WaSH insecurity impacts the lives of communities across the globe, including vulnerable unhoused communities in Skid Row, Los Angeles. Safe, equitable, sufficient, reliable, affordable and dignified access to WaSH services is often not possible for unhoused people, especially at night. In Los Angeles, many of the unhoused participants we interviewed could not access sanitation at night, and shower or wash their clothes regularly. The study findings suggest that the unhoused embark on different survival coping mechanisms to access and meet their daily WaSH needs. They rely on fire hydrants to obtain water for bathing and drinking. They urinate or defecate in buckets or plastic bottles inside their tents. Many also lack sufficient water for basic hand hygiene, showering, and laundry. The lack of basic WaSH services also makes it difficult for unhoused women to manage their menstrual health hygiene safely. The unhoused often have no other choice but to use public spaces (such as sidewalks and buckets) to openly defecate or urinate, wash their clothes, and shower. Overall, it creates barriers for people to fully manage their health, seek employment, and improve their living conditions.
In Los Angeles, unhoused residents studied live in an environment that is scarce of essential WaSH services, which further degrades their physical and mental health and reduces their opportunities for employment. In our study, the aspect of appearance was a common factor reported by participants in reducing their ability to access essential WaSH services. As the study of DeMyers, Warpinski, and Wutich (2017) in Phoenix highlights, WaSH insecurity serves both as a “driver and an inhibitor” of prolonged homelessness. In our study, participants reported difficulty accessing sanitation and hygiene services that enable them to maintain daily body hygiene that in essence would also allow them to be accepted in public spaces and be less discriminated when accessing other supportive services. In particular, limited access to sanitation and hygiene facilities was a problem for the study population, especially for women managing their menstrual hygiene who reported feeling smelly and dirty due to lack of access to shower facilities.
Similarly, Sommer et al. (2020), in their study of menstrual hygiene challenges among unhoused women in New York City, found similar results. Sommer et al. suggest that the absence of safe and private access to sanitation and hygiene services among the unhoused exacerbates menstrual stigma. The reduced access to these serves creates feelings of embarrassment and shame that “hinder women's ability to be comfortable during their periods” and attend to their personal daily activities . Sebert Kuhlmann et al.'s (2019) study also explored the experiences of unhoused women in St. Louis, Missouri and concluded that the inability to afford hygiene products resulted in women engaging in various coping mechanisms, including using rags, tissues, toilet paper, children's diapers, or paper towels to manage menstruation . In Manhattan, New York, Maroko et al. (2020) argues that spatial bias exist in the distribution of public services, with higher quality of sanitation services located in affluent neighborhoods and poorer quality services available among unhoused communities. Thus limiting access to sanitation that is private, safe, and accessible among unhoused women managing menstruation . Overall, the absence of basic WaSH services to maintain a certain appearance and hygiene practices reinforces a cycle of homelessness as seen in Los Angeles and in other cities. The prejudicial attitudes towards unhoused people based on their physical appearance lead to exclusionary policies and further stigmatization that impacts people's ability to exist in public spaces and exit homelessness .
We also found a temporal inaccessibility of WaSH services in Los Angeles. Specifically, the evening was the most challenging time for people to access to sanitation services that are both open and safe to use. While 14% of the study population reported that they openly defecate during the afternoon, 28% are forced to openly defecate at night. Business establishments typically close at 9:00 PM in the community, and most non-profit organizations are not available 24-hours, except for the ReFresh Spot, People Concern, and Union Rescue Mission shelter. As a result, accessing WaSH services is severely limited for an estimated 1,898 unhoused individuals living in the community of Skid Row at night . In the morning and afternoon, participants reported utilizing public restrooms in parks and libraries and restrooms from non-profit organizations (e.g., shelters, soup kitchens, mobile showers, and religious organizations). These places tend to be free and open to the community until closure. However, while services may be more available during the morning and afternoon, participants reported long wait times, inconvenient hours, or out-of-service facilities. These factors discourage a person from maintaining hygiene practices, and forces them to resort to coping strategies, such as showering using buckets inside their tents, rinsing, and doing laundering in sinks of businesses and public restrooms, and throw away their clothing rather than wash it.
Inequities in WaSH Access
This study findings suggests that there is a service hub of WaSH services that that the unhoused report utilizing within the Skid Row community, compared to downtown Los Angeles and the greater Los Angeles area. Participants who reported sleeping in locations outside Skid Row boundaries such as Santa Monica Beach, Hollywood, or South Los Angeles commuted by bus, metro, or foot to access services (mainly shower and laundry). The commute from these neighbourhoods to Skid Row exceeds the JMP global standards for accessing drinking water and or other WaSH of 30-minutes . These participants also expressed that they commuted to Skid Row in the morning and afternoon to access services but left the area at night due to safety reasons. WaSH services outside of Skid Row boundaries are rarely available due to community opposition and criminalization of homelessness through city ordinances. In Los Angeles, two major city ordinances exist that are heavily enforced, including the Los Angeles Municipal Code (LAMC) 41.18(d) that prevents people from sleeping in public areas between the hours of 6 AM to 9 PM . The LAMC 56.11 is another city ordinance that limits unhoused people from having personal property exceeding the equivalent of a 60- gallon container . This enforcement overlaps with street sweeps that sanitation workers conduct to remove encampments across Los Angeles. Moreover, police enforcement criminalizes other coping behaviours, including public urination and defecation, perpetrated due to inadequate access to WaSH [45, 46]. The passage of such anti-homelessness laws in Los Angeles creates environments that reinforce a cycle of poverty. It produces a system that punishes a vulnerable population for their existence and a criminal justice system that views them as pollution and a threat while actively diminishing an unhoused person’s ability to exist in public spaces [47, 48]. In Los Angeles, individuals are criminalized daily for their survival and coping mechanisms (e.g., sleeping in tents/vehicles and public urination/defecation), leading to infraction notices, misdemeanours, unpayable fines, and incarceration [45, 49]. These misdemeanours result in a criminal record that prevents people from qualifying for most housing services, essentially creating a cycle of sustained poverty [19, 34, 49]. The inaccessibility of publicly available WaSH services in Los Angeles serves as a form of oppression for a population that is often removed from public spaces to limit their visibility and potential disruptiveness [48, 50]. As essential WaSH services remain difficult for the unhoused to access, reports of health outbreaks attributed to poor living environments and hygiene have become more pronounced in recent years [51, 52].
While the unhoused residing in Los Angeles in our study experience WaSH insecurity, their experiences are not homogenous. WaSH insecurity is experienced differently among unhoused people, particularly for people of colour and people who sleep outside of Skid Row. Women are especially vulnerable and are forced to cope with limited access to restroom and shower facilities on top of the economic burden of managing their menstrual cycle. Some participants mentioned that they experience discrimination while waiting in line to use services such as a shower or sanitation. Specifically, Black and Latinx unhoused participants reported the experience forms of discrimination that prevent them from accessing shower services in shelter systems and restrooms in business and public establishments. Unhoused men also reported experiencing discrimination when accessing WaSH services more often than women, reducing their access to services that can meet their basic needs. Additionally, the trauma of living on the streets and being exposed to stressful WaSH environments can affect people differently. For women, openly defecating or showering inside their tents can pose a risk for physical violence or harassment. Additionally, in this study, six out of thirty-five female participants reported no longer having their menstrual cycle. Unhoused women who no longer have their menstrual cycle (a condition referred to as amenorrhea that affects one percent of the general population) may be due to trauma and stress-induced living on the streets . Still, more measurements are needed to validate this finding. Of the 35 women that reported they continue to manage their menstrual cycle, 8 (or 22%) reported difficulty accessing feminine hygiene products. Generally, feminine hygiene products are expensive to purchase for the unhoused. Menstrual hygiene products are also not provided consistently in safety-net programs and shelter systems. The work of Kulhmann et al. in Missouri also report this added barrier for low-income women. Kulhmann et al. states that the inability to afford high-cost products becomes an added burden for women, particularly when they cannot use federally funded programs (e.g., Women, Infants, and Children and Supplemental Nutrition Assistance Program) to purchase hygiene products .
Impacts of WaSH Insecurity
The barriers to maintaining good hygiene are numerous for unhoused people. For example, shower facilities are not always at close proximity to participants, with some commuting long distances to access these services. Even when shower services are available in communities like Skid Row, it also does not guarantee people access as participants have to sign up early or they will be part of a long waitlist process that can last all day. Additionally, shower access is subject to out of order facilities or closed facilities. Overall, improving unhoused people’s ability to shower regularly could help decrease skin infections and other health problems and improve employment options. Access to laundry services is limited by affordability and availability. In this study, 48% of participants reported relying on non-profit organizations for laundry services which charge small fees for laundering or are limited by hours of operation. While 39% of participants reported using private laundromats, access was limited by affordability and proximity.
In Los Angeles, the requirement of customer-only access to restrooms and appearance drastically reduces the well-being and capacity of the unhoused to maintain good sanitation practices that would allow them to look “presentable.” As a result, people resort to openly defecating or using buckets inside their tents to conduct their personal necessities. According to the Los Angeles County Public Health Department, being unhoused is becoming increasingly deadly, with an overall steady increase in the all-cause mortality rate of 2.3 times greater than the general population . On average, four unhoused people die daily in Los Angeles . Their life expectancy can be as low as 48 years for women and 51 for men, compared to the general population with a life expectancy of 83 and 79 years, respectively [56, 57]. This lower life expectancy can result from higher death rates, chronic illnesses, mental health, drug use, and disabilities that unhoused people experience compared to the general housed population [58, 59]. Living on the street, specifically in tents, near riverbanks, in RVs or vehicles, and overcrowded homeless shelters increase a person's exposure to health risks. A particular health risk includes communicable diseases exacerbated by malnutrition, poor hygiene practices, and exposure to harmful weather conditions such as cold temperatures and rain .
Importantly, skin-related diseases are the leading cause for which unhoused people to seek medical services [21, 60–63]. In this study, sixty-four participants reported experiencing skin infections. While our study did not collect information on the type of skin lesions and infections affecting participants, Leibler et al.'s (2017) study in Boston, Massachusetts found that unhoused people experience a higher prevalence of nasal colonization of staph compared to the general population. Leibler et al. found 16 unhoused people with MRSA nasal colonization resulting from limited hygiene and crowded living conditions . Overall, skin conditions are made worse by a lack of sanitation and poor hand and body hygiene practices, putting unhoused individuals at a higher risk of infection.
Other endemic poor health outcomes in unhoused communities are head and body lice, scabies, and secondary bacterial infections, all of which can be WaSH preventable diseases . In this study, nine participants reported having body and head lice within a 30-day period. These numbers are much smaller than other studies, including Bonilla et al.'s (2014) study in San Francisco with 203 unhoused people, of whom ten people had head lice and 60 reported body lice. Lice infestation can affect unhoused residents as they do not have consistent and reliable access to clean changes of clothing or bathing facilities [61, 64, 65]. In this study, we only found that a total of five participants had typhus, which is relatively more minor compared to Badiaga et al.'s (2012) study in Marseilles, France, which detected sixty-three people with antibodies against Rickettsia typhi . This vector disease causes murine typhus. One of the reasons for these differences may be that more comprehensive testing is needed to measure the prevalence of this poor access to WaSH-related health outcomes.
Furthermore, dehydration and urinary tract infections were common health conditions reported by the sampled population. In this study, 103 participants reported experiencing dehydration in the past 30 days from the time of interview. While the data collection took place in the two hottest months of the year (June and July), heat exposure and lack of available drinking water can result in heat exhaustion. DeMeyers, Warpinski, and Wutich's (2017) study in Arizona found that lack of vegetation, urban heat island effect, and lack of WaSH services are all factors that increased the risks of dehydration and heat exhaustion  for the unhoused. Lastly, our findings note that a number of people report holding off from using the restroom, especially in the evening time when facilities are closed and inaccessible. These coping strategies can lead people to encounter health problems like kidney and vaginal infections. In this study, 32 people reported urinary tract infections within 30 days of the interview, and 18 were women. Urinary tract infections can result when people delay using a restroom, and lack of adequate access to WaSH services can increase their risk of contracting infections. Women are at higher risk of contracting kidney and vaginal infections. For example, Wenzel et al.'s (2001) study found that many unhoused women in Los Angeles County encounter gynaecological symptoms. In addition to WaSH services, better health care support systems are needed to address unhoused women's needs .
Limitations and Recommendations
Overall, this study describes the WaSH insecurity experiences of unhoused communities living in and around Skid Row, Los Angeles. While this study has contributed to filling gaps in the existing scholarship, there are some limitations to this study. First, this study only surveyed 263 participants, accounting for less than one percent of the County and City of Los Angeles's total unhoused population. The small sample size may have resulted in less statistically significant results. The population is difficult to reach and access, so we used a mixture of snowball and convenience sampling to recruit participants. A random sampling technique to recruit participants would have made the results more generalizable. Additionally, the locations where we sampled some of the population may be attributed to location bias. We partnered with a WaSH non-profit organization on two occasions to provide us with a safe space to recruit participants, which may have led to oversampling population who knew of and use the services provided by the non-profit. As a result, there may have likely being newly unhoused people who were unaware that these services existed and so they were not interviewed, and thus this study may overestimate WaSH access among the unhoused. The type of questions we asked participants may have resulted in recall bias. Participants may not have remembered all of their daily habits within the timeframe given, specifically the WaSH related health outcomes they experienced over a 30-day period. In terms of health data, more in-depth menstrual hygiene management data is needed in this study to measure the way unhoused women cope with menstrual hygiene management, thus resulting in an additional study limitation. Since the population is mobile, there may have also been duplicate interviewees. If recognized, a survey was either omitted from the final analysis or used to validate their initial survey responses. More extensive mixed methods studies are necessary to disentangle these factors and include different cohorts to understand how poor access to WaSH services affects communities differently. The study findings describe the lived WaSH experiences of the unhoused people in the Skid Row community and beyond, and provide a better understanding of a population that is difficult to reach, understudied, and inhumanly treated.
It is important to note that this study does not capture all the intersectional vulnerabilities experienced among unhoused communities. There is a range of demographic groups within the unhoused communities interviewed in this study that experience WaSH insecurity differently. Integrating an intersectionality lens is essential to consider the range of effects of WaSH insecurity on different groups of unhoused to raise awareness of equity, marginalization, and discrimination at the individual and structural levels. It is essential to highlight the marginalized identities among groups of people, including people who identify as transgender, as this study was limited in not capturing the perceptions of this group in more detail. Examining the experiences of other marginalized groups not examined in this study is vital in helping us further understand and acknowledge the added vulnerabilities people experience in accessing services and exiting homelessness.
There is a need to prioritize safe, dignified, affordable, accessible, sufficient, sufficient, reliable, and continuous access to WaSH services in vulnerable communities, including unhoused people . To better understand and mitigate WaSH insecurity in the US and worldwide, there is also a need to move beyond the lens of household WaSH insecurity and include people experiencing homelessness to provide more informed and interdisciplinary knowledge. Furthermore, in Los Angeles, a collaboration between service providers, policymakers, health care systems, and researchers is needed to develop inclusive and equitable solutions. Indeed, improving the way we are addressing homelessness requires an integrative process. Service providers, particularly in the non-profit sector, play a vital role in this process as they work directly with the community and know their needs. The provision of housing with integrated services, including WaSH, can lead to a more comprehensive and successful way to meet the needs of the unhoused. One inclusive recommendation includes developing WaSH service models that are humane, dignified, and available 24-hours a day. The findings from this study highlight that providing safe and available services at all times of the day is needed to meet the needs of the unhoused in Skid Row and the surrounding areas. In Skid Row, the ReFresh Spot is an example of a successful model that works. Community members use the ReFresh Spot because the facilities are well maintained, have friendly staff, are clean, and available when needed. City officials could consider allocating money to WaSH infrastructures and facilities like the ReFresh Spot rather than installing temporary portable toilets and conducting encampment sweeps. In 2018, Los Angeles City officials spent 31 million dollars on street-clean ups . These types of program interventions are not sustainable, humane, and do not target the root of the problem. Lastly, integrating the voices of unhoused residents at the decision-making tables could foster real change and improve these communities' health and living environments because they have the lived expertise and know what services are more valuable to them.
Future studies should consider how to measure network analysis of WaSH facilities. For example, identifying the best location to provide WaSH services in the different communities and characteristics of effective interventions could be identified to make WaSH services more accessible. Additionally, studies should consider measuring the psychosocial health outcomes attributed to WaSH insecurity among unhoused communities. Measuring emotional stress is critical to capture in both scholarly research and policy implementation as unsafe and inadequate access to essential WaSH services can lead to emotional stress and exacerbate mental health diagnoses. Furthermore, studies should consider exploring the effects of WaSH insecurity on medication adherence in the Los Angeles unhoused population [70, 71].