Overcrowded Housing Reduces COVID-19 Mitigation Measures and Lowers Emotional Health Among San Diego Refugees from September to November of 2020

Refugee communities are vulnerable to housing insecurity, which drives numerous health disparity outcomes in a historically marginalized population. The COVID-19 pandemic has only worsened the ongoing affordable housing crisis in the United States while continuing to highlight disparities in health outcomes across populations. We conducted interviewer-administered surveys with refugee and asylum seekers in San Diego County at the height of the COVID-19 pandemic to understand the social effects and drivers of COVID-19 in one of the largest refugee communities in the United States. Staff from a community-based refugee advocacy and research organization administered the surveys from September - November 2020. 544 respondents participated in the survey, which captured the diversity of the San Diego refugee community including East African (38%), Middle Eastern (35%), Afghan (17%), and Southeast Asian (11%) participants. Nearly two-thirds of respondents (65%) reported living in overcrowded conditions (> 1 individual per room) and 30% in severely crowded conditions (> 1.5 individuals per room). Respondents living in affordable housing units or receiving section 8 housing vouchers had a 66% lower probability of living in severely crowded settings (aOR:0.34, 95% CI:0.19 - 0.61). Refugees living in overcrowded and severely overcrowded housing had more than twice the odds to have not accessed COVID-19 testing since the pandemic began (OR: 2.28, 95% CI: 1.38 - 3.78) and had nearly 4 times the odds to report lower emotional health (OR: 3.90, 95% CI: 2.62 - 5.82). Longer United States residency was associated with a 7% reduction in the odds of living in crowded housing per additional year (aOR:0.93, 95% CI:0.90 - 0.97). Overcrowding housing is a structural burden that reduces COVID-19 risk mitigation behaviors. Improved access to affordable housing units or receiving vouchers could reduce overcrowded housing in vulnerable refugee communities.