients with COVID-19, most continued providing services onsite (n = 24 agencies) or offsite (n = 72 agencies), and most had multiple offices. Most agencies also had staff that missed work, tested positive for COVID-19, or quarantined in the preceding 30 days, even though the numbers of the affected staff varied by refugee resettlement agency size, type, and length in operation. Microenterprise agencies (with 0–9 employees), were disproportionately affected compared to larger agencies. Our findings demonstrates that despite the existence of refugee policies aimed at curbing resettlement and travel restrictions, refugee resettlement agencies had to remain operational to continue assisting recently resettled refugees and to resettle refugees that the US continued to accept during the pandemic. For example, the US admitted 1584 refugees in February 2020 and 1110 refugees in March 2020, with admission suspended on March 17 when the United Nations High Commissioner for Refugees (UNHCR) suspended resettlement departures due to the growing COVID-19 pandemic .
The capabilities of US refugee resettlement agencies may be attributed to these agencies’ preparedness and response to the COVID-19 pandemic. For example, at the time of this study during the early stages of the COVID-19 pandemic, nearly 56.9% (n = 41) of refugee resettlement agencies “strongly agree” or “agree” that staff are appropriately trained, 78.9% “strongly agree” or “agree” that their agency is practicing social distancing within their offices (n = 56), and 93.1% “strongly agree” or “agree” that staff are capable of interpreting guidelines issued by the CDC (n = 67). In addition, the majority “strongly agree” or “agree” that staff have timely access to COVID-19 information (93.1%, n = 67) and that their supervisor believes that the CDC guidelines are critical for mitigating COVID-19 in their agency (84.5%, n = 60). Combined, these institutional aspects reflect agency readiness [25, 26]. However, the observed split in views on staffing levels raise concerns about the ability of refugee resettlement agencies to respond in a timely and effective manner to the needs of resettled refugees during health crises.
Strengths and limitations
An important strength of this study is the inclusion of US refugee resettlement agencies with varying organization type (public, private, and faith-based), years in operation, caseloads, capacities, and regional representation. This contributed to in-depth insight into the perspectives of refugee resettlement agencies’ capacity and preparedness to serve clients during COVID-19 and allowed for comparisons of service provision capabilities by agency size, type, and length in operation.
Not assessing the impact of COVID-19 on the lives of resettled refugees is a limitation, as the opinions of refugees might differ from that of the respondents at the refugee resettlement agency. Since the study was conducted during a period when the country was under strict stay-at-home orders, it was not possible to compare pre- and post-COVID-19 impacts on refugee resettlement agencies, and this may have led us to miss some agencies. This is an important issue for future research. Likewise the US Census Bureau  has recently developed and implemented an alternative nonresponse adjustment while several lines of recent evidence also suggest ways to mitigate nonresponse rates [28,29,30,31] that can be used in future studies with good effect under similar contexts. Further, the generalizability of these results is subject to certain limitations. For instance, although we had regional representation across the US, the results presented here are not representative of some agencies that serve refugees (e.g., prisons). The small sample size for some types of agencies (public vs. public), particularly large enterprises, limited more robust statistical analysis and comparison beyond basic descriptive statistics.
Despite its exploratory nature, this study offers insight into the impact of COVID-19 on service delivery systems, particularly on refugee resettlement agencies, and might inform strategies to address service delivery system challenges during times of crisis or disasters.
Implications for research and practice
Future research could focus on understanding pre- and post-COVID-19 impacts on service delivery systems of refugee resettlement agencies, as well as on the perspectives of resettled refugees. Understanding such perspectives is vital for insight into how such cumulative adversities experienced by the refugee community have widened the gaps to social services, and healthcare access, including social support . More specifically, studies could unravel the circumstances under which agency capacities or preparedness to assist refugees varied or changed. Lastly, qualitative research such as focus groups could establish the link between survey data and perspective of agencies working with refugee populations during the post-COVID period. These methods could also help better understand refugee outcomes and experiences.
In practice, this study suggests the potential benefit of actively addressing funding sources to allow refugee resettlement agencies to continue providing specialized services to current refugees during times of crisis or when the number of arriving refugees is low. Moreover, a few models exist, such as the hybrid funding model, that can allow agencies to provide services privately without federal funding, with federal funding and/or with private reimbursement or upfront funding . Notably, although UNHCR suspended resettlement departures due to COVID-19 , US refugee resettlement agencies continued to provide services to their clients. Findings also draw attention to the need for extra vigilance in the monitoring and assessment of refugee resettlement agencies as well as other public-serving agencies during pandemics or natural disasters that may require unanticipated levels of service consumption and delivery. Now that the Biden administration has increased the cap of refugees to 125,000 for 2022 , reinstating the affected infrastructure of resettlement programs may require investment in resettlement infrastructure to bring it to its former state before refugees arrive.
This study explored the capability and preparedness of US refugee resettlement agencies to provide services to clients during the COVID-19 pandemic. Like our previous study , we observed that US refugee resettlement agencies continued to perform despite a lack of funding. This posture can be attributed to the professional predisposition of refugee resettlement agencies to helping the underserved, regardless of capacity or funding levels. Future research on US refugee resettlement agencies’ perspectives by organization type and funding is needed to obtain a more balanced understanding of their practice or operations.
Availability of data and materials
Data are available upon request to the corresponding author.
Coronavirus disease 2019
United Nations High Commissioner for Refugees
Immigration and Customs Enforcement
Institutional Review Board
Centers for Diseases Control and Prevention
Zucker NL. Refugee resettlement in the United States: policy and problems. Ann Am Acad Polit Soc Sci. 1983;467:172–86.
Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med. 2020;382(18):1679–81. https://doi.org/10.1056/NEJMp2003539.
Hasan MZ, et al. Integrated health service delivery during COVID-19: a scoping review of published evidence from low-income and lower-middle-income countries. BMJ Glob Health. 2021;6:6. https://doi.org/10.1136/bmjgh-2021-005667.
Neill R, et al. Evidence of integrated health service delivery during COVID-19 in low and lower-middle-income countries: protocol for a scoping review. BMJ Open. 2021;11(5):e042872. https://doi.org/10.1136/bmjopen-2020-042872.
B. Stuart. How the COVID-19 Pandemic Has Affected Provision Of Elective Services: The Challenges Ahead. https://www.healthaffairs.org/do/10.1377/hblog20201006.263687/full/. (Accessed March 6, 2021).
Cruden G, Campbell M, Saldana L. Impact of COVID-19 on service delivery for an evidence-based behavioral treatment for families involved in the child welfare system. J Subst Abus Treat. 2021;129:108388. https://doi.org/10.1016/j.jsat.2021.108388.
Bojdani E, et al. COVID-19 pandemic: impact on psychiatric care in the United States. Psychiatry Res. 2020;289:113069. https://doi.org/10.1016/j.psychres.2020.113069.
Cochran G, Bruneau J, Cox N, Gordon AJ. Medication treatment for opioid use disorder and community pharmacy: expanding care during a national epidemic and global pandemic. Subst Abus. 2020;41(3):269–74. https://doi.org/10.1080/08897077.2020.1787300.
Kopelovich SL, et al. Community mental health care delivery during the COVID-19 pandemic: practical strategies for improving Care for People with serious mental illness. Commun Ment Health J. 2021;57(3):405–15. https://doi.org/10.1007/s10597-020-00662-z.
Murphy AA, et al. Challenges experienced by behavioral health organizations in New York resulting from COVID-19: a qualitative analysis. Commun Ment Health J. 2021;57(1):111–20. https://doi.org/10.1007/s10597-020-00731-3.
Moise I, Ortiz-Whittingham L, Omachonu V, Clark M, Xue R-D. Fighting the bite during a crisis: capabilities of Florida Mosquito control districts during the COVID-19 pandemic: Research Square; 2020.
Campbell E. Survey: COVID-19 continues to impact service delivery: The Center for Community Solutions. https://www.communitysolutions.com/survey-covid-19-continues-impact-service-delivery/. (Accessed March 6, 2020)
Benjamen J, et al. Access to Refugee and Migrant Mental Health Care Services during the First Six Months of the COVID-19 Pandemic: A Canadian Refugee Clinician Survey. Int J Environ Res Public Health. 2021;18:10. https://doi.org/10.3390/ijerph18105266.
Endale T, St. Jean N, Birman D. COVID-19 and refugee and immigrant youth: a community-based mental health perspective. Psychol Trauma Theory Res Pract Policy. 2020;12(S1):S225–7. https://doi.org/10.1037/tra0000875.
Roy CM, Bollman EB, Carson LM, Northrop AJ, Jackson EF, Moresky RT. Assessing the indirect effects of COVID-19 on healthcare delivery, utilization and health outcomes: a scoping review. Eur J Pub Health. 2021;31(3):634–40. https://doi.org/10.1093/eurpub/ckab047.
Roberton T, et al. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. Lancet Glob Health. 2020;8(7):e901–8. https://doi.org/10.1016/s2214-109x(20)30229-1.
Karas T. US refugee agencies wither as Trump administration cuts numbers to historic lows. https://theworld.org/stories/2019-09-27/us-refugee-agencies-wither-trump-administration-cuts-numbers-historic-lows. Accessed 15 Apr 2022.
Acuto M. COVID-19: lessons for an urban (izing) world. One Earth. 2020. https://doi.org/10.1016/j.oneear.2020.04.004.
Im H, George N. Impacts of COVID-19 on Refugee Service Provision and Community Support: A Rapid Assessment during the Pandemic. Soc Work Public Health. 2022;37(1):84–103. https://doi.org/10.1080/19371918.2021.1974639.
National Academy for State Health Policy. Each State’s COVID-19 Reopening and Reclosing Plans and Mask Requirements. https://www.nashp.org/governors-prioritize-health-for-all.
IBM Corp. IBM SPSS Statistics for Windows, Version 26.0.
Clarke SK, et al. Potential impact of COVID-19 on recently resettled refugee populations in the United States and Canada: perspectives of refugee healthcare providers. J Immigr Minor Health. 2021;23(1):184–9. https://doi.org/10.1007/s10903-020-01104-4.
Fabio M, Parker LD, Siddharth MB. Building on resiliencies of refugee families. Pediatr Clin N Am. 2019;66(3):655–67. https://doi.org/10.1016/j.pcl.2019.02.011.
Refugee Processing Center. How does COVID-19 impact refugee resettlement?. https://www.gcir.org/news/how-does-covid-19-impact-refugee-resettlement. (Accessed March 7, 2021).
Petrović D, Petrović M, Bojković N, Čokić VP. An integrated view on society readiness and initial reaction to COVID-19: a study across European countries. PLoS One. 2020;15(11):e0242838. https://doi.org/10.1371/journal.pone.0242838.
Moise IK, Xue R-D, Zulu LC, Beier JC. A survey of program capacity and skills of Florida Mosquito control districts to conduct Arbovirus surveillance and control. J Am Mosq Control Assoc. 2020;36(2):99–106. https://doi.org/10.2987/20-6924.1.
J. Rothbum. How Does the Pandemic Affect Survey Response: Using Administrative Data to Evaluate Nonresponse in the Current Population Survey Annual Social and Economic Supplement. https://www.census.gov/newsroom/blogs/research-matters/2020/09/pandemic-affect-survey-response.html. (Accessed February 6, 2022).
de Koning R, Egiz A, Kotecha J, Ciuculete AC, Ooi SZY, Bankole NDA, Erhabor J, Higginbotham G, Khan M, Dalle DU, Sichimba D, Bandyopadhyay S, Kanmounye US. Survey Fatigue During the COVID-19 Pandemic: An Analysis of Neurosurgery Survey Response Rates. Front Surg. 2021;8:690680. https://doi.org/10.3389/fsurg.2021.690680. PMID: 34458314; PMCID: PMC8388838.
Moise IK, Kangmennaang J, Hutchings TCSG, Sheskin IM, Fuller DO. Perceptions of Zika Virus Risk during 2016 Outbreak, Miami-Dade County, Florida, USA. Emerg Infect Dis. 2018;24(7):1379–81. https://doi.org/10.3201/eid2407.171650.
Moise IK, Brown KS, Riegel C, Kalipeni E, Ruiz V. Geographic assessment of unattended swimming pools in post-Katrina new Orleans, 2006-2008. Ann Assoc Am Geogr. 2013;103(5):1160–75.
Moise IK, Ruiz MO. Hospitalizations for substance abuse disorders before and after hurricane Katrina: spatial clustering and area-level predictors, New Orleans, 2004 and 2008. Prev Chronic Dis. 2016;13:E145. https://doi.org/10.5888/pcd13.160107.
Boozang P, Traube A, Corlette S, Volk J. A hybrid funding and coverage model to ensure universal access to Mobile crisis services. In: Manatt health, editor. Georgetown University’s Center on Health Insurance Reforms; 2021.
Montoya-Galvez C. U.S. to raise refugee cap to 125,000 spots in 2022. https://www.cbsnews.com/news/immigration-us-refugee-cap-125000-in-2022/. Accessed 15 Apr 2022.
We are grateful to the various refugee resettlement agencies for their support and participation in the study. Special thanks go to Sylvia Acevedo of Gulf Coast Jewish Family and Community Services, Alicia Wrenn of Resettlement and Integration, and Danielle Grigsby of Refugee Council USA (RCUSA) for reviewing the survey and for circulating the it to their affiliates.
No funding source supported this study.
Ethics approval and consent to participate
The Institutional Review Board (IRB) at the University of Miami (IRB ID: 20210247) determined that this study is exempt from review because it is a telephone/internet survey study to learn about the capabilities of US Refugee Settlement Agencies capabilities during the COVID-19 pandemic lockdown. All study participants provided informed written consent before beginning the survey, with a participant’s initiation of a survey constituting giving informed consent.
Consent for publication
The authors declare that they have no conflict of interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Moise, I.K., Ortiz-Whittingham, L.R., Omachonu, V. et al. The impact of COVID-19 on service delivery systems: evidence from a survey of United States refugee resettlement agencies. BMC Health Serv Res 22, 535 (2022). https://doi.org/10.1186/s12913-022-07909-3