University of Southern California Dissertations and Theses

Homeless encampments and access to Water, Sanitation, and Hygiene (WaSH) services in Los Angeles, CA

(USC Thesis Other)

Homeless encampments and access to Water, Sanitation, and Hygiene (WaSH) services in Los Angeles, CA

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content Homeless Encampments and Access to Water, Sanitation, and Hygiene (WaSH)
Services in Los Angeles, CA
by
Lourdes Johanna Avelar Portillo
A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Population, Health and Place)
December 2021
Copyright © 2021 Lourdes Johanna Avelar Portillo
ii
Dedication

To my family, Larry and the teddy bear crew, and the unhoused community of Los Angeles

iii
Acknowledgements
I would like to first and foremost thank God for granting me the opportunity, knowledge,
and wisdom to complete to this journey. I would also like express my most profound
appreciation and gratitude to the unhoused community of Los Angeles. Your willingness to share
your voice and story with me made this project possible. I would also like to thank each service
provider who took the time to share their perspectives and continue fighting for unhoused
people’s rights.
This dissertation project would also not have been possible without my wonderful
committee and mentors. I want to start by expressing my deepest gratitude to my co-advisors:
Dr. Yao-Yi Chiang and Dr. Meredith Franklin. Thank you for your guidance, patience, and
invaluable support. Thank you for believing in my ideas when no one else did and for
significantly impacting my life for the better; I will miss working with you both. I would also
like to thank my outstanding committee members: Dr. Laura Ferguson, Dr. Manuel Pastor, and
Dr. Benjamin Henwood, for your guidance and for always challenging me to think critically for
the betterment of our society. Words cannot express my gratitude and appreciation for your
guidance throughout the years.
Thank you to my supportive and loving parents, Mary Avelar and Jorge Avelar, for
engraining a love for education and teaching me the importance of hard work and compassion.
Thank you for taking a leap of faith and immigrating with my family from El Salvador to
provide us with better opportunities to succeed in life; this is for you! I also would like to thank
my wonderful and loving boyfriend, Dr. Larry Rodriguez. Thank you for your patience, love,
and kindness. Thank you for showing me the true meaning of unconditional love, for always
uplifting me, and believing in my work every day, even when at times. I love you with my whole
iv
heart. To my siblings: Jessy, Jorge, and Diego thank you for your love, guidance, and
encouragement throughout the years. I would be lost without you. I want to also thank my whole
family, especially my Tia Evelyn, Tio Jason, Brandon, Jeremy, Tia Blanca, Tio Oscar, Tia
Sheree, Tio Mario, Tio Tito, all of my tias, tios, primos, and my abuelitos watching over me
from heaven. Thank you for all of your love, encouragement, and for helping my family migrate
to the US in order to have a better life, helping each of us achieve our dreams. This is for you!
Additionally, I would also like to thank the Spatial Sciences Institute for allowing me to
be part of this program and for believing in my work from day one. Thank you, Dr. John Wilson,
for planting this research idea and encouraging me to pursue this project; for your guidance and
support. I want to acknowledge and thank Beau and Richard for their patience, unwavering
willingness to help me with ArcGIS. This dissertation’s analysis would not have been possible
without you. Thank you to all of the faculty and staff in the department for their help throughout
these years.
Furthermore, I would like to thank my support system and community. Thank you to my
best friends Gilda Avila, Neleam Said, Cindy Piao, for their love, guidance, and friendship. I
want to also express my gratitude to Dr. Jeffrey Saver, Stephanie Wong, and everyone I cherish
at UCLA. Thank you for your incredible support and mentorship throughout the years. I would
also like to express my love and gratitude to my colleagues at the Population, Health, and Place
program. Special thanks to my wonderful cohort and my forever family, Yan Xu and Douglas
Fleming. We started this journey together, and I wouldn’t have it any other day. Thank you for
your support and guidance all these years! I am thankful for other extraordinary and beautifully
minded friends and scholars, Lois Park, Xiaozhe Yin, Emily Serman, Kate Vavra-Musser,
Wanting Peng, Leilei Duan, Weiwei Duan, Yijun Lin, Zekun Li, Hayley Song, and all the
v
cohorts in the program. Special thanks to Bob, the dog! We miss you dearly and I thank you for
all of the puppy therapy you provided us throughout the years.
This project would also have not been possible without my extraordinary and brilliant
students, Angelica Vasquez, Charlene Ko, Jimena Gonzalez, Nayib Alvarenga, and the 2018
research group. Thank you for all of your help in this project. Being your instructor, mentor, and
working by your side was one of my favorite memories at USC. I cannot wait to see you all shine
and see your contributions to this world. I would like to also highlight and express my deepest
love to the Latina PhDs at USC group. Thank you for welcoming me and providing me with a
strong bond and hermanidad. In particular, I would like to thank Cynthia Villarreal and Lizette
Solórzano for all of your love, guidance, and support through this dissertation and Ph.D. journey.
vi
Table of Contents
Dedication ....................................................................................................................................... ii
Acknowledgements ....................................................................................................................... iii
List of Tables ................................................................................................................................... x
List of Figures ................................................................................................................................. xi
Abbreviations ............................................................................................................................... xii
Abstract ........................................................................................................................................ xiii
Chapter 1 Introduction ..................................................................................................................... 1
1.1. Research Problem ............................................................................................................... 3
1.2. Dissertation Context: Homelessness in Los Angeles ......................................................... 6
1.3. Research Aims .................................................................................................................... 9
1.4. Significance of the Study .................................................................................................. 11
Chapter 2 Water, Sanitation, and Hygiene (WaSH) Insecurity Experiences in Unhoused
Communities of Los Angeles, CA ......................................................................................... 13
2.1. Introduction ...................................................................................................................... 13
2.2. WaSH insecurity in the United States .............................................................................. 15
2.2.1. Household WaSH Insecurity ................................................................................... 15
2.2.2. WaSH Insecurity Among the Unhoused ................................................................. 19
2.2.3. Knowledge Gap and Study Contributions ............................................................... 21
2.2.4. Los Angeles Homelessness Crisis ........................................................................... 22
2.3. Materials and Methods ..................................................................................................... 25
2.3.1. Target Population .................................................................................................... 25
2.3.2. Survey Data and Data Analysis ............................................................................... 27
2.4. Analysis Results ............................................................................................................... 27
2.5. Interpretation of Findings ................................................................................................. 35
vii
2.5.1. WaSH insecurity in Unhoused Communities of Los Angeles ................................ 36
2.5.2. Disparities in WaSH Accessibility .......................................................................... 38
2.5.3. Health Barriers ......................................................................................................... 39
2.5.4. Limitations and Recommendations ......................................................................... 42
2.6. Conclusion ........................................................................................................................ 44
Chapter 3 Measuring Individual and Institutional Level Accessibility to WaSH in Unhoused
Communities of Los Angeles, CA ......................................................................................... 47
3.1. Introduction ...................................................................................................................... 47
3.2. Background ....................................................................................................................... 49
3.2.1. The Built Environment and Unhoused Communities ............................................. 50
3.2.2. WaSH Insecurity and Unhoused Communities ....................................................... 52
3.2.3. Knowledge Gap and Study Contributions ............................................................... 55
3.3. Data and Methodology ..................................................................................................... 56
3.3.1. Survey Data and Processing .................................................................................... 57
3.3.2. Analysis ................................................................................................................... 59
3.4. Analysis Results ............................................................................................................... 61
3.4.1. Sample Population Demographics .......................................................................... 61
3.4.2. Individual-Level Differences in Access to WaSH .................................................. 65
3.4.3. Facility-Level Differences in Access to WaSH ....................................................... 68
3.5. Interpretation of Findings ................................................................................................. 71
3.5.1. Public spaces and access to WaSH services ............................................................ 72
3.5.2. Individual-Level Differences in Access to WaSH .................................................. 73
3.5.3. Facility Level Differences in Access to WaSH ....................................................... 76
3.5.4. Study Limitations .................................................................................................... 78
3.6. Conclusion ........................................................................................................................ 79
viii
Chapter 4 Identifying WaSH Service Needs in Unhoused Communities from the Perspective of
Service Providers in Los Angeles, CA ................................................................................... 81
4.1. Introduction ...................................................................................................................... 81
4.2. Background ....................................................................................................................... 82
4.2.1. Water, Sanitation, and Hygiene (WaSH) Insecurity ................................................ 83
4.2.2. WaSH Insecurity and Stigmatization of Unhoused Communities .......................... 84
4.2.3. Challenges in Addressing Homelessness ................................................................ 85
4.2.4. Knowledge Gap and Study Contributions ............................................................... 86
4.3. Data and Methodology ..................................................................................................... 87
4.3.1. Research Design ...................................................................................................... 87
4.3.2. Target Population and Sampling Strategy ............................................................... 89
4.3.3. Data Collection Procedures ..................................................................................... 91
4.3.4. Data Analysis ........................................................................................................... 93
4.3.5. Trustworthiness, Validity and Reliability ................................................................ 95
4.3.6. Self-Reflexivity ....................................................................................................... 96
4.4. Analysis Results ............................................................................................................... 96
4.4.1. WaSH Insecurity Impacts in Unhoused Communities ............................................ 98
4.4.2. Improving Access to Services ............................................................................... 110
4.5. Interpretation of Findings ............................................................................................... 117
4.5.1. WaSH Insecurity Impacts in Unhoused Communities .......................................... 118
4.5.2. Improving Access to Services ............................................................................... 123
4.5.3. Policy Recommendations ...................................................................................... 124
4.5.4. Strengths and Limitations ...................................................................................... 128
4.6. Conclusion ...................................................................................................................... 129
Chapter 5 Conclusion .................................................................................................................. 132
5.1. Contributions and Connections ...................................................................................... 133
ix
5.2. Policy Recommendations ............................................................................................... 136
5.3. Limitations and Future Study Recommendations .......................................................... 139
5.4. Dissertation Takeaways .................................................................................................. 142
References ................................................................................................................................... 144
Appendix A Survey Tool ............................................................................................................. 157
Appendix B Closest Facility Analysis Tables ............................................................................. 179
Appendix C Interview Tool Guide .............................................................................................. 185

x
List of Tables
Table 2.1 Frequency Distribution of Sample Population Demographics ...................................... 28
Table 2.2 Frequency Distribution of Variables Associated with Causes of Homelessness .......... 30
Table 2.3 Frequency Distribution of Variables Associated with Personal Hygiene Habits .......... 31
Table 2.4 Frequency Distribution of Health Reported Outcomes Over a 30-Day Period ............. 35
Table 3.1 Population demographics per community level ............................................................ 62
Table 3.2 Reported living conditions per community level over a 30-day period ........................ 63
Table 3.3 Generalized linear model (GLM) output results for WaSH facilities, including all
variable indicators .................................................................................................................. 66
Table 3.4 Closest restroom facility model results for morning time of the day .......................... 179
Table 3.5 Closest restroom facility model results for afternoon time of the day ........................ 180
Table 3.6 Closest restroom facility model results for evening time of the day ........................... 181
Table 3.7 Closest shower facility model results .......................................................................... 182
Table 3.8 Closest laundry facility model results ......................................................................... 183
Table 3.9 Closest drinking water facility model results .............................................................. 184
Table 4.1 List of participating organizations serving unhoused communities in Los Angeles ..... 90
Table 4.2 Generated themes and descriptions presented in qualitative descriptive interviews ..... 97
Table 4.3 Characterization of marginalized identities among unhoused communities ............... 102

xi
List of Figures
Figure 2.1 Study area and sleeping location of study participants overlapped with LA County’s
unsheltered homeless population density ............................................................................... 26
Figure 2.2 Access to different restroom facilities at different times of the day ............................ 33
Figure 3.1 Flow chart of the quantitative data analysis ................................................................. 59
Figure 3.2 Population density map of the unsheltered population of Los Angeles County at the
census tract level per square mile, 2019 ................................................................................. 64
Figure 3.3 Shower facilities across different unhoused communities of Los Angeles ................. 69
Figure 3.4 Laundry facilities across different unhoused communities of Los Angeles ................ 70
Figure 4.1 Flow chart of qualitative data and analysis .................................................................. 94

xii
Abbreviations
CoC Continuum of care
GIS Geographic information system
IRB Institutional review board
LAHSA Los Angeles homeless services authority
PIT Point-in-time
SSI Spatial Sciences Institute
UN United Nations
US United States
USC University of Southern California
WaSH Water, sanitation, and hygiene

xiii
Abstract
Access to water, sanitation, and hygiene (WaSH) are fundamental human needs.
However, global water reports estimate that 2 billion people worldwide live without safely
managed access to these WaSH services. The absence and inadequate access to WaSH result in
WaSH insecurity experiences that increase individual exposure to preventable water-related
health risks and illnesses. While most of the existing research focuses on WaSH insecurity
experiences in the global South, this dissertation shifts the attention to the global North,
specifically Los Angeles, California, USA. This dissertation aims to better understand how
unhoused communities of Los Angeles navigate spaces and places that do not have safe,
sufficient, accessible, and affordable access to WaSH services. The following work presents
three studies that detail the difficulties unhoused communities encounter, each making a case for
interim-level WaSH services that would help address people’s unmet fundamental needs. The
first study, integrates survey data from people with lived experience to identify the coping
mechanisms people use to survive in places lacking access to WaSH. The second study uses
spatial statistics and geographic information systems (GIS) to measure differences in
accessibility based on individual and service-level factors that contribute to experiences of
WaSH insecurity. The final study incorporates service providers' perspectives using qualitative
descriptive interviews to understand the impacts of WaSH insecurity during the SARS-CoV-2
(COVID-19) global pandemic. Together the findings from these studies identify the critical
needs of unhoused communities, and meeting these needs presents important policy implications.
The findings suggest that addressing WaSH insecurity is crucial because WaSH insecurity
reinforces a cycle of homelessness. In other words, WaSH insecurity exacerbates stigmatization,
raises barriers in seeking out mainstream services, and negatively affects people's mental and
xiv
physical health. Therefore, interim-level services, specifically WaSH services, are needed to
address the immediate unmet needs of unhoused residents of Los Angeles.

1

Chapter 1 Introduction
Safe access to water for drinking, sanitation, and hygiene (WaSH) are foundational human needs
and human rights. The United Nations (UN) General Comment 15 on the right to water issued by
the Committee on Economic, Social and Cultural Rights, declares that a person has the right to
have sufficient, safe, physically accessible, and affordable water for personal needs without any
form of discrimination (UN Committee on Economic Social and Cultural Rights (CESCR) 2003).
Additionally, the Human Rights Council recognized in 2007 the equitable access to safe drinking
water and sanitation as a human right (UN High Commissioner for Human Rights 2007). In 2020,
through the Resolution 64/192, the UN’s General Assembly also recognized the human right to
water and sanitation (United Nations (UN) General Assembly 2010). While progress has been
made through the declaration of these human rights, global water reports estimate that 1 in 4 people
or 2 billion people around the world are living without safely managed access to these WaSH
services (World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF)
2017). The absence and inadequate access to WaSH result in WaSH insecurity experiences that
increase individual exposure to preventable water-related health risks.
Experiences of WaSH insecurity are disproportionally in different parts of the global South
(as seen in the work of (Alhassan and Kwakwa 2014; Sultana 2011; Truelove 2011). In this
dissertation, however, I argue that experiences of WaSH insecurity also exist in the global North,
specifically in unhoused communities of the United States (US). To understand the impacts of
WaSH insecurity in unhoused communities, this dissertation utilizes survey data from people with
lived expertise to identify coping survival strategies and measure accessibility based on geography,
individual, and service level factors. At the same time, the dissertation integrates the perceptions
of service providers using interviews that support the survey findings.

2

People experiencing homelessness do not have equitable access to essential WaSH services
due to being housing displaced. In these global water reports, unhoused people are also excluded
and or undercounted as the focus is the household as a unit of WaSH insecurity measurement
(Capone et al. 2020; Meehan, Jurjevich, et al. 2020; Wescoat, Headington, and Theobald 2007).
Therefore, this dissertation challenges the conception that wealthy nations like the US have
universal access to WaSH by exploring the experiences of WaSH insecurity in unhoused
communities. As the findings of the three studies in this dissertation suggest, there is no one-size-
fits-all solution to addressing unmet service needs of unhoused communities. Meaning that
solutions are not always available in the interim while people are experiencing homelessness.
Therefore, interim solutions are needed to provide those stop-gap services for people to meet
people's basic needs, one being access to WaSH. The three studies in this dissertation essentially
argue that experiences of WaSH insecurity reinforce a cycle of poverty in unhoused communities.
This mixed-methods dissertation aims to examine the experiences of WaSH insecurity in
unhoused communities of Los Angeles. An explanatory sequential mixed methods design is used,
with first utilizing quantitative survey data to describe the coping strategies people use to access
WaSH (Chapters 2) and to measure differences in accessibility to WaSH based on individual and
service level factors (Chapter 3). The findings from these two chapters are then explained and
validated by integrating the perspectives of service providers using in-depth interview data
(Chapter 4). This examination could help highlight what effective programs are needed to address
homelessness more significantly and how immediate WaSH interventions could reduce or prevent
disease outbreaks while opening access to other homeless services. Ultimately, understanding the
impacts of WaSH insecurity on communities experiencing homelessness will help bring a new
understanding into what forms of inclusion are needed, including (1) connecting people to safe

3

and equitable WaSH services, (2) how access to these services can be improved, which would then
lead to (3) the prevention of health inequities and systems of environmental injustices. The
following sections of this introductory chapter provide an overview of the problem,
contextualization of the study area, research aims, and study significance.
1.1. Research Problem
Homelessness is a social phenomenon, increasingly visible in many urban and rural
settings. The pathways that lead individuals and families to experience homelessness result from
structural, systemic, and individual risk factors (Katz 2013; Shelton et al. 2009; Wood et al. 1990).
The rise of homelessness in the US, for instance, emerged from the deinstitutionalization of the
1970s and 1980s. The deinstitutionalization resulted in significant cuts in federal housing,
Medicaid, social security, and other federal assistance programs designed to help low-income
people (Foscarinis 2012; Moore Sheeley et al. 2021; Takahashi, McElroy, and Rowe 2002). At the
same time, the deinstitutionalization of mental health care and reduction of mental health funding
contributed to the rise of homelessness in Los Angeles for people coping with mental illnesses
(Durham 1989; Moore Sheeley et al. 2021; Scott 1993; Wuerker 1997). Other factors such as
gentrification, urban development, demolition of affordable housing units without replacement,
and the conversion of low-rent apartments to high-rise loft apartments contributed to the
displacement of people in Los Angeles (Geoff Deverteuil 2019; Moore Sheeley et al. 2021).
Aside from these structural factors, social and individual problems such as being
unemployment, family conflict, divorce/separation, death in the family, domestic violence,
immigration status, substance misuse, and criminal history record contribute to experiences of
homelessness (Katz 2013; Shelton et al. 2009; Wood et al. 1990; Takahashi, McElroy, and Rowe
2002; Wong 2009). Understanding these different structural and individual contributing factors

4

that lead to housing displacement is essential to better address the rise of homelessness and the
type of services needed. In this dissertation, the focus is on the interim level service needs as they
relate to water, sanitation, and hygiene (WaSH) services in Los Angeles, which remains
underexplored.
While the expansion of permanent and affordable housing is crucial in addressing
homelessness in cities like Los Angeles, it should not be the only solution. The three studies that
compose this dissertation address the interim level service needs, particularly the WaSH service
needs of unhoused communities that remain underexplored in Los Angeles. These three studies
also argue that WaSH insecurity negatively impacts unhoused people and reinforces poverty in the
communities. A barrier in access to WaSH, for example, results in physical and mental health
deterioration, increased stigmatization resulting from poor hygiene, and lack of motivation to seek
job opportunities and social services. Efforts to improve access to WaSH services within the
unhoused communities remain a contested arena. For instance, there are “not in my backyard”
(NIMBYs) attitudes from communities that oppose homeless services and or public facilities (e.g.,
public restrooms and handwashing stations) near their homes. People view the provision of these
essential WaSH services as too costly or as a way to enable homelessness and criminal activity
(Green 2017; Los Angeles Community Action Network (LACAN) 2017). Unhoused communities
generally also lack 24-hour access to public facilities (restrooms, showers, laundry), equitable
municipal services (trash collection), and lack a sense of security, which in turn contributes to
forms of environmental and social injustices (Demyers, Warpinski, and Wutich 2017; LACAN
2013; 2017). In the Skid Row community of Los Angeles, for example, an audit report found that
in 2017 there were only nine restrooms publicly available for a population of 1,777 experiencing
unsheltered homelessness (Los Angeles Central Providers Collaborative 2017). Furthermore, anti-

5

homelessness laws criminalize survival coping mechanisms (e.g., sleeping in tents/vehicles and
public urination/defecation), leading to infraction notices and misdemeanors that can lead to
incarceration (LACAN 2013; United Nations (UN) General Assembly 2018). Based on these
factors, it is crucial to address the inaccessibility of essential WaSH services in unhoused
communities of Los Angeles.
Barriers in the provision to WaSH are related to focusing on the Housing First model
approach to homelessness. The Housing First (HF) model prioritizes housing people and
connecting them to social services before treatment as it aids in housing retention (Guerrero,
Henwood, and Wenzel 2014; Henwood et al. 2013). These housing models are essential in
providing people with stability and safety, but the problem is that systemic barriers exist in
getting people housed (ELC and EJWC 2018). While providing permanent housing leads to
access to WaSH services, not everyone qualifies for these services, including undocumented
homeless and people with felonies (Gilleland, Lurie, and Rankin 2017; Keene et al. 2018). In
some cases, fear of their immigration status or stigma around formerly incarcerated people
results in less engagement with service providers (Chinchilla and Gabrielian 2020; Keene,
Smoyer, and Blankenship 2018). Immediate needs of people unable to qualify for social and
housing services, including access to WaSH services, remains unaddressed when only focusing
on one-tier solutions. According to the Environmental Law Clinic (ELC) in Berkeley, there is a
need to diversify addressing the needs of unhoused communities. Thus, it is imperative to also
focus on addressing the interim-levels needs of unhoused people.
In sum, the research problem of this dissertation is that interim level services, specifically
WaSH services are needed to address WaSH insecurity experienced by unhoused communities of
Los Angeles. The reason being that inaccessibility to WaSH creates barriers in exiting

6

homelessness, and negatively impacts physical and mental health deterioration, increases
stigmatization of unhoused communities, and prolongation of homelessness as a result of
joblessness.
1.2. Dissertation Context: Homelessness in Los Angeles
The focus of this study takes place in Los Angeles, a large metropolitan area that is
struggling to address a housing crisis and a public health crisis. In Los Angeles, housing insecurity
is pervasive, with the Homeless Services Authority (LAHSA) estimating that 555,105 people are
at risk of being displaced of housing due to being severely rent-burdened (Los Angeles Homeless
Services Authority (LAHSA) 2020b). On average, LAHSA also reports that 207 people are exiting
homelessness each day, yet there is an inflow of 227 people entering homelessness (LAHSA
2020a). Los Angeles, both at the county and city level, have the largest number of people
experiencing unsheltered homelessness. Based on the annual point-in-time (PIT) homeless count
estimates, on a single night in January 2020, LAHSA estimated 66,436 people are experiencing
homelessness across the county, 72% of whom live in tents, vehicles, and other forms of
makeshifts (LAHSA 2020b). At the city level, LAHSA estimated that 41,290 people experience
homelessness (LAHSA 2020b). These estimates may be a severe underestimation of the actual
situation, as they do not consider homeless persons temporarily staying in motels, “couch surfing,”
and staying with family or friends (UN General Assembly 2018).
Los Angeles is also struggling to address a public health crisis. In this dissertation, the
public health crisis refers to WaSH insecurity experiences that further increase health disparities
in marginalized unhoused communities. The disinvestment in public infrastructure and inadequacy
in addressing the needs of unhoused communities has contributed to notable health outbreaks seen
in Los Angeles, including the 2013 tuberculosis, 2017 Hepatitis A, and the 2018 typhus outbreaks

7

(Center for Disease and Control Prevention (CDC) 2018; County of Los Angeles Department of
Public Health 2018b; Karlamangla 2018; Liu, Chai, and Watt 2020). Considering these factors,
Los Angeles is an ideal study area to examine how WaSH insecurity affects unhoused
communities.
In addition, the passage of anti-homelessness laws in Los Angeles creates environments
that reinforce a cycle of homelessness. Ordinances such as the Los Angeles Municipal Code
(LAMC) 41.18(d) in the City of Los Angeles, for instance, prevent people from sleeping in public
areas between the hours of 6 am to 9 pm. The LAMC 56.11 limits unhoused people to have
personal property exceeding the equivalent of a 60-gallon container (Los Angeles Municipal Code
2016). A violation of this ordinance results in a citation ranging from $100 to up to $400 for their
quality of life, justified by the fact that their belongings and encampments can create public health
and safety hazard (LAMC 56.11 2016; Holland and Zhang 2018). Moreover, police enforcement
criminalizes other coping behaviors, including public urination and defecation, perpetrated due to
inadequate access to WaSH. These coping strategies can lead a person to be registered as a sex
offender (Shure 2019). The passage of such laws creates targeted criminalization in Los Angeles.
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 (Bonds and Martin 2016; Mitchell 1997).
Ensuring access to adequate WaSH services for all is fundamental for sustaining life
practices, improving public health, and living environments. In Los Angeles, the availability of
safe and public WaSH services remains limited. In a 2017 audit of public restrooms, the Los
Angeles Central Providers Collaborative (LACPC) reported nine restrooms available overnight for
a total population of 1,777 unsheltered unhoused people in Skid Row (Los Angeles Central

8

Providers Collaborative 2017). As a result of WaSH scarcity found in unhoused communities of
Los Angeles, programs focused at providing WaSH services have expanded. In 2016, LavaMae
x

(formerly known as Lava Mae) for example, expanded their mobile hygiene programs to serve
unhoused communities of Los Angeles through “pop-up care villages” which provide people with
access to showers and restrooms, while also connecting people to other continuum of care
programs including, dental hygiene, health clinics, and hairdressers (LavaMaex 2021; Sommers-
Dawes 2016). In 2018, the Skid Row ReFresh Spot operated by Homeless Healthcare Los Angeles
(HHCLA) came to fruition and opened their doors to the community of Skid Row, advocating for
human right to WaSH and the need to provide harm reduction services (Kekhtman 2019). The
ReFresh Spot is a program funded by Mayor Eric Garcetti and one of the two 24-hour hygiene
centers in the community of Skid Row, providing people with access to showers, restrooms,
laundry services, and other essential services at no cost (Los Angeles Homeless Services Authority
(LAHSA) 2020c). The People Concern, formerly known as LAMP Community is also another
hygiene center operating 24-hours in Skid Row. Other non-profit WaSH organizations serving
unhoused communities of Los Angeles includes, Shower of Hope, Project Ropa, and Laundry
Truck LA, all of which aim to fill gaps in continuum of care through the provision of hygiene and
sanitation services. In 2018, Safe Parking programs also emerged to not only provide unhoused
people living in vehicles a safe place to rest but also provide people with access to hygiene and
sanitation services (Los Angeles Homeless Services Authority (LAHSA) 2019). Furthermore, as
a response to public health crisis associated with poor access to WaSH, in 2019 the City of Los
Angeles worked towards addressing the dire needs of WaSH services in unhoused communities of
Los Angeles through programs such as the Mobile PIT Stop program operated by Urban Alchemy
and the Five Keys. The PIT Stop program provides access to mobile showers trailers and trains

9

formerly incarcerated and people with lived experience of homelessness to be ambassadors that
monitor public restrooms (Five Keys Schools and Programs 2021; Yu 2019). Lastly, the current
COVID-19 global pandemic contributed to the expansion of community driven effort to fills gaps
in services, including Water Drop LA non-profit that delivers potable drinking water to different
unhoused communities across Los Angeles (Kanbarian 2020). The Los Angeles Community
Action Network (LA CAN) and the University of Southern California also worked towards
creating do-it-yourself handwashing stations in Skid Row to ameliorate hygiene needs during the
pandemic (DiGuiseppi et al. 2021). While all of these programs and community led efforts are not
the only ones that exist in Los Angeles and are addressing the dire need of WaSH services, these
are prominent organizations mobilizing in improving access to WaSH in unhoused communities.
Having said that, there is still a lack of investment in more permanent and sustainable WaSH
solutions, including additional access to 24-hour facilities across Los Angeles. The enforcement
of anti-homelessness laws, including anti-loitering and anti-camping ordinances also contributes
to added barriers including service disruptions making it more challenging to address the
homelessness crisis and for providers to improve delivery of services.
1.3. Research Aims
In this dissertation, I argue that WaSH interventions are essential in addressing the
immediate needs of unhoused communities of Los Angeles. Using surveys designed for and
collected from unhoused people this dissertation identifies survival WaSH strategies and measures
differences in accessibility (considering geography, individual, and service-level factors) which,
combined with service provider interviews, reveal new policy perspectives for addressing interim-
level WaSH needs. The dissertation is composed of three articles. The following sections provide
an outline for each chapter and the research aims I attempt to from a WaSH insecurity lens.

10

The first study in this dissertation, entitled Water, Sanitation, and Hygiene (WaSH)
Insecurity Experiences in Unhoused Communities, provides a descriptive overview of WaSH
insecurity in Los Angeles. Building on the WaSH insecurity framework, the study expands the
understanding moving beyond the household level by examining survey data collected pre- SARS-
CoV-2 (COVID-19) pandemic from people with lived expertise of homelessness. This first study
argues that WaSH insecurity is a deeply rooted social justice problem as unhoused people do not
have adequate access to the necessary and essential WaSH services to sustain their physical and
mental well-being. Furthermore, this study highlights the need for immediate WaSH interventions
to meet the needs of unhoused communities. Overall, this study addresses two research aims:
Aim 1a: Explore the WaSH access challenges unhoused people encounter in Los Angeles

Aim 1b: Examine the different coping survival strategies unhoused communities used to
gain access to WaSH services

Subsequently, the second study, Measuring Individual and Institutional Level Accessibility
to WaSH Services in Unhoused Communities of Los Angeles, CA, digs deeper into the differences
that occur in accessing WaSH services raised in the first study by examining the individual
demographic and service level (geography, distance, affordability, accessibility, and quality)
contributing factors to WaSH insecurity experiences. This second study examines the same survey
data collected before the COVID-19 pandemic and integrates generalized linear regression models
(GLM) and spatial analysis methods in geographic information systems (GIS) to explore
heterogeneity in access to WaSH services. Addressing individual and service level factors is
crucial because we need to seek more inclusive and equitable policies to address housing insecurity
and homelessness. At the same time, also identify gaps in the services provided. This study
addresses two main research aims:

11

Aim 2a: Identify population vulnerability factors that contribute to WaSH insecurity
experiences

Aim 2b: Identify service-level factors that contribute to the high (or low) level of
engagement by unhoused community members

The final study, entitled, Identifying WaSH Service Needs in Unhoused Communities from
the Perspective of Service Providers in Los Angeles, CA, builds on the scholarship from the
previous two studies. While the previous two studies examine data from people with lived
expertise of homelessness, this third study integrates the perceptions and experiences of service
providers. Using qualitative descriptive interviews with fifteen service providers from the private
and public sector collected during the COVID-19 pandemic, this study explains the findings from
the two quantitative studies by identifying five key areas: impacts of inaccessibility, impacts of
identity, impacts of COVID-19, service design, and service advocacy that are for policy
implications. This final study alludes to policy implications needed to improve access to essential
WaSH services, including engaging with the community to receive feedback on service design and
advocating for investment in providing more permanent and sustainable solutions. This study
addresses the following research aims:
Aim 3a: Understand the ways WaSH insecurity impacts unhoused communities from the
perspective of service providers

Aim 3b: Identify what service providers can do to improve access to WaSH services in
unhoused communities

1.4. Significance of the Study
The significance of this study lies in examining experiences of WaSH insecurity beyond
the household level to understand better the barriers unhoused people in Los Angeles encounter.
The new knowledge and understanding from this study will also highlight inequities experienced

12

by homeless persons. Specifically, this dissertation sheds light underexplored impacts of WaSH
insecurity in unhoused communities. Additionally, this dissertation explores the multiple factors
of oppression that can make unhoused people vulnerable, including their gender identity, sexual
orientation, age, disability status, race, and immigration status, among other factors. Additionally,
current policies focus on ineffective street cleanups while still violating human rights and failing
to meet minimum standards for access to WaSH as recommended by the UN for refugee camp
settings (UN General Assembly 2018). Therefore, the studies shift the focus beyond the household
level by identifying the forms of vulnerability unhoused people experience when navigating WaSH
services. At the same time, the studies also help identify the type of services needed to serve the
community improves their quality of life. Lastly, this study will generate knowledge that will be
extensible for future studies studying homelessness and access to WaSH services in other parts of
the world.
The three articles that form the composition of this dissertation are stand-alone
manuscripts. As a result, each study contains a literature review, methodology, results, and
discussion section. These three studies are also interconnected as each elaborates on a different
aspect of WaSH insecurity experiences. Each study validates arguments made from a distinct
analytical and data standpoint. The concluding chapter provides the key findings and connections
across these three articles, including a future outlook on the research direction, limitations, and
policy implications based on the three study findings.

13

Chapter 2 Water, Sanitation, and Hygiene (WaSH) Insecurity Experiences in
Unhoused Communities of Los Angeles, CA

This study focuses on understanding the impacts of water, sanitation, and hygiene (WaSH)
insecurity from people with lived expertise of homelessness. In addition, the study addresses the
coping strategies unhoused people use due to inadequate or lack thereof access to WaSH
services. This study contains six sections, and the structure is as follows: first, section 2.1
provides a brief introduction of the problem statement, followed by section 2.2 that reviews
current literature and identifies the study contribution. Subsequently, section 2.3 describes the
data and methodology of this quantitative study. Section 2.4 presents the results of the data, and
section 2.5 provides a discussion of these findings. The study concludes with a summary of the
essential findings and directions to future studies.
2.1. Introduction
Access to water, sanitation, and hygiene (WaSH) services represent foundational human
needs; however, people who are unhoused lack access to equitable, safe, affordable, and
sufficient WaSH services, resulting in WaSH insecurity experiences. In high-income countries
like the United States (US), WaSH insecurity remains an underexplored area. In global water
reports, specifically, the US claims to have universal access to safely managed drinking water
and sanitation services (Jepson et al. 2017; Meehan, Jepson, et al. 2020; Wescoat, Headington,
and Theobald 2007). The Joint Monitoring Programme (JMP) of the World Health Organization
(WHO) and the United Nations Children's Fund (UNICEF), for example, produce global
estimates on progress made related to WaSH. The JMP broadly defines WaSH security as having
safe access to uncontaminated drinking water, basic toilets that properly dispose of waste, and

14

availability maintain good hygiene practices (e.g., handwashing, menstrual hygiene management,
and food hygiene) to reduce disease incidence (Alhassan and Kwakwa 2014; World Health
Organization (WHO) and the United Nations Children’s Fund (UNICEF) 2019). WaSH security
considers five broad factors: quality, quantity, accessibility, affordability, and reliability. A gap
or absence of any of these factors is an indicator of WaSH insecurity. In JMP’s recent
assessment, the US reported that 99 percent of its population has access to a safely managed
drinking water supply from acceptable sources and free of contaminants (WHO/UNICEF 2019).
Simultaneously, the US estimated roughly 95 percent of its population has access to safely
managed sanitation services, with no data provided for hygiene services (WHO/UNICEF 2019).
However, this misconception of universal access to WaSH services is problematic because
certain marginalized groups remain excluded from these global water estimates.
Reports such as the ones provided by the JMP are limited by the data countries share. In
the US, water estimates come from the American Housing Survey (AHS) and the US
Environmental Protection Agency’s Safe Drinking Water Information System datasets (Capone
et al. 2020; WHO/UNICEF 2018; n.d.; Wescoat, Headington, and Theobald 2007). The unit of
measurement in these datasets is the household unit, which excludes unhoused people from these
estimates.
The majority of WaSH insecurity research also tends to focus on the household as the
unit of measurement, leaving out perspectives from unhoused individuals. In this cross-sectional
study, we shift the focus of WaSH insecurity from the household to the houseless level to
address unhoused communities' unmet needs in Los Angeles, CA. Specifically, this study
addresses two main questions: (1) What WaSH challenges do people experiencing homelessness
encounter in Los Angeles? and (2) How do unhoused communities cope and access WaSH

15

services in different spaces and places? Ultimately, this study seeks to advance the understanding
of WaSH insecurity for unhoused people to highlight the need for interim services that can help
improve people's lives and health through equitable, safe, sufficient, and reliable access to WaSH
services. We begin the study with an overview of the existing literature on WaSH insecurity in
the US. The third section explains the data collection methods and tools. Section four presents
the study findings based on survey data collected from 263 adults with lived expertise of
homelessness in Los Angeles. The paper concludes with a discussion of the impacts that WaSH
insecurity has on unhoused residents and ways to better address people’s needs in a more
humane, significant, and equitable manner.
2.2. WaSH insecurity in the United States
This section will provide an overview of the current literature on WaSH insecurity to
identify the gaps in knowledge and the significance of this study. This section begins with 2.2.1,
which discusses studies exploring WaSH insecurity experiences at the household level across
communities in the US. Section 2.2.2 examines the current studies that move beyond the
household and examine how it impacts unhoused communities. This section concludes with
2.2.3, providing a contextualization of homelessness in Los Angeles, an underexplored study
area.
2.2.1. Household WaSH Insecurity
WaSH insecurity, or as water scholars often refer to as “water insecurity” for short, is
commonly measured at the household level (Jepson et al. 2017; Meehan, Jepson, et al. 2020;
Wutich et al. 2017). The literature on household water insecurity suggests it does exist in the US
and disproportionally affects migrant farming communities, Indigenous communities, and low-
income urban communities (Balazs et al. 2011; Balazs and Ray 2014; Jepson 2014; Deitz and

16

Meehan 2019; Meehan, Jepson, et al. 2020; Meehan, Jurjevich, et al. 2020). First, migrant
farming communities experience household WaSH insecurity, as seen in the work of Balazs et al.
(2012) and Jepson (2014). For example, in California's San Joaquin Valley farming
communities, Balazs et al. sampled community water systems at the household level. They found
that households of migrant workers are disproportionally exposed to high levels of arsenic-
contaminated drinking water (Balazs et al. 2011, 2012). These studies also found that race,
income, and homeownership all played a factor in WaSH insecurity experiences. In other words,
communities with lower homeownership, predominantly Latinx and lower-income, have higher
odds of being exposed to elevated arsenic levels in their household water systems (Balazs et al.
2012; Balazs and Morello-Frosch 2013). Such communities do not have the financial and
infrastructural capacity to reduce pollutant levels in their household water systems, resulting in
WaSH insecurity (Balazs et al. 2012).
Similarly, South Texas colonias (informal and often impoverished migrant communities)
along the U.S.-Mexico border experience household WaSH insecurity. In colonias, WaSH
insecurity has to do with water affordability, water quality acceptability, and water distress
(Jepson 2014; Jepson and Vandewalle 2016). Water distress in the study included emotions
attributed to the access, pricing of WaSH services, time and effort spent on WaSH services. The
study found that only those households that can afford water service connections experience
WaSH security. While residents living below the federal poverty line experience WaSH
insecurity, ad services get shut off due to the inability to pay for water utilities. In other
instances, even if water service connections are in place, families are confronted with drinking
water quality issues. As a result, families resort to purchasing drinking water from vending

17

machines and bottled water, creating additional economic burdens and psychosocial stressors
(Jepson 2014; Jepson and Vandewalle 2016).
Indigenous communities worldwide also disproportionally lack access to essential WaSH
services. In the global North, roughly half of American Indian and Alaska Native communities
across the US experience some form of WaSH insecurity (Crepelle 2019). Alaska, for example,
is home to 229 (out of 574 federally recognized) tribal nations. However, studies show
communities of Alaska Natives are in remote, rural areas that lack the infrastructure to connect
households to essential WaSH services (Cozzetto et al. 2013; Eichelberger 2018; Gessner 2008;
Hennessy et al. 2008; Hennessy and Bressler 2016; Mitchell 2019; National Congress of
American Indians 2020; Wenger et al. 2010). Studies also highlight that providing sanitation and
hygiene services is challenging in remote Arctic communities that experience extreme weather
conditions, including erosion and flooding, affecting 86 percent of Alaska Native villages
(Hennessy et al. 2008; Mitchell 2019). Severe flooding caused by the thawing of permafrost in
the communities contributes to sewage contamination in the drinking water supply (Mitchell
2019). The disparity in access to essential WaSH services also leads to health challenges,
particularly increased risk of respiratory and gastrointestinal diseases as proper handwashing and
other hygiene practices become challenging (Gessner 2008; Hennessy et al. 2008; Mitchell 2019;
Wenger et al. 2010).
In other Indigenous communities in the US Southwest, the Navajo and Hopi tribal lands
of Arizona, Utah, and New Mexico, similar WaSH insecurity experiences are reported. For
example, residents in the Navajo Nation travel long distances, some driving as far as 40 miles to
collect water using barrels in bordering towns to meet their basic needs (Cozzetto et al. 2013;
Crepelle 2019; Deitz and Meehan 2019; Roller et al. 2019). Studies estimate that there are about

18

1200 mine sites abandoned in the Navajo Nation, which have exacerbated levels of arsenic,
uranium, vanadium, and manganese in groundwater supplies, exceeding national standard levels
(Crepelle 2019; Ingram et al. 2020; Roller et al. 2019). WaSH insecurity forced people to haul
water or, considering the cost and time of hauling water, use unregulated water sources (Ingram
et al. 2020; Mitchell 2019). In other instances, communities obtain water services from
community tanker trucks that deliver water every month (McGraw 2016). Overall, studies
estimate that 30 to 40 percent Navajo Nation households do not have access to running water
(Deitz and Meehan 2019; Mitchell 2020). As a result of this inaccessibility to essential WaSH
services, households in the Navajo Nation consume as little as three gallons of water per person,
per day, compared to the 80-100 gallons of water that the average American household uses per
day (Roller et al. 2019; the United States Environmental Protection Agency 2018). It is evident
from these studies that access to WaSH insecurity at the household level also disproportionally
affects Indigenous communities in the US.
Lastly, WaSH insecurity also significantly affects other communities of color. In their
study, Deitz and Meehan (2019) argue that WaSH insecurity is a regionally clustered and
racialized problem. Specifically, regions that experience a lack of water and sewage connections
tend to disproportionally be in communities primarily composed of Black, Indigenous, and other
people of color (BIPOC). The community of Flint, Michigan, is a well-known example of a
water crisis disproportionally affecting the Black community (Butler, Scammell, and Benson
2016; Morckel and Terzano 2019). In Flint, since 2014, poor water governance and resource
segregation contributed to the exposure of thousands of residents to elevated levels of lead in
their drinking water supply (Butler, Scammell, and Benson 2016; Meehan, Jepson, et al. 2020).
Despite addressing the water crisis, lingering distrust exists among residents regarding their

19

water quality and infrastructure (Morckel and Terzano 2019). In North Carolina, studies have
found that residents in peri-urban Black communities also lack connection to regulated and
monitored municipal water systems, exposing communities to elevated levels of bacterial
contaminants and lead (Heaney et al. 2011; Heaney et al. 2013; Stillo and Macdonald Gibson
2017; Stillo et al. 2019). In Baltimore and Cleveland, WaSH insecurity is a problem of
affordability. Families have their services shut off due to being unable to pay their water utility
bills, which exceed two percent of Black median household incomes (Montag 2019). These
studies show different experiences and aspects of WaSH insecurity studied at the household level
and challenge the notion that water is, in fact, universal, safe, affordable, and reliable (Meehan,
Jepson, et al. 2020). Nevertheless, as we advance knowledge on WaSH access, security, or lack
thereof, it is also vital to further complicate the rhetoric by exploring communities that do not
have a permanent and secure place to call home.
2.2.2. WaSH Insecurity Among the Unhoused
While studies have explored household WaSH insecurity in different marginalized
communities across the US, as discussed in the previous section, WaSH access among unhoused
populations remains an underexplored topic. In limiting WaSH insecurity to household-level
analyses, we ignore individuals who do not have access to permanent housing options or
available shelter from existing findings, as is the case for unhoused communities. People who are
unhoused already live at the margins of society and face constant violations of their fundamental
human rights, including the right to adequate housing, water, and health, which are inextricably
connected (United Nations 2003). At the same time, unhoused communities are exposed to
pollution, extreme weather conditions, and have limited access to adequate WaSH services,
making individuals disproportionately at risk for infectious and contagious diseases (Bonds and

20

Martin 2016; Karlamangla 2018; Leibler et al. 2017; Los Angeles Central Providers
Collaborative (LACPC) 2017; Popkin, D’Anci, and Rosenberg 2010). Furthermore, unhoused
communities include vulnerable groups that encounter psychological trauma from living on the
streets. This trauma perpetuates a cycle of poverty. It can lead to risk-taking behaviors (e.g.,
substance use and misuse), impacting mental health outcomes and making these issues
contributors to and symptoms of homelessness (Devuono-Powell 2013; Flanigan and Welsh
2020; Harris et al. 2017). Therefore, to better understand the impacts of WaSH in our
communities, we need to look beyond the household and examine the experiences of WaSH
insecurity among unhoused communities.
WaSH insecurity for unhoused people exacerbates the marginalization they experience in
their daily lives. For example, in Phoenix, Arizona, DeMyers, Warpinski, and Wutich's (2017)
study examined how WaSH insecurity and heat exposure differ based on a person's living
condition. In other words, WaSH insecurity is experienced differently based on whether a person
is living in shelters, encampments, and or without a roof (Demyers, Warpinski, and Wutich
2017). The study is one of the first to highlight that WaSH insecurity creates environmental
injustices and distinct barriers in a person exiting homelessness (Demyers, Warpinski, and
Wutich 2017). Leibler et al. (2017, 2018) also suggest poor access to hygiene facilities and
consequently poor hygiene practices lead to poor physical health. Poor access to WaSH also
increases the risk of infectious diseases, most seen in unhoused people and coping with mental
health problems and substance use (Leibler et al. 2017).
Furthermore, Speer (2016) argues that only focusing on a housing framework to address
homelessness can be limiting. Instead, we need to understand the rights of unhoused people who
cope with the lack of infrastructural access in cities that aim to marginalize, exclude, and sanitize

21

homeless encampments in public spaces (Speer 2016). In communities like Fresno, poor access
to WaSH leads to further stigmatization of unhoused people. Lack of publicly available facilities
forces unhoused residents to be unable to maintain daily hygiene practices and resort to open
defecation (Speer 2016).
Similarly, Capone et al.'s (2018) study in Atlanta examined open defecation practices
among unhoused people due to limited publicly available sanitation facilities. The study tested
discarded human stool, which found enteric pathogens, posing an increased risk of infection by
fecal-oral route in unhoused communities (Capone et al. 2018; 2020). Lastly, Flanigan and
Welsh (2020) explore encampments along the San Diego River and show how people living
along riverbeds tend to be more socially isolated and disconnected from services compared to
encampments in downtown areas. The study found that living in waterways creates barriers to
access safe WaSH services due to living in secluded areas that also pose a higher risk of
exposure to contaminated water and disease outbreaks (Flanigan and Welsh 2020; Rose 2019).
2.2.3. Knowledge Gap and Study Contributions
Examining the experiences of WaSH insecurity among unhoused communities is
essential. The existing studies address the impacts of poor access to water, sanitation, and
housing on marginalized unhoused populations. While these existing studies have made
significant contributions and provided new insights on a population that remains invisible and
underserved, these studies briefly address the perspective of people with lived expertise of
homelessness. In reviewing these studies, there are existing gaps in the scholarship of WaSH
insecurity in the US and unhoused communities. First, there have been no studies that address
homelessness and WaSH insecurity using a large sample size of survey data from people with
lived expertise in Los Angeles.

22

Additionally, more studies should consider integrating data collected at different times of
the day and encompassing all forms of WaSH access; these include drinking water, restrooms,
showers, laundry services, and handwashing stations. Integrating these types of WaSH services
is crucial as we aim to understand better the specific needs of unhoused communities, which can
help facilitate immediate interventions that can improve health outcomes and living
environments in unhoused communities. Furthermore, WaSH insecurity in Los Angeles remains
underexplored. In 2019, Los Angeles had the second-highest number of homeless individuals in
the US, roughly 56,257 people, in a single night (Henry et al. 2020). This study applies insights
from the studies mentioned above to fill knowledge gaps (and observe similarities) by studying
Skid Row's community in Los Angeles.
2.2.4. Los Angeles Homelessness Crisis
Homelessness is a social and humanitarian crisis, increasingly visible in many urban and
rural areas. The pathways that lead an individual to be displaced of housing are complex and
numerous. Still, it is a result of structural factors (i.e., criminal justice system, the housing
market, and social policies) and individual factors (unemployment, formerly incarcerated,
domestic violence, substance use disorder, mental health problems, immigration status) (Katz
2013; Piat et al. 2015). Furthermore, Flannigan and Welsh (2020) highlight that experiences of
trauma, violence, and victimization while living on the streets can lead to substance misuse and
mental health outcomes, making these both contributors and symptoms of homelessness
(Flanigan and Welsh 2020; Huey 2016). As a result, this reinforces an endless cycle of poverty in
the streets.
According to the 2019 Annual Homeless Assessment to Congress provided by the US
Department of Housing and Urban Development (HUD), on a single night in January, 567,715

23

people (or 17 for every 10,000 people) experience homelessness across the US (Henry et al.
2020). These point-in-time (PIT) counts are estimates conducted annually in January and provide
a snapshot of homelessness on one day in different parts of the nation. Based on the PIT
estimates, New York and California are the two states with the largest estimates of people
experiencing homelessness (Henry et al. 2020). The only difference is that at the Continuums of
Care (CoC) level, 95 percent of New York City’s unhoused population is sheltered, compared to
only 25 percent of the unhoused residents in Los Angeles City and County (Henry et al. 2020).
In this study, the focus of WaSH insecurity shifts to the City of Los Angeles, an
underexplored area, to challenge misconceptions that in the US, there is universal or near-
universal access to safe WaSH services. Los Angeles is a city that has historically been
struggling with a homelessness crisis (Holland 2019). In 2019, the annual PIT count estimates
provided by Los Angeles Homeless Services Authority (LAHSA) reported roughly 59,000
people experiencing homelessness countywide (Los Angeles Homeless Services Authority
(LAHSA) 2019). In 2020, this number increased by 13 percent countywide, with 72 percent of
the population living in unsheltered conditions (LAHSA 2020). In Skid Row alone, an estimated
4,462 people experience homelessness in a single night, of whom roughly 2,100 are unsheltered
and living in tents, vehicles, and makeshifts (LAHSA 2020). However, these estimates may be a
severe underestimation of the actual situation, as they do not take into account the current global
COVID-19 pandemic outcomes and other forms in which homeless individuals temporarily live,
including using motels, "couch surfing," and staying with family and friends (UN General
Assembly 2018).
The statistics of unsheltered homelessness in Skid Row are alarming. Unsheltered people
live in increasingly marginalized positions, with insufficient access to essential services,

24

including WaSH services. Efforts to improve access to WaSH services within the homeless
communities remain a contested arena. People often view the provision of these essential
services as too costly or a way to sustain homelessness and criminal activity (Green 2017; Los
Angeles Community Action Network (LA CAN) 2017; Rowe 2019). In other instances, the
placing of services tends to be historically in “undesirable locations, a reflection of the placement
of undesirable people in undesirable places” (Demyers, Warpinski, and Wutich 2017, p. 74).
Furthermore, Los Angeles Central Providers Collaborative (LACPC), a community-based
group of Skid Row residents and organizations conducted in 2017, audits public toilets available
in the community. The audit reported that only nine public toilets were available in Skid Row for
a population of roughly 1,777 unsheltered individuals in 2017 (LACPC 2017). Skid Row
generally lacks 24-hour access to public facilities restrooms, showers, laundry) and lack
consistent municipal services (trash collection). The community also experiences a lack of access
to equitable municipal services (trash collection), trees and vegetation that can provide shade,
and a sense of security, contributing to environmental injustice (LACPC 2017; LA CAN 2013,
2017). As a result of not having these essential WaSH services, the reporting of health outbreaks
attributed to poor living environments and hygiene has been more pronounced over the years
(Center for Disease and Control Prevention (CDC) 2018; County of Los Angeles Department of
Public Health 2018). Moreover, individuals are criminalized for survival coping mechanisms
(e.g., sleeping in tents/vehicles and public urination/defecation), leading to infraction notices and
misdemeanors, unpayable fines, and incarceration (Holland and Zhang 2018; UN General
Assembly 2018). In turn, misdemeanors result in criminal records preventing people from
qualifying for most housing services and essentially creating a cycle of existing poverty
(Demyers, Warpinski, and Wutich 2017; LA CAN 2017; UN General Assembly 2018).

25

2.3. Materials and Methods
This is a cross-sectional descriptive study of 263 unhoused people in the Los Angeles
area. All study participants were living in the Los Angeles region at the time of the interview.
The surveys were collected in Spanish and English in two months (June and July) in the summer
of 2019. Each survey took approximately 30-60 minutes to complete. All study activities,
including data collection, were reviewed and approved by the University of Southern California
Institutional Review Board (IRB) before data collection. Study participants that both consented
and completed the questionnaire formed part of the final in the analysis. Participants were given
a gift card and bottled water, regardless of whether they did or did not complete the survey
interview. The study focused on the community of Skid Row (Figure 2.1). Participants enrolled
in the study were interviewed within the boundaries stretching from 3rd to 7th Street (North and
South) and Alameda to Main Street (East and West). However, participants reported sleeping
locations at the interview time were located beyond Skid Row's borders, as seen in Figure 2.1.
2.3.1. Target Population
This study used a mixture of convenience and snowball or chain sampling to recruit
participants. These including unhoused people who resided in Skid Row, passers-by within the
designated study area, which on occasion extended to participants in nearby tents and friends of
participants. The sample population also included Lava Mae
x
© non-profit organization guests in
two locations of downtown Los Angeles: City Hall and St. Francis Center. This partnership with
Lava Mae
x
helped provide the research team a safe space to conduct surveys. In exchange, the
team provided hygiene kits and bottled water to guests regardless of study participation. This
study defines an unhoused person as someone who does not have a safe, permanent, and stable
housing location (e.g., “living on the streets” in encampments, tents, vehicles, or other forms of

26

makeshift housing). People living in emergency or temporary shelters also formed part of this
study as these participants do not have a permanent and stable place to live. This definition is in
alignment with the definition of homelessness provided by HUD (2012). The study team was
aware that people are unhoused are a vulnerable population; therefore, participation in the study
was anonymous, voluntary, and only adult participants over the age of 18 who gave oral consent
were enrolled. The reasoning for only enrolling adults is because youth and children require
parental or guardian permission to participate in a research study. However, unhoused youth and
children may not have a parent or guardian to make these decisions, which raises concerns as to
whether it is ethically justifiable. At the same time, the level of questions asked in this study,
may trigger past traumas and complex emotional content that they could not foresee even during
the consent process.
Figure 2.1. Study area and sleeping location of study participants overlapped with LA
County’s unsheltered homeless population density.
Source: Los Angeles Homeless Services Authority point-in-time estimates in 2019.

27

2.3.2. Survey Data and Data Analysis
The overall goal of collecting survey data was to understand better the everyday lives of
unhoused people in Los Angeles and how they cope with WaSH insecurity. The survey
questionnaire contained categorical variables, including population demographics, living
conditions, length of homelessness, and main reasons that led participants to their housing
displacement. Additionally, binary variables were collected to represent different types of WaSH
services utilized at different times of day (e.g., morning, afternoon, and night). To better measure
access to WaSH services, the questionnaire also asked participants about their daily hygiene
practices, including showering, handwashing, clothing change, and laundering. Lastly, health
outcomes reported within 30 days from the interview are included in the analysis (Y/N) variables
to understand better the health risks of people who are unhoused and possibly attributed to
inadequate access to WaSH services. Data was collected using paper surveys, and each survey
had a unique study identification. Each paper survey was abstracted and coded onto a database.
Incomplete surveys did not form part of the final analysis. Each variable coded was verified
using survey metadata. After completing the data abstraction and coding, it was reviewed and
verified twice before entering the analysis phase. I then imported survey data into R Studio
version 1.3.1093 to calculate descriptive statistics. Participants’ sleeping locations at the time of
their interview were geocoded using Esri Survey123, matched to the survey data, and then
visualized using ArcGIS Pro version 2.7.
2.4. Analysis Results
A total of 263 participants enrolled in the study; 33 lived in emergency shelter systems,
and 230 lived in unsheltered conditions. Table 2.1 summarizes the study population
demographics, with roughly 70 percent of the population reported being male. The majority of

28

the participants enrolled (n= 133) reported sleeping in Skid Row boundaries (7th and 3rd and
Alameda and Main streets). However, some participants also reported sleeping in other
communities outside of Skid Row boundaries, including downtown Los Angeles (n = 73) and the
greater Los Angeles area, including Santa Monica, Venice, Hollywood, and South Los Angeles
(n =57). The average age was forty-eight years. Only eight participants younger than 24 years
enrolled in the study. People of color overrepresented the sampled population, with
approximately 41 percent of the participants identifying as Black and 30 percent Latinx, with
only 15 percent identifying as White. In total, 84 percent of the study population was chronically
homeless, meaning that they have been continuously homeless for more than a year. The average
time the sampled population reported experiencing homelessness was sixty-five months (5.4
years), with only forty-one participants reporting to have less than a year of being unhoused.

Table 2.1. Frequency Distribution of Sample Population Demographics (N = 263)

Characteristic Category Count (%)
Gender identity Cisgender male 180 (68.44)
Transgender male 2 (0.76)
Cisgender female 79 (30.04)
Transgender female 1 (0.38)
Missing 1 (0.38)
Age 18 to 24 8 (3.04)
25 to 34 33 (12.55)
35 to 44 55 (20.91)
45 to 54 69 (26.24)
55 to 61 60 (22.81)
Greater than or equal to 62 32 (12.17)
Missing 6 (2.28)

29

Table 2.1. Continued

Characteristic Category Count (%)
Race/ethnicity Black/African American 109 (41.45)
Latinx/Hispanic 80 (30.42)
White 39 (14.83)
Another group 17 (6.46)

American Indian/Alaskan
Native 11 (4.18)
Asian and Pacific Islander 3 (1.14)
Missing 4 (1.52)
Sexual orientation Heterosexual 222 (84.03)
Bisexual 18 (6.84)
Gay or lesbian 13 (4.94)
Asexual 1 (0.38)
Other identity 1 (0.39)
Missing 9 (3.42)

Table 2.2 highlights different contributing factors to a person experiencing homelessness
in this study. The most commonly reported factor was unemployment or loss of their job with
roughly 27 percent of the sampled population. Additionally, fifty-seven participants reported that
their housing displaced resulted from the lack of affordable housing in Los Angeles or being
evicted due to inability to afford to paying. Substance use and misuse was the third commonly
reported cause of a person being unhoused (n=55), followed by family conflict (n=54).
Furthermore, roughly 8 percent of the sampled population reported the cause for being unhoused
is due to their immigration status or being formerly incarcerated. Lastly, a small percentage (3
percent) of participants reported to be unhoused due to experiencing domestic violence.

30

Table 2.2. Frequency Distribution of Variables Associated with Causes of Homelessness

Cause Count (%)
Unemployment 95 (26.46)
Unaffordable housing/eviction 57 (15.88)
Drug/alcohol misuse 55 (15.32)
Family conflict 54 (15.04)
Other* 30 (8.36)
Mental health disorder 26 (7.24)
Family/spousal death 16 (4.46)
Physical disability 15 (4.18)
Domestic violence/sexual abuse 11 (3.06)

Note: The percentages represent 359 responses given by N = 263 since this was a multiple-response
question. The “other” category includes immigration status and formerly incarcerated people/recently
released from prison.

Table 2.3 provides a summary of reported personal WaSH-related practices in the study
population. Overall, only 27 percent of the participants reported showering almost every day (4
days or more in the week). The majority of study participants (n = 189) reported showering at
most three times a week, if at all. The most-reported sources that participants used to shower
were non-profit organizations, including the ReFresh Spot, a community-driven project that
provides restrooms, showers, and laundry services available 24-hours in Skid Row. In other
instances, people used sinks in public parks to do a quick rinse with paper towels and water, also
referred to by participants as a “bird bath” (n = 25). Participants also reported using buckets
inside their tents to shower (n = 16). Participants reported available bathhouses inaccessible due
to excessive wait times, an extensive waitlist system to access these facilities, or facilities being

31

out of order. A small fraction of participants also reported illegally opening fire hydrants to
obtain water for bathing (n = 3).
The inaccessibility of laundry services in the community is also highlighted in Table 2.3.
More than half of the population reported only washing their clothes at most three times a month.
Almost 27 percent of the sample population reported not being able to do laundry at all.
Inaccessibility of laundry services was one of the most reported complaints, with study
participants citing a lack of structural facilities and being unable to afford to do laundry. The
laundry locations most commonly used by participants were the ReFresh Spot, LAMP
Community, Weingart Center, and Downtown Women's Center, all non-profit organizations. A
small number of participants (a combined 14.43 percent) reported using buckets inside their tents
or sinks from public parks to wash their clothes.
More than 60 percent of the study population reported washing their hands before
preparing meals, before eating, and after utilizing the restroom in terms of handwashing
practices. However, participants would wash their hands using hand sanitizer or rinse only using
bottled water due to not having soap readily available.

Table 2.3. Frequency Distribution of Variables Associated with Personal Hygiene Habits

Characteristic Category Count (%)*
Showering 0-1/week 101 (39.00)
2-3/week 88 (33.97)
4 or more/week 70 (27.03)
Location for showering Non-profit organization 204 (71.83)
Other* 29 (10.22)
Public restroom 25 (8.80)
Tent/bucket 16 (5.63)
Business establishment 10 (3.52)

32

Table 2.3. Continued

Characteristic Category Count (%)
Laundering 0-1/month 68 (26.67)
2-3/month 138 (54.12)
4 or more/month 49 (19.22)
Location for laundering Non-profit organization 118 (47.40)
Laundromat 90 (36.14)
Tent/bucket 25 (10.04)
Public restroom 9 (3.61)
Business establishment 7 (2.81)
Handwashing (cooking) Rarely 44 (17.60)
Sometimes 48 (19.20)
Always 158 (63.20)
Handwashing (eating) Rarely 15 (5.98)
Sometimes 55 (21.91)
Always 181 (72.11)
Handwashing (restroom) Rarely 11 (4.31)
Sometimes 31 (12.16)
Always 213 (83.53)

Note: The percentages for shower and laundry locations are based aggregated by multiple responses given
by N = 263. Not all categories sum to the total sample size due to missing data not shown. Other places
participants reported showering included the Los Angeles river, water from fire hydrants, hotels, motels,
and friend/family’s home.

In addition to collecting information on personal hygiene practices, participants also
reported the different types of restroom facilities they used within a given day (Figure 2.2). We
observed that access to restrooms was most difficult and unreliable at night-time, reducing the
usage of restrooms from public facilities and non-profit organizations. As a result, 6 percent (n =
17) of the participants reported delaying restroom use until the next day (see Figure 2.2). The
discussion section describes the implications of this on women's health. Overall, the most

33

common restroom places people utilized were buckets inside tents or public spaces (streets,
sidewalks, and alleyways). The highest was at night time with 131 participants (50 percent of the
population interviewed). The second highest restroom type used were public facilities, including
restrooms in parks, libraries, and staffed Pit Stop program toilets, particularly in the morning (n
= 96) and afternoon (n = 113) times. Non-profit organizations (e.g., shelters and mobile hygiene
facilities) and business establishments were utilized more during the morning and afternoon due
to hours of operation. Lastly, 71 percent (n = 184) of the study population reported that at some
point in their day, they had to hold off from going to the restroom due to a lack of publicly
available restrooms in the community.

Figure 2.2. Access to different restroom facilities at different times of the day (N = 263).
Note: The other category includes restroom sources include motels, friend/family’s home,
or workplace.

Morning Afternoon Night
Restroom type per time of day
Count
0 50 100 150
Morning Afternoon Night
0 50 100 150
Public
Businesses
Nonprofits
Other
Street/Tent
NotUsed
Public
Business
Nonprofits
Other
Street/Tent
NotUsed

34

Other forms of WaSH insecurity experiences observed among study participants were
poor accessibility to public fountains and drinking water. Half the study population self-reported
sufficient drinking water, and the other half self-reported they do not drink enough water.
However, when asked the total water intake in a day, more than half of the population (54
percent) reported an intake of one to three (16 oz) bottled water a day. Only 35 participants
reported an intake greater than six bottled water per day. People reported obtaining drinking
water from donations or self-purchasing at stores. Sixteen participants illegally opening fire
hydrants for drinking water due to inaccessibility to drinking water fountains. Roughly 34
percent of the study population also reported using libraries and parks (Gladys, San Julian, and
Grand Park, and Placita Olvera) to access drinking water and refilled bottled water. As a result of
public facilities being closed at night-time, participants (n = 99) reported purchasing bottled
water from supermarkets or refilled bottled water to store it for evening use.
Furthermore, this study collected health variables to capture health risks related to poor
access to WaSH services. Table 2.4 represents a list of reported health outcomes that participants
were coping with within 30 days from the interview. The most commonly reported health
condition was skin infections (40 percent), migraine headaches (35 percent), followed by
dehydration (34 percent). One thing to note is that the fieldwork and data collection took place
during the hottest two months of the year in Los Angeles (June and July). Diarrhea was also a
commonly reported health condition that people were coping with at the interview time (n = 55).
In terms of menstrual cycle management, only 35 women reported having their menstrual cycle,
and six women in their reproductive age reported experiencing amenorrhea. Still, more measures
are needed to validate these findings.

35

Table 2.4. Frequency Distribution of Health Reported Outcomes Over a 30-Day Period

Category Health Outcome Count (%)
Hygiene practices related Skin infection 64 (39.02)
Diarrhea 55 (33.54)
Fungus 27 (16.46)
Head and body lice 9 (5.49)
Typhus 5 (3.05)
Hepatitis A 4 (2.44)
WaSH insecurity related Migraine/headache 105 (35.12)
Dehydration 103 (34.45)
Constipation 59 (19.73)
Urinary tract infection 32 (10.70)

Note: Total sample is N = 263; however, this was a multiple-response question. As a result, counts do not
sum up the total sample size. Percentages as based on people who indicated a health condition
experienced in the past 30-days from the interview time. Percentages aggregated per sub-section. Missing
did not form part of the calculation.

2.5. Interpretation of Findings
WaSH insecurity impacts the lives of communities across the globe, including vulnerable
communities experiencing homelessness in Los Angeles. Having affordable, safe, sufficient, and
reliable access to WaSH services is not always an option for an unhoused person. In Skid Row's
community, people cannot access a restroom, shower regularly, and wash their clothes. These
WaSH insecurity experiences pose increased health risks to a population with weakened immune
systems and lower life expectancies (Maness and Khan 2014; National Health Care for the
Homeless Council 2011; Ngo and Turbow 2019). The study findings suggest that people embark
on different survival coping mechanisms to access vital WaSH services. One of the survival

36

strategies people reported was relying on fire hydrants to access water for bathing and drinking.
In other instances, participants relied on using buckets or plastic bottles inside their tents to
urinate or defecate, exemplifying forms of inhumane survival mechanisms that people utilize due
to the scarcity of services available in the community. Simultaneously, this sheds light on a water
crisis experienced in Los Angeles that reduces individuals' ability to care for their health,
improve their living conditions and social position. In the following sections, I leverage the
critical findings from the survey data to provide insight into the challenges and implications of
WaSH insecurity experienced by unhoused populations in Los Angeles.
2.5.1. WaSH insecurity in Unhoused Communities of Los Angeles
In Los Angeles, unhoused residents live in an environment that is scarce of essential
WaSH services, which further degrades their physical and mental health and opportunities to
seek employment (Demyers, Warpinski, and Wutich 2017; Leibler et al. 2017; Poremski,
Whitley, and Latimer 2014). As seen in the work of DeMyers et al. (2017) study in Arizona and
Leibler et al. (2017, 2018) in Boston, the inability to reliably find a safe shower and a change of
clothes contribute to the stigma of homelessness that is deeply rooted in our society. Similarly, in
Los Angeles, WaSH insecurity creates health barriers for exiting the cycle of homelessness.
People trying to navigate essential services have no other choice but to use public spaces (such as
sidewalks and buckets; the only available resources) to conduct personal necessities.
In this study, we also found temporal inaccessibility of services in the community of Skid
Row. Specifically, the evening is the most challenging time to access a restroom that is both
open and safe for many reasons. Business establishments typically close at 9:00 PM in the
community, and most non-profit organizations are not available 24-hours, except the ReFresh
Spot and Union Rescue Mission shelter. As a result, accessing WaSH services becomes a severe

37

limitation for an estimated 1,898 unsheltered homeless in the population of the community of
Skid Row (LAHSA 2019). 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 be
open/available to the community until closure. However, while services may be more available
during the morning and afternoon, participants reported long wait lines, sign-ups for waitlists, or
out-of-service facilities. These factors discourage a person from maintaining hygiene practices,
where they resort to using survival strategies to conduct their necessities.
The survey findings suggest that most of the WaSH services people reported utilizing are
within the Skid Row area, the community at the epicenter of WaSH services compared to
downtown Los Angeles and the greater Los Angeles area. In total, fifty-seven participants
traveled to Skid Row by bus, metro, or foot to access services (mainly shower and laundry) that
are not available in the communities where they typically sleep. The average distance people
reported traveling was roughly four blocks (an estimated 5-minute walk), with the maximum
time a person spent trying to access services in Skid Row being 1-2 hours. The time it takes for
some participants to access WaSH services is beyond the JMP standards that state access to
essential drinking water and or other WaSH services should not be longer than 30-minutes
(WHO/UNICEF 2018). Participants reported sleeping in their tents and makeshift housing
outside of the Skid Row boundaries (near freeways, beaches, and greater downtown Los Angeles
area) due to a fear of violence associated with staying in Skid Row. Participants expressed they
commuted to Skid Row in the morning and afternoon to access services but leave the area at
night. Racialized groupings also exist on the streets, with Latinx communities residing near
downtown Los Angeles such as Placita Olvera, a historic Mexican heritage street.

38

In contrast, Skid Row is a predominantly Black or African American community.
Furthermore, community members outside Skid Row boundaries reported constant policing,
which Bonds and Martin (2016), in their study, state the removal of encampments are forms of
environmental injustices, often seen in commercial, tourist, and residential areas. Bonds and
Martin's findings also indicate that the law is selectively enforced, meaning that people tolerate
homelessness within city limits, as long as they are not publicly visible (Bonds and Martin
2016). In Los Angeles, city ordinances exist to restrict unhoused people from building
encampments at certain times of the day. For example, in Los Angeles, the Municipal Code
(LAMC) 56.11, later amended as Ordinance No. 184182, allows the City to seize people's
belongings and dispose of their belongings. This enforcement overlaps with street sweeps that
sanitation workers conduct to remove encampments. Notices of encampment sweeps are required
to be posted 24-72 hours in advance. Still, these are not always consistent and can happen based
on community requests and or a weekly/biweekly basis depending on the community. In 2019, in
the downtown community, outside Skid Row, during fieldwork and data collection, notices were
seen indicating clean-ups as part of the LAMC 56.11 ordinance enforcement and conducted
every Tuesday at 3 PM. But these types of services may not be currently the same due to
disruptions during the COVID-19 pandemic and or increased enforcement.
2.5.2. Disparities in WaSH Accessibility
Although Los Angeles homeless populations all experience WaSH insecurity, different
demographic groups do not experience the exact needs/challenges in access to WaSH, including
women, elderly, sexual minority groups, to name a few. This study only captured a small sample
of people who identified as LGBTQI+, yet they reported experiencing fear while waiting in line
to use a shower and restroom. Additionally, the trauma of living on the streets and being exposed

39

to stressful environments can affect people differently. For instance, six women in reproductive
age groups using no contraception reported no longer having their menstrual cycle in the
sampled group. Women experiencing amenorrhea (which affects 1 percent of the general
population) may result from trauma and stress-induced living on the streets. Still, more
measurements are needed to validate this finding (Nawaz and Rogol 2020). Women also reported
difficulty accessing feminine hygiene products. Generally, feminine hygiene products are
expensive to purchase (as a result of gender-based pricing of products commonly known as the
“pink tax” ), and in unhoused communities, these are not provided consistently in safety-net
programs and shelter systems (Crawford and Spivack 2017; Sebert Kuhlmann et al. 2019). In
Sebert Kuhlmann et al. (2019) study, unhoused women in St. Louis, Missouri, encountered
difficulty managing their menstrual cycle due to being able to afford hygiene products and
difficulties with transportation (time and cost) reach stores that sell products at more affordable
price. As a result, women utilized different coping mechanisms, including using rags, tissues,
toilet paper, children's diapers, or paper towels were taken from public restrooms (Sebert
Kuhlmann et al. 2019). In this study, homeless women experienced difficulty coping with their
menstrual cycle and reported feeling “dirty” and “unable to find a shower.” In addition to gender
differences, this study found racial differences in the sample, with predominantly Black and
Latinx homeless individuals experiencing forms of discrimination that prevented them from
accessing public restrooms and restrooms from business establishments. But statistical
measurements are needed to capture differences in these demographic factors better (see also
Chapter 3).
2.5.3. Health Barriers
The barriers to health care access and maintaining good health are numerous for

40

unhoused people. For instance, the economic inability to access laundry services and the
requirement of customer-only access to restrooms can drastically reduce a person's well-being
and capacity to maintain good hygiene practices. 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 (Los
Angeles County Department of Public Health 2019). On average, three unhoused people die
daily. 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 (Gorman and Blair
Rowan 2019; Lopez 2019). This lower life expectancy can result from higher death rates, chronic
illnesses, and disabilities that the homeless experience compared to the general population (Ngo
and Turbow 2019; O’Connell 2005). Living on the street, specifically in tents, near river banks,
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 (Lexis-Olivier Ray 2021).
Importantly, skin-related diseases are the leading cause for people experiencing
homelessness to seek medical services (Leibler et al. 2017; 2018; Maness and Khan 2014;
Popkin, D’Anci, and Rosenberg 2010; Raoult, Foucault, and Brouqui 2001). In this study, sixty-
four participants reported experiencing skin infections. The type of skin lesions and infections,
however, were not measured in this study. However, Leibler et al.'s (2017) study found that
unhoused people experience a higher prevalence of nasal colonization of staph compared to the
general population. Their study found 16 unhoused people with MRSA nasal colonization that
resulted from limited hygiene and crowded living conditions (Leibler et al. 2017). Overall, skin

41

conditions are made worse by a lack of sanitation and poor hand and body hygiene practices,
which puts homeless individuals at a higher risk of infection.
Other poor health outcomes that are endemic in unhoused communities are head and
body ice, scabies, and secondary bacterial infections, all of which can be WaSH preventable
diseases (Maness and Khan 2014). 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 clothes or bathing facilities (Bonilla et al.
2009; 2014; Maness and Khan 2014). 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, that 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 among commonly reported
health conditions by the sampled population. In this study, 103 participants reported
experiencing dehydration. The data collection took place in the two hottest months of the year
(June and July), yet heat exposure and lack of available drinking water can result in heat
exhaustion. In 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 risks
of dehydration and heat exhaustion. Lastly, the findings note that a small number of people hold
off from using the restroom, especially in the evening time when facilities are closed and

42

inaccessible. These coping strategies can lead people to encounter health problems such as
kidney and vaginal infections. In this study, thirty-two people reported urinary tract infections
within a 30-day period, of whom eighteen were women. Urinary tract infections may result from
people being forced to delay restroom use, and not having adequate access to WaSH services
raises the risk of contracting infections. Specifically, women are at risk of contracting kidney and
vaginal infections, as shown in Wenzel et al.'s (2001) study that found that unhoused women in
Los Angeles County encounter gynecological symptoms, and better health care support systems
are needed for unhoused women.
2.5.4. Limitations and Recommendations
Overall, this study describes the different forms in which the unhoused cope with WaSH
insecurity in different spaces and places. It is also important to note the study limitations. While
this study only surveyed 263 participants, which accounts for less than one percent of the County
and City of Los Angeles's total unhoused population. Yet, these findings are still representative
of the lived experiences of those people in this study. The type of questions that we asked
participants may have resulted in recall bias. Participants may not remember all of their daily
habits and places visited to carry those personal habits. Lastly, since the population is mobile,
there may have 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.
Homelessness is a multifaceted crisis. While there is no “one size fits all” solution, we
can generate interventions that can better serve our unhoused community members, one being

43

increasing access to essential WaSH services. Addressing WaSH insecurity among homeless
communities is essential because, as shown in studies, access to the most basic human needs can
reduce health risk and transmission of infectious diseases. Reducing the risk of infectious
diseases is crucial, even more so now during this global COVID-19 pandemic, where constant
and reliable access to WaSH services reduces the risk of transmission. As a whole, access to
WaSH services can create healthier communities, particularly in unhoused communities that live
in open environments and have weakened immune systems (Ngo and Turbow 2019; Tsai and
Wilson 2020).
There is a need to prioritize providing safe, affordable, equitable, and accessible WaSH
services in vulnerable communities. 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 insecure
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, can play a vital role in this
process as they work directly with the community and know their needs. As a result, advocating
for the provision of housing with integrated immediate services can lead to a more
comprehensive and successful way to address the needs of homeless populations. One of these
inclusive recommendations includes developing WaSH service models that are humane,
dignified, and available 24-hours in a day. The findings from this study highlight that providing
safe and available services at all times of the day are needed the most to meet people’s needs in
the community. In Skid Row, the ReFresh Spot is an example of a successful model that works.

44

Community members use the ReFresh Spot because the facilities are well maintained, have
friendly staff, clean, and are available when needed. City officials should consider allocating
money to more permanent WaSH facilities like the ReFresh Spot rather than installing temporary
portable toilets and conducting encampment sweeps. In 2019, the city spent 24 million dollars on
street-clean ups. These types of services are not sustainable, humane, and target the root of the
problem. Lastly, integrating the voices of unhoused residents at the decision-making tables can
foster real change and improve communities' health and living environments because they are the
ones with the lived expertise and know what services are more accessible.
2.6. Conclusion
The findings from this study suggest that while high-income countries like the US claim to have
universal access to WaSH services, vulnerable and disadvantaged populations, including people
experiencing homelessness, face WaSH insecurity daily. The access to public facilities, including
restrooms and laundry services for homeless people, remains contested in the public sector,
making it more challenging to address this vulnerable population's needs better. To this end, this
study asks several questions: what challenges do people who experience homelessness encounter
accessing WaSH services? What are the coping survival mechanisms people use to find access to
these services? The results suggest that inaccessibility to WaSH results is not homogenous, with
some groups in the population being more vulnerable than others in accessing services.
Additionally, this study sheds light on people's daily challenges and coping strategies when
living in places with insufficient, safe, affordable, and reliable access to WaSH services. Due to
this inaccessibility of services, unhoused people have no other choice but to engage in different
survival coping strategies such as utilizing buckets inside their tents to go to the restroom. In
other instances, people use the sinks of public restrooms to do laundering and travel long

45

distances to access one of the few shower facilities in Skid Row. People engage in these survival
strategies because they are safer than walking a few blocks or miles to a shelter at night. These
practices are also more affordable and accessible as most public restrooms close early evenings.
While these coping strategies are necessary for daily survival in unhoused communities, they
also highlight the need for infrastructural investment of WaSH facilities that can provide a safe,
clean, good quality, and dignified level of service. Otherwise, ignoring these immediate services
can result in a cycle of poverty and prolonged homelessness due to people spending time and
effort to access WaSH services. It could contribute to people's deterioration of their physical and
mental well-being and further stigmatization.
Regarding accessibility within the three communities where people reported sleeping, the
epicenter of resources allocated is Skid Row. On the other hand, communities outside of Skid
Row's boundaries have fewer WaSH services available as reported available for unhoused
community members. People choose to sleep outside of Skid Row's boundaries because they do
not feel safe there at night-time. During the daytime, people residing in Venice, Santa Monica,
and Hollywood travel up to a two-hour one-way commute to Skid Row, the area with the most
access to services. 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 can be identified to make those
services more accessible.
Additionally, future studies should consider measuring the psychosocial health outcomes
(or water distress) attributed to WaSH insecurity in unhoused communities. Measuring water
distress 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

46

health diagnoses. Furthermore, studies should consider exploring the effects of WaSH insecurity
on medication adherence in the Los Angeles unhoused population. Therefore, it is critical to
examine how poor access to drinking water and or restroom may result in people not adhering to
taking prescribed medications needed to sustain their (as seen in Coe et al. 2015; Wang,
Dopheide, and Gregerson 2011).
WaSH insecurity among unhoused people connects to forms of environmental injustices,
mental health problems, and other preventable poor health outcomes. While there is no “one-
size” fits all solution, this work suggests that expanding water infrastructure provisions (e.g.,
restrooms, drinking fountains, and laundry services) and making these services available 24-hour
can improve people's lives and health. Thus, tackling WaSH insecurity in homeless and other
vulnerable communities can not only improve people’s health but can lead to healthier living
environments and communities.

47

Chapter 3 Measuring Individual and Institutional Level Accessibility to
WaSH in Unhoused Communities of Los Angeles, CA

This second study delves deeper into the issues raised in the earlier study (Chapter 2) by
expanding the analytical lens to the individual (demographics) and service (distance,
affordability, safety, accessibility, and quality of service) factors that contribute to WaSH
insecurity experiences. The overall structure of this chapter is as follows: the chapter begins with
section 3.1, introducing the problem statement. Subsequently, section 3.2 provides a review of
relevant literature and identifies the study contribution, followed by section 3.3 that describes the
data and methodology. In the final sections, the chapter presents the study findings based on 263
surveys collected in 2019 before the current global COVID-19 pandemic using logistic
regression models (GLM) and network analyst extension in geographic information systems
(GIS) to measure the distance of facilities to participant’s sleeping locations. Section 3.5
provides an interpretation of the analyses while also evaluating the landscape in WaSH
accessibility in Los Angeles. Overall, this chapter outlines the importance of expanding WaSH
services in communities of Los Angeles while also ensuring that services need to be accessible
by all unhoused residents. Including services accessible to the elderly, people with disabilities,
pet owners, and have staff that treats people with dignity can help improve people's access to
these essential services and improve their living conditions and well-being.
3.1. Introduction
In the United States (US), unhoused people are impacted by the inaccessibility of access
to water, sanitation, and hygiene (WaSH) services. The inaccessibility of these types of services
creates barriers in people’s livelihoods and increases health disparities in communities already

48

vulnerable to chronic illnesses and health outbreaks (County of Los Angeles Department of
Public Health 2018a; Liu, Chai, and Watt 2020). For unhoused people, WaSH insecurity is an
issue of availability, affordability, quality, and lack of public infrastructural investment in cities
to provide marginalized communities access to reliable services (Ares et al. 2017; Avelar Portillo
et al., n.d.; Los Angeles Community Action Network (LACAN) 2017; Speer 2016). In Los
Angeles, as noted in chapter 2, WaSH insecurity experiences result from a lack of publicly
available services. However, other significant factors at the individual and institutional level
remain underexplored.
All in all, poor access to WaSH services forces unhoused people to resort to various
survival strategies. These coping strategies include public urination, open defecation inside tents,
and opening fire hydrants to obtain water for drinking, bathing, and laundering (Avelar Portillo
et al., n.d.; Capone et al. 2018; 2020; Frye, Capone, and Evans 2019; Speer 2016; Wong 2009).
None of these coping strategies utilize safely managed sources, and increases added health risks
among unhoused communities.
While it is challenging to access safe, affordable, and consistent WaSH services among
unhoused communities, little is known whether access to services is equitable. This study argues
that there is not a one-size-fits-all solution in addressing homelessness and WaSH insecurity.
More specifically, this study addresses two questions: (1) What individual level (gender identity,
racial/ethnic, age, and length of homelessness) factors contribute to people’s ability to access
WaSH services in Los Angeles, CA, and (2) What institutional level (service providers) factors
contribute to the way people choose to engage with WaSH services available in the community?
The purpose of addressing these questions is to explore heterogeneity among unhoused people.
Addressing the diverse experiences of unhoused residents is important because as we invest in

49

addressing housing insecurity and homelessness, we need to seek more inclusive and equitable
policies that address all unhoused community members' immediate and interim needs.
Furthermore, exploring existing differences in access to WaSH services and people’s
level of engagement with different service providers can help identify unmet needs and service
gaps in the community. While the long-term solution to homelessness is ensuring access to
adequate and affordable housing, this study highlights the need for interim interventions,
including increasing access to WaSH services in public spaces with large homeless
encampments. The overall results from this study can lead to driven policy decisions. The results
can help guide efforts to increase access to fundamental WaSH services needed to achieve health
equity, improve our unhoused neighbors' quality of life, and living environments.
Los Angeles is a large metropolitan area struggling to address a housing crisis and a
public health crisis. The Los Angeles Homeless Services Authority (LAHSA) annual point-in-
time (PIT) homeless count estimates, estimated 66,436 people are experiencing homelessness
across the county, 72% of whom live in tents, vehicles, and other forms of makeshifts (LAHSA
2020b). In Los Angeles, there is also disinvestment in public infrastructure and inadequacy in
addressing the needs of unhoused communities have contributed to notable health outbreaks and
increased risk of communicable diseases (Center for Disease and Control Prevention (CDC)
2018; County of Los Angeles Department of Public Health 2018b; Karlamangla 2018; Liu, Chai,
and Watt 2020). Therefore, it is imperative to examine how WaSH insecurity affects unhoused
people differently and identify gaps in the provision of services.
3.2. Background
This section encompasses a central review of studies that have focused on unhoused
communities, particularly studies that have examined the existing vulnerabilities among these

50

communities and their intersections to WaSH insecurity. It begins with discussing the built
environment, particularly the role of public places and survival nexus of people experiencing
homelessness. The literature from this section sheds light that while unhoused people are
criminalized for using public spaces, they have a form of agency when it comes to the type of
services they choose to utilize. Additionally, section 3.2.2 explores the way population
characteristics contribute to vulnerability factors among unhoused communities. In reviewing the
current knowledge, this section highlights this study's potential gaps and contributions.
3.2.1. The Built Environment and Unhoused Communities
In communities across the US, public spaces are contested arenas. For a person
experiencing homelessness, public space is their sustaining environment, yet anti-homelessness
policies criminalize unhoused people’s ability to exist in public spaces and places (Bonds and
Martin 2016; Marr, DeVerteuil, and Snow 2009; Mitchell 1997; Stuart 2015). Mitchell (1997)
argues that anti-homelessness laws intend to control the behavior and spaces utilized by people
experiencing homelessness. In other words, survival on the streets is criminalized through local
policies and laws aimed at “redefining what is [an] acceptable behavior in public space[s]” to
revitalize cities while in effect reducing the spaces unhoused people utilize to survive (Mitchell
1997, 305). Stuart’s (2015) study also traces back the policing of homelessness in public spaces
of Los Angeles to the 1990s, where unhoused people were the primary targets of policies of
containment, “zero-tolerance,” “quality-of-life” policing. Such policies aim to remove and
contain the expansion of “unkempt, unpredictable, and potentially mentally ill individuals in
newly coveted spaces” that inhibits the mobility of capital in urban cities (Stuart 2015, 943). The
criminalization of homelessness through quality-of-life legislates against basic life-sustaining
activities, such as sleeping in a car, sitting, or storing personal belongings in places where people

51

cope to exist without access to a shelter or permanent home (Robinson 2019). Central to these
efforts exist local ordinances aimed at removing unhoused communities from public spaces.
While the criminalization of homelessness limits people’s ability to exist in public
spaces, Marr, DeVerteuil, and Snow (2009) argue that unhoused people do still possess a form of
agency in the spaces and places that they choose to occupy as part of their survival mechanisms
living on the street. Marr and colleagues infer there are different levels of engagement based on
the availability of services across communities. For instance, in Los Angeles County, some
places are heavily institutionalized, such as the community of Skid Row. By institutionalized, the
authors refer to communities that provide an array number of services, including soup kitchens,
shelters, Single Room Occupancy (SRO) hotel units, and other social services needed by
unhoused people (Marr, DeVerteuil, and Snow 2009). At the same time, there are also those
places that do not provide sufficient services to unhoused people, often beach cities or affluent
neighborhoods (Marr, DeVerteuil, and Snow 2009). The distribution of services in different
communities shapes the pattern of coping survival strategies engaged by unhoused people.
Understanding the distribution of services is crucial to note, particularly regarding access to
WaSH services. It can influence the decision-making process that people engage daily to access
these services. In summary, unhoused people may be criminalized and stigmatized in public
spaces. Nevertheless, they have autonomy when it comes to the utilization of services. People's
agency needs to be explored more because people's level of engagement can inform us more on
the existing quality of services and inform us on successful service models based on their
experiences that are needed more in the community.
In Los Angeles, the criminalization and removal of unhoused people from public spaces
are counterproductive towards addressing homelessness. Sleeping on the streets, for example, is

52

a facet of life for unhoused people, but only legal at certain hours of the day through the
enforcement of the Los Angeles Municipal Code (LAMC) 41.18(d). This municipal code makes
it illegal for people experiencing homelessness to sleep, sit, or lie in public spaces between the
hours of 9 p.m. and 6 a.m. (L.A., Cal., Code art. I, § 41.18 1968). The LAMC 56.11(2016) is
another ordinance that limits people sleeping in public areas. Specifically, it reduces the ability
for unhoused people to occupy sidewalks and having personal property that exceeds a 60-gallon
container because it may be considered a public hazard ( L.A., Cal., Code art. VI, § 56.11 2016).
Furthermore, the LAMC 41.47.2 makes it a misdemeanor for a person to urinate and defecate in
public. In California, it classifies public urination as a sex offense (L.A., Cal., Code art. I, §
41.47.2 2003; Shure 2019). In some instances, a violation of these anti-homeless laws is
accompanied by citations, with an average cost of $150 or more, contributing to compounded
day-to-day survival challenges for unhoused people. Specifically, citations can be challenging
for unhoused people who cannot afford to pay these fines, leading to added burdens of warrants
and risk for incarceration (Holland and Zhang 2018; Herring 2016). These ordinances serve as
forms of oppression that limit survival techniques in public spaces utilized by people without
adequate access to housing. Instead, we need to be directing efforts to serve the community with
permanent infrastructure that can meet their WaSH needs.
3.2.2. WaSH Insecurity and Unhoused Communities
It is estimated that 1.1 million people in the US live in households with no connection to
water infrastructure (Meehan, Jurjevich, et al. 2020). However, these estimates of water poverty
do not consider the number of people living without access to shelter and permanent housing. As
a result, Meehan et al. (2020) argue that 2 million people are likely living without secure access
to WaSH services in the US. Existing studies that address the experiences of WaSH insecurity

53

among unhoused communities argue that the lack of investment in public infrastructure in cities
drives people to embark on public urination and defecation practices that increase public health
risk in these vulnerable communities (Capone et al. 2018; Los Angeles Community Action
Network (LACAN) 2017; Speer 2016). The study of DeMyers, Warpinski, and Wutich (2017)
found that compared to living in shelter systems, people living in tents and without a roof
disproportionally encounter more difficulty accessing adequate and sufficient WaSH services.
Similarly, Flannigan and Welsh (2020) examine the hard-to-reach unhoused communities
residing in riverbeds that choose to live in these precarious and unsafe places in efforts to avoid
interaction with criminal justice systems. Flannigan and Welsh argue that due to being forced to
live in unsafe spaces, people living near waterways encounter more barriers in accessing
services, including access to WaSH services, putting these individuals at a substantially higher
risk of poor health outcomes (Flannigan and Welsh 2020). Differences in WaSH access among
unhoused populations, however, remain heavily underexplored.
Studies focusing on addressing homelessness have also noted that unhoused populations
are not homogenous groups. Individual factors, particularly demographic and biographic factors,
contribute to added vulnerability to navigating services, residing in public spaces, and exiting
homelessness (Stuart 2015). Gender differences are one of these vulnerabilities. Compared to
unhoused men, women experiencing homelessness have a higher risk of violence and harassment
when living on the streets (Downtown Women’s Action Coaliton 2020; Kuo 2019). A 2019
report made by the Downtown Women’s Center highlighted that “women who reported most
often sleeping on the streets were more likely to have experienced domestic violence (45.0%)
and sexual assault (45.6%) than the general population” (Kuo 2019, 18).

54

Additionally, Rowe and Wolch’s (1990) study, for example, found that women are more
likely than men to seek a relationship for protection due to their vulnerability to physical abuse
and attack in Skid Row. In some cases, these relationships or companionships can provide access
to a safety net, emotional support, and resources, including access to food and water (Rowe and
Wolch 1990). WaSH insecurity may also impose additional challenges to unhoused women
when coping with their menstrual cycle. In shelters and bathhouses, a 2017 audit report found
that these places not only do not provide inconsistent access to feminine hygiene products, but
restroom facilities often lack privacy, forcing women to feel exposed and vulnerable (Los
Angeles Central Providers Collaborative 2017). Furthermore, the inability to safely manage
menstrual hygiene leads unhoused women to resort using unhealthy and unsanitary options to
clean their bodies that may lead to gynecological health conditions, including urinary tract
infections (Los Angeles Central Providers Collaborative 2017; Parrillo and Feller 2017; Rimawi,
Mirdamadi, and John 2014; Wenzel et al. 2001).
In the same way that gender constructs intersect with WaSH insecurity, race, age,
physical and mental disability are vulnerability factors that remain underexplored in unhoused
communities. For example, in Los Angeles, the unhoused population is disproportionally
overrepresented by people of color (LACAN 2017; LAHSA 2020b). Differences in access to
WaSH services among unhoused communities have not been measured in existing studies. In the
study of Chinchilla and Gabrielian (2020), although not explicitly connected to WaSH insecurity,
the authors state that disparities in accessing services results from deeply rooted structural
racism. Chinchilla and Gabrielian also found that the unhoused population that identifies as
Latinx has lower rates of service use due to different social vulnerabilities in this group,
including language barriers and citizenship or documentation status (Chinchilla and Gabrielian

55

2020). Age is also another contributing factor to vulnerability for unhoused communities that
remains underexplored in the realm of WaSH insecurity. According to LAHSA’s PIT count
estimates from 2020, the rate of senior unhoused people has increased by 20 percent since 2017
(LAHSA 2020b). It is crucial to address age disparity because the elderly unhoused population
continues to increase, and they have an accumulation of chronic disadvantages that impedes their
ability to access services properly and exit homelessness (Applewhite 1997; Donley and Wright
2018; Kuhn, Richards, and Roth 2020; LAHSA 2021). Furthermore, Leibler et al. (2017) argue
that WaSH insecurity negatively impacts the physical and mental health of people experiencing
homelessness. In particular, chronically unhoused people coping with drug and substance misuse
have more inadequate hygiene practices and, thus, more significant health risks exacerbated by
the insecurity of services (Drake and Wallach 1991; Leibler et al. 2017; Riley et al. 2012;
Rosengard et al. 2001). These individual factors are important to consider as we try to better
address housing insecurity and provide immediate interventions needed in unhoused
communities.
3.2.3. Knowledge Gap and Study Contributions
Based on the literature review, we know that public places are contested areas where
unhoused people are not welcome. The literature also suggests that experiences of living on the
street may differ per person and are not homogenous. In reviewing these studies, I recognize
gaps in the scholarship and identify significant contributions. First, this study digs deeper into
differences that occur in accessing WaSH in different communities. Marr, DeVerteuil, and
Snow’s (2009) study, for example, focus on the distribution and location of emergency shelters.
Similarly, this study will take the concepts from Marr’s study and explore the location and
distribution of existing WaSH services. Second, this study explores individual vulnerability

56

factors among the sampled population, particularly exploring how population demographic
factors can contribute to differences in access to WaSH. Specifically, by focusing on addressing
the gender identity, racial/ethnic, age, and length of homelessness factors contributing to access
disparities in these marginalized communities. Acknowledging heterogeneity among unhoused
populations and their level of difficulty accessing WaSH services is important because it is an
area that remains incredibly underexplored and can help address people's needs better. The last
contribution of this study is advancing our understanding of WaSH accessibility by integrating
service level factors that influence the level of engagement by community members. Measuring
these service level factors can inform us of service quality to identify service gaps and unmet
needs. Addressing disparity in access to WaSH at the community, individual, and institutional
(service providers) level can help us identify the type of services needed to serve communities
better.
3.3. Data and Methodology
This study utilizes survey data from adults with lived expertise of homelessness collected
in June and July of 2019 (Avelar Portillo et al., n.d.). As stated in the introductory section, this
study focuses on the experiences of unhoused people living in Los Angeles. Data collection took
place in the four boundaries of Skid Row (7
th
and 3
rd
and Alameda and Main Streets) and parts of
downtown Los Angeles. However, some participants enrolled in the study reported their primary
sleeping location in other parts of the greater Los Angeles area, including Hollywood, Santa
Monica Beach, Venice Beach, and South Los Angeles. Therefore, some of the study findings are
presented at three community levels: Skid Row, downtown Los Angeles, and greater Los
Angeles. In doing so, it illustrates the number of participants sleeping in these different
communities and how these different spaces may elucidate different levels of engagement with

57

service providers. These divisions are also crucial because Marr, DeVerteuil, and Snow (2009)
highlight that communities with different services shape survival patterns in unhoused
communities. The sampling technique utilized to recruit study participants was a mixture of
convenience and snowball or chain sampling, including unhoused people within the designated
study area. Participants would invite other people from neighboring tents. Before the survey data
collection, participants were screened, consented, and provided with the study objectives. All
participants enrolled were adults over the age of 18. The Institutional Review Board (IRB) of the
University of Southern California approved all study activities before the start of the study.
3.3.1. Survey Data and Processing
The survey tool utilized collected information on individual characteristics to understand
better the distinct experiences of unhoused people navigating through services and public spaces
that may not provide them with adequate access to WaSH. The type of questions captured in the
survey instrument included demographics, such as a person’s race/ethnicity, gender identity,
sexual orientation, age, and educational level. Participants also reported their most recent
sleeping location (only the main street intersections to protect participant’s confidentiality),
living conditions in the past 30 days (at the time of interview), causes that contributed to their
displacement of housing, and length of homelessness. To measure forms of WaSH insecurity,
participants reported on personal hygiene practices, frequency of those practices, and locations
utilized to conduct their personal necessities, including laundering, showering/bathing, going to
the restroom, and locations used to obtain drinking water. Additionally, participants reported on
the reasons for choosing specific services and locations and whether they had encountered
experiences of discrimination when accessing services. For the complete survey instrument
utilized, see Appendix A.

58

Data collected from surveys did not contain any identifiable information to protect
participant’s confidentiality. Data was collected using paper surveys, each with a unique study
identification. Each paper survey was abstracted and coding onto a database. Incomplete surveys
were removed and not considered in the final analysis. Each variable coded was verified using
survey metadata. After completing the data abstraction and coding, it was reviewed and verified
twice before entering the analysis phase to double-check that the information entered was correct
and reflected the information from the paper surveys. Participant's rough estimates of sleeping
locations were collected at the time of interview utilizing only main street intersections and
entered using the Esri Survey123 mobile application. These locations were matched to the survey
data.
The data processing for the location of WaSH services utilized per participant was two-
fold. First, only participants provided using a specific service or establishment formed part of the
final study analysis. In other words, participants that included a specific name or location of a
shelter, non-profit organization, or other business establishment formed part of the analysis.
Second, the addresses of places utilized were found through a Google search and verified using
the organization or business website. When no location was matched, I located public reports
that identified the location of specific facilities, as was the case for finding the location of all
public automated toilets in downtown Los Angeles. The addresses were then entered in Excel,
imported into ArcGIS Pro version 2.7, and geocoded using the ArcGIS World Geocoding
Service.

59

3.3.2. Analysis

Figure 3.1. Flow chart of the quantitative data analysis.

The study’s methodology and analytical framework are illustrated in Figure 3.1. I utilized
R Studio 1.3.1093 and ArcGIS Pro to measure WaSH insecurity experiences in unhoused
communities to analyze the survey data. To answer the first research question, I utilized
generalized linear models (GLM) to measure the association between difficulty accessing
different WaSH services and individual-level characteristics. The reasoning for choosing GLM
was that it does not assume a normal distribution. Additionally, the outcome variable in the
models, “difficulty accessing WaSH services,” is a binary variable (Yes/No). The dependent
Survey data
(N = 263)
Facility level
factors
Individual
level factors
Race, gender identity,
sexual orientation, age,
length of homelessness,
community
N = 100
unique
facilities
Distance,
affordability,
accessibility
Research Question 1 Research Question 2
WaSH
Insecurity
Generalized
linear models
Drinking water
Restroom
Laundry
Shower
Handwashing stations
Network Analyst
Closest Facility
(distance
measurement)
Records excluded =
no specified WaSH
location
Morning Restroom N = 186
Afternoon Restroom N = 163
Night Restroom N = 191
Shower N = 203
Laundry N = 133
Drinking Water N = 91
Participant Records Included
Decision Making Factors
Actual used
vs.
closest facility
measured
Differences in
access to
WaSH
Geocode
facilities
Difficulty Accessing WaSH
Popularity
WaSH facility
index
Demographics

60

variables are categorical (e.g., gender, race, age, sexual minority groups, community, and length
of homelessness). Associations tested were chosen based on the review of relevant literature and
observing the lack of studies that explore heterogeneity among unhoused groups as it pertains to
differing experiences accessing WaSH services.
To measure the second research question, I utilized a geographic information system
(GIS). More specifically, using ArcGIS Pro’s Network Analyst extension to measure what
factors contribute to the way people choose to engage with service providers. First, I measured
the distance between participant’s reported sleeping locations to the WaSH facility closest to
them per type (restroom, shower, laundry, and drinking water), following a road network. The
facilities considered were only the ones reported by the sampled population. I then compared the
results to people’s actual used facility to help identify whether the distance is a significant
decision factor to people accessing specific services. In R, I created a table to organized the
output data of the closest facility results to match participant’s survey data with the actual
utilized facility, the first closest ranked facility, and total distance traveled. In doing so, I created
a popularity index of WaSH facilities that measure the most utilized facility. This popularity
index is based on three assumptions: first, the effort people make to use a service, including the
number of facilities skipped to get to use the facility, median distance traveled, and the total sum
of participants that reported using the facility. Lastly, I matched this popularity index results with
the different decision-making factors participants reported engaging when choosing to use a
specific WaSH facility. These decision-making factors include distance, affordability, and
accessibility. Accessibility is an aggregated factor that considers safety, availability at all times,
pet friendly, cleanliness, accessibility for people with disabilities, and friendly staff. The
following section outlines the study results.

61

3.4. Analysis Results
This section will describe the results from the regression models and the network analyst
closest facility analyses. The section begins with subsection 3.4.1 that provides an overview of
the sample population demographics, followed by section 3.4.2 that provides the generalized
linear model results for the individual and community level factor differences in access to
WaSH. This section concludes with the findings from the closest facility analysis to identify the
service level factors that contribute to different community engagement.
3.4.1. Sample Population Demographics
In total, 263 participants consented and formed part of the final analysis. Table 3.1
summarizes the community-level demographics. Based on the participant's reported primary
sleeping location, 134 people reported sleeping within Skid Row community boundaries (7
th
and
3
rd
and Alameda and Main streets). Additionally, 92 participants reported sleeping within
downtown Los Angeles, whereas 37 reported sleeping within the greater Los Angeles area,
including Hollywood, Santa Monica Beach, Venice Beach, and South Los Angeles. Examining
across communities, it is predominantly male across all three communities. However, more
female participants (38 percent) reported residing in Skid Row than the other two communities.
The community of Skid Row was predominantly Black/African American (roughly 47 percent),
whereas downtown and greater Los Angeles area were Latinx dominant (41 and 30 percent,
respectively). The average time the sampled population reported experiencing housing insecurity
was five years. Most of the elderly population resided in Skid Row in the sampled population,
whereas those younger than 34 years old reported residing in downtown Los Angeles or greater
Los Angeles area.

62

Table 3.1. Population demographics per community level

Community
Characteristic
Skid Row
n=134 (100%)
Downtown LA
n=92 (100%)
Greater LA
n=37 (100%)
Gender identity
Female 50 (37.60) 23 (25.00) 6 (16.22)
Male 81 (60.90) 68 (73.91) 31 (83.78)
Transgender 2 (1.50) 1 (1.09) 0 (0.00)
Missing 1 (0.75) 0 (0.00) 0 (0.00)
Age
18 to 34 15 (11.20) 20 (21.74) 6 (16.22)
35 to 44 29 (21.64) 14 (15.22) 12 (32.43)
45 to 54 39 (29.10) 24 (26.09) 6 (16.22)
55 to 61 29 (21.64) 24 (26.09) 7 (18.92)
62 and older 18 (13.43) 9 (9.78) 5 (13.51)
Missing 4 (2.99) 1 (1.08) 1 (2.70)
Race/ethnicity
Black/African
American 63 (47.01) 29 (31.52) 17 (45.94)
Latinx 31 (23.13) 38 (41.30) 11 (29.73)
White 16 (11.94) 17 (18.48) 6 (16.22)
Other 20 (14.93) 8 (8.70) 3 (8.11)
Missing 4 (2.99) 0 (0.00) 0 (0.00)
Time homeless
Less than 1 year 19 (14.18) 15 (16.30) 7 (18.92)
1-3 years 53 (39.55) 36 (39.13) 15 (40.54)
4-6 years 19 (14.18) 16 (17.40) 7 (18.92)
7 years or greater 36 (26.87) 23 (25.00) 6 (16.22)
Missing 7 (5.22) 2 (2.17) 2 (5.40)

Note: Percentages are based on total N per community.

63

Table 3.2 summarizes the reported living conditions from the sample population. Overall,
most people reported sleeping in tents, particularly in Skid Row and downtown Los Angeles.
Makeshift or rough living conditions, meaning sleeping without a tent, was the second-highest
living condition reported in the sample. Both downtown and the greater Los Angeles area
reported more makeshift living compared to Skid Row. Shelter living was higher for people
living in Skid Row compared to the other two communities (N=40). In total, only 34 participants
across all communities reporting sleeping in their vehicle and 22 staying in a motel or hotel. The
primary reported factors that attributed to people being displaced from housing included
unemployment or loss of a job (26 percent), unable to afford to pay rent (16 percent), drug and
alcohol misuse (15 percent), and family conflict (15 percent).

Table 3.2. Reported living conditions per community level over a 30-day period

Community
Living condition
Skid Row
n=134
Downtown LA
n=92
Greater LA
n=37
Tent 80 (30.89) 48 (32.21) 15 (22.06)
Makeshift 70 (27.03) 56 (37.58) 21 (30.90)
Shelter 40 (15.44) 7 (4.70) 5 (7.35)
Vehicle 18 (6.95) 9 (6.04) 7 (10.29)
Family/friends 15 (5.79) 7 (4.70) 6 (8.82)
Hotel/motel 10 (3.86) 5 (3.36) 7 (10.29)
Other
a
26 (10.04) 17 (11.41) 7 (10.29)
Total Responses
b
259 (100.00) 149 (100.00) 68 (100.00)

a
Other category includes Single Room Occupancy (SROs), group home, rehabilitation facility, emergency
rooms, and jail systems.
b
This was a multiple response question, therefore the total count per community does not add up to
N=263. Totals are based on the total number of responses received per community.

64

Figure 3.2 shows a map of the three communities people reported residing overlay with
the unsheltered unhoused population density of Los Angeles County per square mile. The map
also illustrates the locations of all WaSH facilities reported by the sampled population and the
estimated sleeping location of all study participants. Participants reported using one hundred
different facilities, most located downtown, and only nineteen facilities in Skid Row for an
unsheltered population of roughly 2,000.

Figure 3.2. Population density map of the unsheltered population of Los Angeles County at the
census tract level per square mile, 2019.
Source: Los Angeles Homeless Services Authority (LAHSA) point-in-time estimates in 2019.

Note: The darkest the shade, the higher the density of people experiencing unsheltered
homelessness.

65

3.4.2. Individual-Level Differences in Access to WaSH
In the first part of this study analysis, I examine the individual-level factors that may lead
to differences in the ability to access WaSH services. Table 3.3. summarizes the results from the
generalized linear models. The reference groups in each of these models included: male,
heterosexual, White, people between the ages of 18-34, length of homelessness less than a year,
and the Skid Row community. In the first model, I tested the differences in difficulty accessing
restrooms among the sampled population. The results from the model indicate that compared to
all three communities, people living in the greater Los Angeles area, the odds of having
difficulty finding restrooms was two times greater than people living on Skid Row and
downtown Los Angeles (OR = 2.5, 95% CI: 1.05-6.23). Additionally, for people experiencing
homelessness for more than 6 years, the odds of encountering difficulty accessing a restroom
were three times greater than those who have less than a year of experiencing homelessness (OR
= 3.3, 95% CI: 1.38-8.29). Regarding racial differences in access to restrooms, for people who
identified as Black/African American and Latinx, the odds were 0.35 (95% CI: 0.14-0.86) and
0.3 (95% CI: 0.11-0.76), respectively, lower compared to White unhoused people.
Table 3.3 also illustrates the differences in accessing laundry places. The model shows
that unhoused people identifying as a sexual minority were four times greater in encountering
difficulty accessing laundry services compared to their heterosexual counterparts (OR = 4.07,
95% CI: 1.62-11.44). The odds of accessing handwashing stations in the greater Los Angeles
area were two times more difficult than Skid Row (OR = 2.49, 95% CI: 1.09-5.85). Furthermore,
people between the age group of thirty-five and forty-four have 2.6 (95% CI:1.04-6.53) times the
odds of having more difficulty accessing handwashing stations than younger unhoused groups.
No other statistically significant differences were observed for other WaSH services. In the
discussion section, however, I will provide more detailed information to explain these models.

66
Table 3.3. Generalized linear model (GLM) output results for WaSH facilities, including all variable indicators
Water, sanitation, and hygiene (WaSH) models

Restroom Shower Laundry
Variable OR
Lower
bound
(95% CI)
Upper
bound
(95% CI) OR
Lower
bound
(95% CI)
Upper
bound
(95% CI) OR
Lower
bound
(95% CI)
Upper
bound
(95% CI)
Intercept 1.16 .32 4.28 1.67 .49 5.75 2.27 .64 8.35
Female .94 .50 1.75 .84 .45 1.54 1.07 .57 2.02
Sexual minority 1.80 .75 4.54 1.46 .63 1.50 4.07** 1.62 11.44
Race/ethnicity
White - - - - - - - - -
Black/African
American .35* .14 .86 .96 .42 2.18 .51 .21 1.22
Latinx .31* .11 .76 .64 .27 1.50 .43 .17 1.04
Other .48 .15 1.51 .60 .20 1.78 .38 .12 1.17
Age
18-34 - - - - - - - - -
35-44 1.19 .48 2.96 .67 .28 1.62 .53 .21 1.30
45-54 1.89 .78 4.66 1.31 .55 3.11 1.31 .54 3.22
55-61 1.03 .41 2.54 .44 .18 1.10 .40* .15 .98
> 62 .98 .35 2.78 .66 .24 1.79 .62 .22 1.71
Time (years)
< 1 - - - - - - - - -
1-3 1.55 .69 3.59 .66 .29 1.47 .99 .43 2.27
4-6 1.58 .60 4.23 .79 .30 2.03 .54 .20 1.43
> 6 3.33** 1.38 8.29 1.02 .43 2.38 .93 .39 2.24
Community
Skid Row - - - - - - - - -
DTLA .95 .51 1.77 1.14 .62 2.30 1.30 .69 2.43
Greater LA 2.50* 1.05 6.23 1.92 .84 4.50 .97 .41 2.28

67
Table 3.3. Continued

Drinking water Handwashing stations Public fountains
Variable OR
Lower
bound
(95% CI)
Upper
bound
(95% CI) OR
Lower
bound
(95% CI)
Upper
bound
(95% CI) OR
Lower
bound
(95% CI)
Upper
bound
(95% CI)
Intercept .63 .17 2.18 .36 .10 1.25 .62 .17 2.15
Female .87 .47 1.61 .90 .44 2.25 .67 .36 1.23
Sexual minority .76 .31 1.81 1.71 .73 4.10 1.23 .53 2.87
Race/ethnicity
White - - - - - - - - -
Black/African
American 1.47 .63 3.50 1.10 .47 2.50 .90 .39 2.04
Latinx 1.20 .50 2.90 .64 .27 1.52 .47 .20 1.11
Other 1.66 .55 5.10 .76 .25 2.23 .60 .20 1.77
Age
18-34 - - - - - - - - -
35-44 2.03 .83 5.10 2.56* 1.04 6.53 .82 .34 2.02
45-54 1.76 .73 4.31 1.77 .73 4.43 1.45 .61 3.47
55-61 .94 .38 2.34 1.88 .76 4.77 .79 .32 1.95
> 62 1.22 .43 3.46 1.56 .55 4.49 1.07 .39 2.95
Time (years)
< 1 - - - - - - - - -
1-3 .67 .30 1.50 .98 .44 2.25 1.59 .70 3.77
4-6 .35* .13 .91 1.11 .42 2.90 2.07 .79 5.58
> 6 1.24 .53 2.90 1.06 .45 2.52 2.17 .91 5.37
Community
Skid Row - - - - - - - - -
DTLA .96 .52 1.80 1.36 .73 2.52 1.21 .65 2.23
Greater LA 1.40 .60 3.20 2.49* 1.09 5.85 2.04 .89 4.77

Note: OR = odds ratio; CI = confidence interval. *p< 0.05; **p< 0.01.

68

3.4.3. Facility-Level Differences in Access to WaSH
In conjunction with examining individual-level differences in access to WaSH services, I
also wanted to capture different institutional-level factors that contribute to the way people
choose to engage with WaSH services available in the community. The results from the closest
facility analysis are shown in Tables 3.4 to 3.9 (See Appendix B). In total, there were 69
different restroom places the sample population reported using at different times of the day, not
including their tent locations. In Table 3.4, for instance, we can observe that 91 and 114
unhoused people respectively reported relying on their tents both in the morning and night. In
contrast, only 45 people utilized buckets inside their tents in the afternoon. In the afternoon,
people reported utilizing public places like the Los Angeles central public library, which was the
closest facility to only one person. However, seven participants reported using with a median
traveled distance of a mile. The median distance is used in all of these models to avoid skewed
results by the small sample size of respondents per facility. One of the common factors people
reported for choosing their tent instead of using nearby facilities was distance and accessibility.
At night time, for instance, 87 participants reported using their tent because it was easily
accessible.
Compared to restrooms, the two types of services people reported traveling the most were
for accessing showers and laundry services. For shower usage, people reported using 34 facilities
other than their tent. Of these 34 facilities, the most utilized were non-profit organizations such
as the ReFresh Spot, St. Francis Center, and Midnight mission. The ReFresh Spot facility was
mainly measured to be the closest place for fourteen people, but eighty-four ended up utilizing
their services with a median distance traveled of 0.34 miles. In Figure 3.3. it illustrates all of the
shower facilities reported with the sampled population density. The size of the circles represents

69

the highest count, and the color represents the distance traveled; the darker the circle, the larger
the distance. Although the median distance was reported in these models, the longest distance
reported was 16 miles, with two participants residing in the Santa Monica area. The smallest
distance was that of 0.07 miles traveled observed in the Skid Row community.

Figure 3.3. Shower facilities across different unhoused communities of Los Angeles.
Note: The size of the circles represents the number of participants that reported using those
facilities. The filled color of the circles represents the median traveled distances to different
shower facilities. The lighter to darker shades representing shorter to longer distances traveled.
These were overlaid with the density of all participants interviewed in this study.

There were only 22 places participants reported utilizing to do laundering compared to
shower services, not including people's tent locations. Table 3.8 highlights the three most
popular facilities: the ReFresh Spot, the People Concern, and tents. The ReFresh Spot, however,

70

resulted in being the most popular place. The model measured that the ReFresh Spot was closest
to eighteen people, yet eighty-one participants reported utilizing their services. Some factors
driving this high usage in places like the ReFresh Spot were predominantly due to its
affordability (n=56) and accessibility (n=41). For instance, in places like the People Concern,
people are charged to use their services; hence, more people reported that they choose to go to
the ReFresh Spot because it is accessible more than its affordability. Figure 3.4. illustrates the
different laundry places reported by the sampled population, predominantly located in the
community of Skid Row.

Figure 3.4. Laundry facilities across different unhoused communities of Los Angeles.
Note: The size of the circles represents the count of participants that reported using those
facilities. The filled color of the circles represents the median traveled distances to different
laundry facilities. The lighter to darker shades representing shorter to longer distances traveled.
These were overlaid with the density of all participants interviewed in this study.

71

Table 3.9 summarizes the results of the closest drinking water facilities. There were fifty-
two places that the sample population reported to access drinking water. There was slightly more
variation in the types of places utilized but significant distance differences. While the Refresh
Spot was estimated to be the closest for nine participant’s sleeping locations, thirteen ended up
obtaining drinking water from there because it was accessible. Midnight mission was estimated
to be the closest for four people, whereas nine participants reported obtaining water from this
shelter. Establishments like McDonald's near Washington boulevard and Daiso in Little Tokyo
and public places like libraries and parks were among other facilities used to obtain water due to
being accessible and not based on distance.
Lastly, in this study, participants were asked whether they have experienced a form of
discrimination while unhoused as a result of their race, gender identity, social status, legal status,
age, and sexual orientation. Of the sampled population, 43 percent of the sample population
reported gender-based discrimination accessing services due to their race or ethnicity. In
addition, 23 percent reported gender-based discrimination benefiting women, whereas 19 percent
reported experiences of discrimination as a result of their age. Forty-two participants reported
discrimination in access to services based on their appearance/social status of homelessness and
23 percent based on a disability. In the following section, I will dig deeper into the implication of
these findings.
3.5. Interpretation of Findings
Much of the academic work recognizes that differences in unhoused communities exist,
but it remains heavily underexplored regarding the nexus of WaSH insecurity and housing
insecurity. While it is evident that people experiencing housing insecurity do not have safe,
affordable, and consistent WaSH services, the findings from this study help illuminate that

72

differences among groups also exist, which may contribute to people’s inability to access them in
the first place. In addition, navigating through different places that may provide access to these
essential services may also provide people some form of agency as they decide on what places
they engage to survive on the streets. Understanding these different experiences is important to
better address unmet needs and existing disparities detrimental to a person's life, health, and
living environment. In this discussion, the findings are interpreted and broken into three sub-
categories. Subsection 3.5.1 details the community-level differences in access to WaSH services,
followed by 3.5.2 that interprets the individual demographic factors contributing to differences in
access to WaSH. Subsection 3.5.3 provides a further examination of the service level factors that
influence community engagement. This section concludes by noting possible study limitations.
3.5.1. Public spaces and access to WaSH services
To first understand differences in WaSH insecurity experiences, it is important to
understand the role of the built environment. According to Marr, DeVerteuil, and Snow's (2009)
study, in Los Angeles, there are heavily institutionalized places providing various services,
including shelters, soup kitchens, and other resources that may facilitate the survival of unhoused
communities. The authors also make the argument that there are places that lack access of
services entirely. The findings from this study elucidate this argument by examining three
communities created based on people’s reported sleeping areas. Most WaSH services reported in
this study, for example, were located in the community of Skid Row compared to parts of
downtown and greater Los Angeles. The disparity of access to adequate WaSH services can also
be seen in the number of participants (n=37) that sleep in parts outside the Skid Row boundaries
and that travel during the day to access services that may not be available in their sleeping areas.
The placement and lack of services may result from heavier criminalization of homelessness in

73

these public environments and opposition to bring these types of homeless services into
communities outside Skid Row. As a result, it forces people to commute long distances to access
essential services not available in their residing communities. In addition, different local laws are
in place that restrict unhoused people from building encampments, which this study elucidates
based on the reported living conditions in the sample population. For instance, tent living was
more prominent in Skid Row than communities outside these boundaries in greater Los Angeles.
Additionally, more people reported living in shelter systems available in Skid Row. As Bonds
and Martin's (2016) study argues, these forms of anti-homeless and containment laws,
particularly in places outside the “Skid Rows,” serve as forms of environmental injustices. They
note that it is often observed when the law is selectively enforced in specific communities,
tolerating homelessness and homeless services in certain city limits. This is seen with the
enforcement of the Los Angeles Municipal Code (LAMC) 41.18(d) in the City of Los Angeles,
that reduces the ability for unhoused people to exist in public spaces. Furthermore, the placement
or lack of services in communities of Los Angeles, or lack thereof in access to essential WaSH
services, also further creates public health inequities.
3.5.2. Individual-Level Differences in Access to WaSH
While community-level differences highlight the availability and distribution of WaSH
services, this section further explores the individual-level that contribute to differences in WaSH
access. In other words, individual characteristics and vulnerabilities can shape adaptation
patterns for people living in Skid Row, downtown, or greater Los Angeles communities.
Specifically, demographic factors were utilized to measure whether it contributes to people’s
inability to access WaSH services. First, no statistically significant differences were found
among gender groups for all types of WaSH services models. Nevertheless, participants did

74

report experiences of discrimination in accessing services based on their gender. In some
instances, unhoused men stated that it is easier for unhoused women to access certain services. In
Takahashi, McElroy, and Row's (2002) and Stuart's (2015) studies, they make a similar
argument. These scholars state that people have more sympathy for women. Compared to
unhoused men, women with children may have greater access to services that help them exit
homelessness than single unhoused women and men. However, unhoused women do suffer
additional burden and violence. Older women reported visiting Skid Row to access services in
the sample population but not to sleep due to safety reasons. Although not measured well in this
study, women also encounter added stigmatization and challenges, particularly coping with
menstrual and body hygiene. Showers and bathroom facilities are difficult to come by outside
homeless shelters and Skid Row boundaries, depriving women of managing menstruation with
privacy, dignity, and cleanliness, often leading to poor health outcomes (Kuo 2019; LACAN
2017).
In addition to exploring gender differences, the length of a person experiencing housing
insecurity did attribute to differences in accessing WaSH services. Prolongation of homelessness,
particularly experiencing homelessness for more than six years, resulted in more difficulty
accessing services. This finding is the opposite of what I assumed people entering homelessness
or being unhoused for less than a year would encounter more challenges due to not knowing
where services are located. In the model, prolongation of homelessness resulted in more
difficulty accessing restrooms and drinking water. Older adults in the models did not show
statistically significant differences in vulnerability. However, it is important to highlight that they
are a vulnerable group among the unhoused, precisely because they have higher rates of chronic
health problems. Older adults experiencing homelessness are particularly a vulnerable group as

75

they may face greater obstacles. These obstacles include age discrimination or discrimination in
obtaining employment or stable housing, access to public services (including a bathroom in
public businesses), which may further impede their ability to transition off the streets and exit
homelessness (Tompsett, Fowler, and Toro 2009). In this study, 19 to 20 percent of the sampled
population reported discrimination access services experiences because of their age and
disability.
The regression models only estimated that people identifying as Black or Latinx have less
difficulty accessing restrooms, but no other statistically significant differences were found.
However, racial disparities do exist in unhoused communities when trying to navigate access to
WaSH services. First, this study found that the community of Skid Row was predominantly
overrepresented Black or African American compared to communities in downtown Los Angeles
that were predominantly Latinx or White. These different racial landscapes may exist due to anti-
Latinx sentiments in these communities and the fact that White unhoused people are an
underrepresented group in Los Angeles, compared to other communities in the state. Second, 43
percent of the sample population reported experiences of discrimination accessing WaSH
services because of their race. Discrimination in accessing services is critical to highlight
because it also creates disparities in health outcomes due to inadequate access to WaSH services.
Lastly, Suzanne Speak's (2010) and Chinchilla and Gabrielian's (2020) studies highlight the
importance of examining immigration and homelessness. Speak argues that migrants arrive in
the city to reach “the American dream,” yet some arrive into a situation of urban poverty,
homelessness, a loss of social networks, and deprivation of services (Speak 2010).
Undocumented homeless may also encounter language barriers, in addition to economic barriers,
which exacerbate discrimination (Chinchilla and Gabrielian 2020). In this study, a small

76

percentage of participants reported being undocumented, which may be an undercount due to the
constant fear of deportation as a result of their legal status. Of those that reported their status,
they identified the issue of not qualifying to receive public assistance (food stamps, housing
services, and Section 8), further widening the gap in exiting homelessness and gaining access to
services (Chinchilla and Gabrielian 2020; Gilleland, Lurie, and Rankin 2017; Speak 2010).
3.5.3. Facility Level Differences in Access to WaSH
Examining WaSH insecurity from the perspective of unhoused communities is important
because it informs us of gaps in services and unmet needs. The second study aims to measure
service-level factors that contribute to people’s levels of engagement with available WaSH
services. Specifically, I examined whether distance or proximity to facilities played a significant
role in people's decision-making when accessing WaSH services. I also examined the reported
differences in reasons for accessing particular services. In this study, the findings highlight that
distance is important when accessing certain, but not all, services but not. In particular, distance
is an important factor in the decision-making of using restrooms in the morning and evening. In
Skid Row, for example, some of the facilities that exist are predominantly non-profit service
providers, with a few publicly available restrooms. Many of these facilities close early in the
evening or are out of order, unclean, or unsafe to use.
Furthermore, only a few facilities are open overnight, resulting in people resorting to
using their tents instead of walking to the shelter in the evening and feeling unsafe. At night-
time, in particular, a person reported utilizing the public restroom from the police department
because they perceived it to be safe, but this is not the norm, particularly with the often
criminalization that the unhoused communities experience. In the afternoon, however, distance is
less of a determining factor. There is also less reliance on using tents as places are open,

77

including food establishments, public libraries, parks, and non-profit organizations that may
provide safely managed restroom service.
In the facility models, the usage of shelter systems to meet their basic WaSH needs was
minimal in the sampled population, compared to other types of non-profit organizations such as
the Refresh Spot, St. Francis Center, and the People Concern. In particular, the Refresh Spot was
the most popular facility for all types of WaSH services measured, based on traveled usage
numbers, facilities skipped, and preference. In further examining the success rate of this facility,
people attributed to using the Refresh Spot not only because the services they provide are free of
cost (e.g., laundry loads) but it provides a quality of services that makes people feel safe and
dignified. Participants reported that the Refresh Spot has friendly staff, it is accessible, even
when there are wait times, the services are always clean and safe. Affordability is an essential
factor, especially when navigating access to laundry services. The Refresh Spot is not one of the
few, if not only facilities in Skid Row that provides access to these services for free. This is
important to note as a few participants reported relying on private laundromats to wash their
clothes, some of which traveled further distances.
Lack of adequate WaSH services in the community leads to people embarking on coping
survival strategies that are not safe and dignified. For example, walking or commuting long
distances to access services, utilizing the sink of a public park to do laundry or bathe, and being
forced to pay for a gym membership to access the restroom and shower amenities. Overall, there
is a need to provide better and improve access to WaSH services in unhoused communities
needed to combat existing health disparities.

78

3.5.4. Study Limitations
While this study has contributed to filling the knowledge gap in the nexus of WaSH
insecurity and housing insecurity, it is also important to identify potential pitfalls and limitations
in the study. First, the small sample size in this study may have resulted in less statistically
significant results, not allowing us to see more heterogeneity among unhoused populations.
There were also two assumptions in the closest facility models: walking was their primary mode
of transportation for people navigating to and from different WaSH services. This may not be
entirely accurate as unhoused people are mobile, and some do use public transportation.
However, the distance between driving and walking to a location is the same, with the only main
difference being the travel time. The other assumption made in the model was that since people
reported using multiple facilities, only the first-mentioned WaSH service was utilized in this
study analysis which may not represent all of the daily behaviors people engage in daily.
Additionally, the format of the survey questions could have improved to validate some of the
demographic questions better and WaSH insecurity experiences—for instance, better-capturing
gender identities, particularly for people identifying as transgender. In terms of WaSH insecurity
experiences, most public spaces were not part of the analysis. People only mentioned using
“public parks” or “public toilets” but did not specify an exact location. Hence, I had to limit the
sample size for the closest facility analyses, including those that provided an exact name or
location to a WaSH facility. In the models, only one of the many places that people utilized was
explored in this closest facility measurements. Lastly, these results would have benefited from an
intersectional analytical lens to include other interaction factors in the models as there may be
intersectional vulnerabilities among the unhoused in gaining access to WaSH services and in the
agency of choosing what WaSH services people utilize.

79

3.6. Conclusion
The findings from this study contribute to the existing literature gap on the nexus of
WaSH insecurity and housing insecurity in Los Angeles. In this study, I argue that WaSH
insecurity is experienced in a wealthy city like Los Angeles and that it is experienced differently
across communities. In particular, people with more prolonged housing insecurity, the elderly,
and living outside dense service areas are more vulnerable to experiences of WaSH insecurity. In
addition, I provide evidence that different decision-making factors exist that contributes to the
way unhoused people choose to engage with different WaSH informal and formal service
providers. Distance plays a role in the way people choose to access services, but it is not the
main contributing factor. Different forms of accessibility, including the perception of safety,
cleanliness, friendly staff, affordability, and availability when needed, played a more significant
role in the ways people engage with different WaSH service providers.
Addressing both the heterogeneity among groups of people experiencing homelessness
and the quality of services in unhoused communities is important as we move forward to better
addressing homelessness and people’s interim needs. Specifically, we need to seek more
inclusive and equitable policies that can help improve and increase access to fundamental WaSH
services. Furthermore, more models are needs like the Refresh Spot that can provide more
dignified, affordable, and permanent access to WaSH services to unhoused communities,
particularly in communities with large encampments. Existing facilities should also consider
extending their hours of operation to improve access to services throughout the day, particularly
with evening time being the most challenging for unhoused people to access restroom facilities.
Additionally, communities across the larger metropolitan area of Los Angeles should invest in
public WaSH infrastructure that will improve access in public spaces, which can help reduce the

80

risk of communicable diseases and help improve the lives of unhoused communities. Overall, the
results from this study shed light on the need to prioritize better providing safe, affordable,
equitable, and accessible WaSH services in vulnerable communities. These types of WaSH
services can improve quality of life and break existing health disparities as people wait to be
connected to housing services.

81

Chapter 4 Identifying WaSH Service Needs in Unhoused Communities from
the Perspective of Service Providers in Los Angeles, CA

In the previous two chapters, the focus was on understanding the impacts of water, sanitation,
and hygiene (WaSH) insecurity from people with lived experience of homelessness. Chapters 2
and 3 both highlight WaSH insecurity experiences among unhoused communities pre-pandemic,
specifically the survival coping strategies, individual-level vulnerabilities, and service-level
factors that determine the usage of services. In this chapter, however, the focus shifts to
examining WaSH insecurity from the perspective of service providers. The complementary
views of service providers in this dissertation can facilitate the development of effective
interventions needed to improve the type of services needed in unhoused communities. The
structure of this chapter begins with section 4.1 that provides a brief introduction of the problem
statement. This is followed by section 4.2 that reviews relevant literature. Subsequently, section
4.3 describes the data and methodology used in this study. Then section 4.4 describes the
interview results, and the remaining chapter provides an analytical interpretation of the findings,
concluding with future recommendations.
4.1. Introduction
In Los Angeles, 555,105 people are severely rent-burdened and at risk of being displaced
from housing (Los Angeles Homeless Services Authority (LAHSA) 2020b). On average,
LAHSA reports that 207 people exit homelessness each day, yet 227 are falling into
homelessness each day (LAHSA 2020a). As the pipeline inflow of people entering homelessness
continues to rise, it is imperative to develop effective solutions that not only focus on the
provision of housing but also address interim level services needed to meet people’s basic needs.

82

Addressing interim-level needs, in particularly, the WaSH needs of unhoused people at that
transitional period (from the time entering homelessness to somebody being connected to
housing services) remains heavily underexplored from the point of view of providers. Therefore,
the purpose of this cross-sectional qualitative descriptive study is to understand from the
perspective of service providers, the ways in which WaSH insecurity impacts unhoused
communities across Los Angeles.
This chapter study explores two main research questions. The first question centers on
how do service providers perceive WaSH insecurity impacts unhoused communities? The second
focuses on addressing ways in which service providers can improve access to services and
address unmet needs in the community. The aim of addressing these two questions is to
understand the perspectives and experiences of service providers serving unhoused communities
so as to inform policy recommendations moving forward. Integrating the views of service
provides can help identify the types of WaSH services needed and identify different aspects of
services in need of improvement, including design, staffing, quality, and distribution. This is
important because ensuring appropriate expansion of effective WaSH programs in unhoused
communities can improve quality of life and health, which is even more so relevant now as a
result of added risks from the current SARS-CoV-2 (COVID-19) global pandemic. The
following section presents the current knowledge to identify gaps in the literature.
4.2. Background
This section provides an overview of the existing literature to present different studies
that contributes to the understanding of WaSH insecurity, stigmatization, and challenges in
addressing homelessness. This literature background section concludes with a description of gaps
found in the literature to highlights this study’s contributions.

83

4.2.1. Water, Sanitation, and Hygiene (WaSH) Insecurity
Access to WaSH services, including drinking water, toilets, showers, and laundry
services, are essential for human dignity and personal and public health maintenance.
Nevertheless, unhoused communities do not have safe and equitable access to these life-
sustaining services (Avelar Portillo et al., n.d.; Demyers, Warpinski, and Wutich 2017; Flannigan
and Welsh 2020). WaSH insecurity experiences of unhoused people remain underexplored,
particularly in high-income countries of the global North that report universal access to WaSH
(Meehan, Jepson, et al. 2020). However, a few studies like DeMyers, Warpinski, and Wutich
(2017) shed light on the significant barriers that unhoused people encounter as a result of WaSH
insecurity in Phoenix, Arizona. In their study, DeMyers, Warpinski, and Wutich integrate the
perspectives of water distributors, service providers, and people experiencing homelessness to
argue that WaSH insecurity is not a stand-alone phenomenon. In other words, WaSH insecurity
creates added burdens in physical and mental health deterioration of unhoused people, prolongs
homelessness, and joblessness. The authors also highlight that WaSH insecurity experiences
differ based on living conditions, disproportionally affecting unsheltered unhoused people that
are not part of large encampments or shelter communities, as they are hard to reach by service
providers or live further away from services. Flannigan and Welsh (2020) study similarly argues
that experiences of WaSH insecurity are greater for those harder to reach isolated populations
living by riverbeds in San Diego, California. Flannigan and Welsh argues that as a result of
people being pushed to precarious living environments due to criminalization of homelessness,
people are less likely to be connected to essential services. In other instances, lack of WaSH
services results in open defecation practices and in people embarking in different coping survival
mechanisms to access these services (Avelar Portillo et al., n.d.; Capone et al. 2018; Frye,
Capone, and Evans 2019)

84

4.2.2. WaSH Insecurity and Stigmatization of Unhoused Communities
WaSH insecurity creates added barriers among unhoused communities as it increases
forms of marginalization and stigmatization, all of which reinforces a cycle of poverty.
According to Phelan, Link, and Moore (1997) a number of aspects of homelessness results in
greater social exclusion aside from their poverty level, including unkempt appearance of
unhoused individuals, as well as the association of negative public attitudes towards unhoused
people coping with mental illness and substance abuse that adds to their stigmatization.
Similarly, the work of Clifford and Piston (2017) discusses these prejudicial attitudes towards
unhoused people based on their physical appearance that characterize individuals as potential
“pathogen threats” that then lead to exclusionary policies and further stigmatization that impacts
people’s ability to exists in public spaces and exit homelessness (Clifford and Piston 2017, 506).
This can be seen in anti-homeless ordinances that serve as forms of oppression and seek to
remove unhoused from public spaces in order to limit their visibility and potential disruptiveness
of pristine cities. (Mitchell 1997; Stuart 2015). Poor access to WaSH services exacerbates these
forms of stigmatization and exclusion among unhoused communities that are unable to access
essential services to maintain a certain appearance and hygiene practices (Demyers, Warpinski,
and Wutich 2017; Goodling 2020; Sebert Kuhlmann et al. 2019)
On the other hand, disinvestment in permanent and sustainable solutions results in added
marginalization and health disparities. This is seen in Felner et al. (2020) study that examines
health inequities shaped by public perception and the built environment through the perspectives
of transitional aged youth experiencing homelessness in San Diego. This study in particularly
focuses on the hepatitis A virus (HAV) outbreaks that occurred back in early 2016 to late 2017 in
San Diego and across the US, predominantly affecting unhoused people. The findings from this
study suggest that temporary public health interventions aimed to serve vulnerable unhoused

85

communities reinforced stigma and marginalization. This was seen in the lack of investment to
long-term infrastructure and in the placement of temporary services such as handwashing
stations that help reduce the spread of infectious diseases, which were physically located in
restricted geographic regions, hidden from the public eye. Similarly, a report conducted in the
city of Berkeley, California highlights on this aspect of uneven distribution and placement of
publicly available restrooms in parks, with most restrooms located in communities where there
are no unhoused encampments (The Environmental Law Clinic (ELC) and the Environmental
Justice Coalition for Water (EJWC) 2018).
4.2.3. Challenges in Addressing Homelessness
Addressing the homelessness crisis is challenging with majority of efforts solely focused
on the Housing First model approach, which overlooks addressing interim-level needs for
unhoused people at that transitional period. The unresolved tension between housing and non-
housing services remains. Understanding these realities is vital to break the barriers of service
delivery and improve the quality of existing services. While providing permanent housing leads
to access to the most essential services, including WaSH access, not everyone qualifies for
housing, including undocumented homeless and people with felonies (Gilleland, Lurie, and
Rankin 2017; Keene et al. 2018). In some cases, fear of their immigration status or stigma
around formerly incarcerated people results in less engagement with service providers
(Chinchilla and Gabrielian 2020; Keene, Smoyer, and Blankenship 2018). As such, interim level
needs of people, including access to WaSH services, remains unaddressed when only focusing
on one-tier solutions.
Additionally, the current global COVID-19 pandemic has contributed to added
challenges in addressing the homelessness crisis. While the pandemic has raised awareness of the

86

importance of securing access to WaSH which can help reduce the risk and transmission of
infectious diseases it is also important to highlight that unhoused communities do not have safe,
affordable, and sufficient access to WaSH, creating added public health and human rights
challenges (Howard et al. 2020; Loftus and Sultana 2020). According to the Centers for Disease
Control and Prevention (CDC), people experiencing homelessness are at a higher risk than the
general population of contracting infectious diseases, including COVID-19 thus addressing the
needs of these communities is imperative to reduce health disparities (Centers for Disease and
Control Prevention (CDC) 2021). Additionally, the pandemic has altered the way unhoused
people can access essential WaSH services due to the closure of libraries, gyms, and restaurants
or coffee shops not allowing restroom use. In San Francisco, for example, a report by the
Coalition on Homelessness found that unhoused people experienced added challenges during the
pandemic in obtaining and access drinking water at grocery stores or restaurants because of their
appearance and closure of public places (Coalition on Homelessness 2021).
4.2.4. Knowledge Gap and Study Contributions
In reviewing these studies, the current knowledge suggests that WaSH insecurity heavily
impacts unhoused communities, and the provision of these types of services remains a contested
arena. While these studies integrate multiple perspectives to better understand the needs of
unhoused communities, this chapter will shed light on the heavily underexplored experiences of
Los Angeles, a city confronted with the highest count of unsheltered unhoused people in the
nation (Henry et al. 2021).While existing studies have examine the impacts of WaSH insecurity
among the unhoused in other cities in the state of California (Flannigan and Welsh 2020; Speer
2016; Verbyla et al. 2021), no studies have examine this phenomenon in Los Angeles through
the perspective of service providers. The study of Verbyla et al. (2021), for example, integrates

87

the perspective of service providers to address WaSH insecurity impacts in unhoused
communities living in riverbeds in San Diego. But while this study makes significant
contributions in presenting the challenges of WaSH insecurity, it does not incorporates an
intersectional lens in addressing these issues. Including an intersectional lens in addressing
WaSH insecurity impacts is important as it sheds light to intersecting identities of individuals
and intersecting vulnerabilities (Goodling 2020). Thus the purpose of this chapter study is to
understand the different impacts of WaSH insecurity from the perspective of service providers.
While also identify ways access and delivery of services can be improved so as to inform policy
recommendations. The following section illustrates the methodology and describes the data
utilized in this study.
4.3. Data and Methodology
This descriptive qualitative study addresses WaSH insecurity from the perspective of
service providers. This data and methodology section will explicate more in-depth the research
design, target population, sampling strategy, data collection procedures, and analysis integrated
to address the primary study research questions. The remainder of this section outlines self-
reflexivity integrated into this study to situate my positionality as a researcher and in the
constructed knowledge of this study.
4.3.1. Research Design
According to Creswell and Creswell (2018), a qualitative study is an inquiry process of
understanding a social phenomenon or human problem. In this study, the phenomenon examined
is understanding how WaSH insecurity impacts unhoused communities in Los Angeles coming
from the perspective of fifteen service providers. The framework and design of this study are
using qualitative descriptions to describe the perspectives, perceptions, and experiences of

88

service providers and community organizations serving unhoused communities. While other
major theoretical frameworks exist, including grounded theory, phenomenology, narrative, and
ethnography, to name a few; utilizing qualitative description is appropriate in this study because
the main goal is to describe the “who, what, and where of experiences” that target at better
understanding human views and behaviors (Sandelowski 2000; 2010). Additionally, it is
important to acknowledge that this study does not integrate the views from unhoused people
experiencing the phenomenon (phenomenology), it does not grounded on existing theories
(grounded theory), nor is it based on oral histories and submersion in unhoused communities and
settings (narrative and ethnography). Instead, this study focuses on using qualitative description
to gain an understanding of how WaSH insecurity affects unhoused people from the point of
view and experiences of providers that serve these communities.
Sandelowski argues that “descriptions always depend on the perceptions, inclinations,
sensitivities, and sensibilities of the describer” (Sandelowski 2000, 335). Thus, qualitative
descriptive research draws on the specific responses given by the different study participants as
analyzed by the researcher. The analysis of the data also follows a natural inquiry form that
requires no commitment to a theoretical view. Majority of qualitative descriptive framework is
typically implemented in public health research (Chafe, Harnum, and Porter 2016; Isaacs 2014;
Neergaard et al. 2009; Roudsari and Latifnejad Roudsari 2019). In the work of Chafe, Harnum,
and Porter (2016), for example, qualitative description design was utilized to improve level of
care for patients in the emergency department (ED) by medical health care providers. The
knowledge gathered from this study was then reported back to the staff in the ED in hopes of
generating sustainable solutions to improve treatment and pain management in patients
presenting in an ED setting. Similarly, qualitative descriptive approach in this study will help

89

describe the phenomenon from the perceptions and views of service providers and community
organizations to inform policy recommendations needed to address unmet WaSH needs in
unhoused communities of Los Angeles. The following section will detail the sampling and target
population used in this study.
4.3.2. Target Population and Sampling Strategy
The target population for this qualitative descriptive study included providers from the
public and private sector serving (in)directly unhoused communities in Los Angeles. In total,
fifteen providers were interviewed, three from the public sector and twelve private or non-profit
organizations. Public sector service providers included individuals from the county or local
government agencies such as the Los Angeles Central Public Library and Recreation and Parks
department, which indirectly serve unhoused communities through access of public restrooms
and water fountains. Private sector providers included non-profit organizations who have hands-
on experience directly serving and advocating for unhoused community members. Some of the
targeted organizations included those who directly provide WaSH services to the community,
such as the ReFresh Spot, LavaMae
x
, Water Drop LA, and the People Concern. Other non-profits
recruited were ones who provide WaSH services in tangential to other main continuum of care
services such as Safe Parking LA who provides unhoused people access to restrooms, but the
main focus of this organization is in providing a safe parking space overnight for people living in
vehicles. Additionally, legal aid and housing organizations were targeted for this chapter study to
provide new perspectives on housing, service design, and gaps in addressing WaSH insecurity.
But also these organizations can help identify better integrative solutions that can better address
the unmet needs of unhoused communities. Table 4.1 provides a list of the organizations who
formed part of the sample population.

90

Table 4.1. List of participating organizations serving unhoused communities in Los Angeles

Name of Organization (N=15) Service(s) Provided
The ReFresh Spot Shower, restroom, laundry, drinking water, phone
charging station, car-sharing ride
LavaMae
x
Mobile shower and restroom
Water Drop LA Bottled drinking water and hygiene supplies
Project Ropa Clean clothing, hygiene kits, and water
The Laundry Truck LA Mobile laundry
The People Concern Shower, laundry, and restroom
Safe Parking LA Overnight parking, restroom, social services
Skid Row Housing Trust Affordable housing
Lorcan O’Herlihy Architects Architectural and design services
Los Angeles Central public library Restroom, drinking water, and social services
City of Los Angeles Recreation and Parks
Department
Restroom and temporary shelter
American Civil Liberties Union (ACLU) Southern
California
Free legal aid and representation
Social Model Recovery Systems Alcohol and drug prevention and wellness
Inner City Law Center Legal aid on tenant defense, citations
Government agency
a
Sanitation, hygiene, and trash collection

a
Participant did not grant permission to disclose the name of the organization

Purposive sampling was utilized for this study because the focus was to include
organizations who serve unhoused communities directly or indirectly to learn from their
perspective how WaSH insecurity the communities they serve. The type of organization
contacted were based on prior knowledge gathered from survey data collected from people with
lived experienced who reported the services and organization names they utilize (see chapters 2

91

and 3). Additionally, organizations were contacted based on in-depth research done online to
find services available in Los Angeles, including organizations involved in homelessness
advocacy, housing services, and government agencies. Prior to recruiting service providers to be
interviewed, study procedures and activities were reviewed and approved by the University of
Southern California Internal Review Board (IRB). Based on guidelines provided by the IRB,
only adults over 18 years of age formed part of this study.
Recruitment of service providers in this chapter study was done via email and phone.
However, due to the limitations provided by the current global pandemic and the “Safer at
Home” emergency COVID-19 orders in Los Angeles, majority of the staff and stakeholders were
working from home and were reached via email (City of Los Angeles 2021). Contact
information of the different service providers and community organizations was found through a
Google search engine, in their social media platforms and organizational websites. In total,
thirty-five different organizations were contacted but only twenty-two responded to email
inquiries. Follow-ups were sent three times before lost to follow-up. In total, fifteen service
providers consented, were interviewed, and formed part of the final analysis. Sample recruitment
continued until a point of saturation had been reached, in other words, when no new themes
emerged from the interviews.
4.3.3. Data Collection Procedures
The data collected in this study were semi-structured qualitative descriptive interviews
with service providers and community organizations between March and April 2021. All
interviews were conducted via a videoconferencing platform, either through Zoom or the
provider's preferred choice of video conferencing technology. The length of the interviews
ranged from 40 to 120 minutes. At the time of the scheduled interview, all participants were

92

provided with the study objectives and consent. Fourteen of the fifteen providers consented to
use the organization’s name in the study findings and to digitally audio record the interviews.
An interview guide tool was utilized to conduct the interviews. The guide included pre-
determined themed questions that asked service providers to describe their point of view and
perceptions, particularly: (1) how do service providers perceive WaSH insecurity impacts
unhoused communities? and (2) what can service providers do to improve access and usage of
services? The guided tool was tested and modified after conducting two interviews. The final
guide consisted of thirty-five questions, each within a respective pre-determined theme (see
Appendix C). In addition to the interview guide tool, follow-up questions formed part of the data
collection. These follow-up questions came naturally from conversations during the interview.
To address the first research question focusing on the way service providers perceive
WaSH insecurity impacts unhoused communities, some of the topic questions included, (a)
where do you believe the biggest shortage is across the different types of water, sanitation, and
hygiene facilities?, (b) who do you believe are the most vulnerable groups within the unhoused
community in accessing WaSH services?, and (c) how has the COVID-19 pandemic impacted
access to WaSH services in the community? (see Appendix C for the complete guide).
In order to address the second research question focused on important factors to consider
to improve access of WaSH services in the community, providers and community organizations
were also asked: (a) what do you believe are the main barriers that prevent unhoused people from
gaining equitable and safe access to WaSH services?, (b) what do you believe is one of the best
ways the City has addressed the WaSH needs of the community?, and (c) what are the different
types of immediate strategies and interventions that can be provided to improve access to WaSH
services in the community. Due to people’s time constraints and availability, questions during

93

the interview were prioritized based on achieving the study objectives. Additionally, memo notes
were taken during and after each interview and used to compare ideas with the research team
during debriefing sessions following each interview. These memos provided an additional data
source, including the researcher’s and research team’s main takeaways from the interviews,
views, and emotions.
4.3.4. Data Analysis
Figure 4.1 illustrates the analytical process for this chapter study. First, interview
transcripts were exported from Zoom onto a word document and reviewed for accuracy using the
recorded audio files. Each transcript was verified twice by research assistants to ensure the
transcript reflected the service providers’ experiences and perceptions. After cleaning each
transcript and memo notes, these were imported and iteratively analyzed using NVivo 12
(version 12.6.1) qualitative analysis software. NVivo helped organize all of the text data into one
place to inductively identify themes from the data. Following the cleaning and verification
process of each transcript, the data organization within NVivo was arranged based on generated
categories and subcategories commonly referred to as “codes.” Since qualitative data are text-
based, one way to analyze the data is through a textual coding process. Creswell and Creswell
(2018) refer to the coding process as “bracketing chunks” of words, phrases, sentences, or the
entire paragraph into categories. In this study, a codebook was generated first by using an open
coding strategy. In other words, the research team read through the transcripts and identified
broad categories that were salient to understanding homeless service providers perspectives. In
total, 34 initial codes consisted of segments or standard references from the raw interviews. For
example, a code “WaSH services” was applied to interview transcript segments that referred to

94

the provision of WaSH services. A final codebook was generated based on feedback provided by
the research team, based on group coding and discussion activities.

Figure 4.1. Flow chart of qualitative data and analysis.
Source: Figure adapted from Creswell and Creswell, Research Design: Qualitative,
Quantitative, and Mixed Methods Approaches Fifth Edition (London: SAGE
Publications, 2018), 192.

After all interview transcripts were transcribed and single coded, they were analyzed
using thematic analysis to explore common patterns and themes related to impacts of WaSH
insecurity, service design improvement, population vulnerabilities, and impacts of COVID-19.
Coding the data
Impacts of WaSH
Accessibility
Heterogeneity in
Unhoused
Communities
Service Design
Improvement
Importing into NVivo
for textual analysis
Themes Generated
Impacts of WaSH
Inaccessibility
Impacts of
COVID-19
Interview Data
(transcripts)
Cleaning and
verifying transcripts
for analysis
Interpretation of themes

95

These initial themes were re-grouped after comparing, contrasting, and sorting the codes that
exemplified the perspectives and information shared from service providers. For example, an
initial code category such as “impacts of WaSH insecurity” was re-categorized and re-grouped to
distinguish between codes that highlight the benefits of WaSH accessibility and others that
described the detriments of poor WaSH accessibility. In total five different major themes
emerged from the data. The themes were revisited after receiving additional feedback to ensure
completeness and high quality of transcription. The final themes that emerged from the final
analysis will be discussed in detail in section 4.4 and interpreted further in section 4.5 to make
meaning of the data and the phenomenon examined.
4.3.5. Trustworthiness, Validity and Reliability
To ensure the trustworthiness of the data and validate findings, prior to conducting the
study, a quantitative survey study with 263 participants with lived experienced provided initial
information on their experiences of WaSH insecurity. These conversations with unhoused people
helped establish questions and familiarity with the subject before beginning interviews with
service providers. In addition, the sampling utilized in this qualitative study was purposive to
only include service providers that can offer a perspective communities they serve. The research
team would also meet after each interview to discuss and further refine each set of themes,
compared memo notes. To maintain reliability in the findings, interview transcripts were checked
twice before coding them to ensure the text contained each participating service provider's actual
and correct expressions and these transcripts re-coded after peer examination to ensure
completeness in the analysis. Lastly, the findings presented in this study are considered a truthful
and authentic reflection of the views and perceptions provided by participants.

96

4.3.6. Self-Reflexivity
To remain true to the methodology implemented in this study, it is important as a
researcher to be consciously reflexive of one’s positionality in the research process and mindful
of how one's attitudes and beliefs make meaning and produce knowledge in this study to
acknowledge any potential biases (Berger 2015). First, it is important to acknowledge my
positionality in the research as a woman of color, an immigrant from El Salvador, and a person
with no lived experience of homelessness. My role in this research process comes from that of an
“outsider” who only has the experience of speaking to unhoused community members. However,
it is also important to note that my personal and epistemological stances have largely shaped the
focus of this study and allowed me to approach the study with some form of knowledge to be
culturally sensitive in the ways of addressing specific topics during the conversations with
service providers.
4.4. Analysis Results
The results presented in this section are based on fifteen interviews with homeless service
providers. Table 4.2 provides a description of the major themes and categories that emerged from
the ongoing review, refinement, and revisions in the analytical process. It is important to note
that the findings presented in this section are predominantly based on responses from private-
sector providers as a result of limited sharing of information from government and public based
agencies. Additionally, participant responses and views were based on their different
experiences, positionalities, and politics at play, including funding conflicts. The organization of
this analysis section is as follows. First, this section provides a detailed description of the five
major emergent themes: (1) impacts of inaccessibility, (2) impacts of accessibility, (3)
heterogeneity among the unhoused community, (4) service design improvement, and (5) impacts

97

of COVID-19. The first three themes aim to answer the research question focused on
understanding the way WaSH insecurity impacts unhoused communities from the perspective of
service providers. This section concludes with a description of the two remaining themes, service
design and impacts of COVID-19, that helps identify ways in which providers can improve
access to WaSH services to better address the unmet needs of unhoused communities. Following
the presentation of these results, section 4.5 provides a more in depth interpretation and
meanings of these findings.

Table 4.2. Generated themes and descriptions presented in qualitative descriptive interviews

Research question Major theme Code category Description
Question 1:
How does WaSH
insecurity impacts
unhoused communities?
Impacts of
(in)accessibility
Navigating limited access
to WaSH
Recognizing the negative
impacts of poor access to
WaSH services
Health deterioration
Social stigma and
exclusion
Impacts of accessibility Breaking cycle of
homelessness
Recognizing the positive
impacts in improving
access to WaSH services
Sustaining and protecting
life
Heterogeneity among
unhoused communities
Demographic differences Individual level factors
and intersectional
identities that contribute
to added vulnerabilities in
unhoused communities
Intersectional identities
Question 2:
What are ways in which
service providers can
improve access to
services?
Service design
improvement
Quality of services Service level factors
needed to address WaSH
insecurity and other
service needs
Distribution of services
Maintenance of
relationships
Impacts of COVID-19 Reduced access The negative and positive
outcomes that resulted
from the global pandemic Restructure of service
landscape

98

4.4.1. WaSH Insecurity Impacts in Unhoused Communities
From the analysis of the qualitative descriptive data, the three strongest themes that
emerged relevant to the first research question focused in addressing the way WaSH insecurity
impacts unhoused communities includes: (1) impacts of inaccessibility, (2) impacts of
accessibility, and (3) heterogeneity among unhoused communities. Each of these major themes
contribute something different to answer this first research question. This is followed by a
conclusion that ties all three themes and data relevant to answering this first research question.
4.4.1.1. Impacts of WaSH Inaccessibility
The first major theme that emerged from the data is the way inaccessibility of WaSH
services impacts unhoused communities in Los Angeles. This first theme focuses on three
categories including: (a) navigating limited WaSH access, (b) health deterioration, and (c) social
stigmatization, all of which exemplify the detrimental impacts of WaSH inaccessibility from the
perspective of service providers. First, providers describe that in the face of WaSH
inaccessibility, people navigate to find ways in gaining access to these limited services. For
instance, providers describe unhoused people utilize public spaces, including restrooms of parks
and libraries to bathe and access drinking water. This was identified by the Los Angeles Central
Library provider who expresses, “people experiencing homelessness gravitate towards public
spaces, you know parks, libraries… it's pretty common knowledge they do come to libraries to
try to bathe.” In addition, lack of public water infrastructure forces people to navigate limited
WaSH access by depending on gym memberships to obtain drinking water from fountains and
access showers and restrooms. Providers also report that across the City, there are not enough
WaSH services including drinking public fountains and hygiene centers. As a result of this
inaccessibility to WaSH services, people walk and travel long distances to find access to these

99

services in more centralized service hub neighborhoods, such as the community of Skid Row. On
the other hand, providers like the ReFresh Spot and Water Drop LA argue that while Skid Row
has access to services, they are not enough to serve the large unsheltered population and that the
community lacks in particularly clean and safe drinking water infrastructure which results in
unhoused people having to travel long distances outside of the community to purchase bottled
water that for many, it can be an added economic and physical burden.
Additionally, the inaccessibility of WaSH services contributes to the health deterioration
of unhoused people. Service providers, for example, describe that inadequate access to WaSH
services creates emotional distress. In particularly, the limited number of safe public facilities
available overnight creates feelings of fear and anxiety. This is exemplified by the Inner City
Law Center provider who describes, “just talking to a client I remember her saying, ‘can we
continue talking like I have to go use a public restroom at a park?’ She just had me on the phone
with her just because there was a lot of anxiety about those situations.” In other words, the
inability to safely access public restrooms in places like Skid Row can lead to psychosocial
distress, particularly fear of sexual assault seen among unhoused woman navigating limited
WaSH services at certain times of the day. The inaccessibility of WaSH services also creates
public health risks in environments that unhoused communities occupy. Providers state that as a
result of WaSH insecurity and infrequent municipal services, unhoused confront with constant
pest infestations, which can increase their risk to infectious diseases such as typhus and hepatitis
A outbreaks. The ACLU refers to this as a “state created danger” in unhoused communities. In
which the poor investment in public WaSH infrastructure increases health disparities and risks of
infectious diseases and other WaSH related illnesses, which is relevant with the current and
ongoing COVID-19 pandemic. Furthermore, providers state that inadequate access to drinking

100

water, for instance results in other forms of health deterioration, such as heat sickness,
dehydration, and poor medical adherence, more so prominent in the summer time. As the Water
Drop LA provider frames it:
You can survive without a shower, it impacts your health, but you can’t survive without
drinking water… people tap the fire hydrants and that's not clean and if not that, then they
have to spend their own money on paying for gallons [of water] and especially in the
hotter months…Shortage of drinking water is critical to health, especially for people that
are on medications, if they are already struggling with addiction, and even aside from
those health complications, just being outdoors.

Lastly, the inaccessibility of WaSH services in essence creates a cascading effect with
limited access contributing to health deterioration, all of which further amplifies social exclusion
and stigmatization in unhoused communities. This form of cascading effect is best exemplified
by providers stating the longer unhoused people are not able to stay clean and look “presentable”
to society, the more they are socially excluded from public spaces. Experiences of WaSH
insecurity perpetuates social exclusion and stigmatization that unhoused people experience
through the inability to maintain consistent hygiene practices and habits. The People Concern
provider for example states, “when you’re experiencing homelessness, one of the most common
stereotypes, you know, [is that] people are smelly, people are dirty.” On the other hand, Water
Drop LA provider argues the reason people are not able to maintain consistent personal hygiene
practices and are furthered stigmatized for being “dirty and unsanitary” by society is due to “the
City that just perpetuates that and forces that upon them.” Meaning that the disinvestment in
water infrastructure in cities reinforces the social exclusion and stigmatization of unhoused
people in public spaces. Unhoused people have irregular and inconsistent access to showers and
other hygiene services needed to sustain their livelihoods. There is not enough public water
infrastructure across communities in Los Angeles results in people engaging in different survival

101

strategies. Thus, forcing people to navigate in spaces that do not have adequate access to WaSH
services, increases their physical and mental health deterioration, all of which further exacerbates
social exclusion of unhoused communities in public spaces.
4.4.1.2. Impacts of Accessibility
In contrast to the negative impacts of WaSH inaccessibility, this second theme examines
the benefits attributed to the provision of WaSH services. Providers for example, describe the
positive impacts of WaSH accessibility in two ways: (a) breaking the cycle of poverty and (b)
protecting and sustaining life. First, providers describe that by providing access to WaSH
services, it can help in breaking the chain and cycle of homelessness, as these services empowers
people’s self-esteem and motivates people to seek employment and other social services.
According to the Skid Row Housing Trust, having access to WaSH services is one of the most
basic necessities under Maslow’s hierarchy of needs theory (Maslow 1943). In other words,
having access to WaSH can serve as a motivating factor, it can improve people’s self-esteem and
mental health. Similarly, Project Ropa provider describes the access to clean clothes restores
people’s dignity and optimism that can be pivotal in helping break the cycle of homelessness:
You come out and you're clean you put on your clean clothes you have this you know not
only have you restored dignity, but you have this optimism that you kind of feel like you
can conquer the world in a way, and so within that bubble, maybe that's when you go and
you actually look for employment, or you look for housing or you, you know you have a
moment where you, you know you look dignified.

Access to WaSH services is also a critical component in the sustainment and protection
of life. For some providers, the ability to access WaSH services is all about protecting people’s
lives, human rights, and providing people with their most basic necessities. The ACLU
organization, for instance argues the “narrative around water is necessary for life, you’re going to
die, like in one or two days, if you don’t have access to water…so we really need to pay attention

102

to people’s inalienable right to water, right to life.” Meaning, access to WaSH is needed to
improve health outcomes in unhoused communities. But it is also connected to a broader
narrative that access to these services are human rights that are essential to sustain life and daily
activities. Similarly, providers such as Water Drop LA who discusses that “providing water
infrastructure is less so about encouraging homelessness and more so about protecting life.” In
other words, contrary to the social misconception that providing services encourages
homelessness, access to these stop-gap WaSH services instead helps sustain people’s ability to
survive while being unhoused. Furthermore, the access to services helps protect unhoused
people’s health during periods of time that they are living at their most vulnerable.
4.4.1.3. Heterogeneity Among Unhoused Communities
During the interviews, it also became evident from service providers' perspectives that
certain groups among the unhoused are more vulnerable than others. The third emergent theme
in this study is the existing heterogeneity among the unhoused. In other words, a person’s
identity can attribute to an added form of vulnerability and marginalization, on top of being
unhoused, particularly in accessing services. Based on providers perspectives, two
categorizations emerged from the data: (a) demographic characterization differences, and (b)
intersectional vulnerable identities. Table 4.3 highlights the main characterizations mentioned in
the interviews.

Table 4.3 Characterization of marginalized identities among unhoused communities

Characteristic Category Description
Gender Women and transgender people
a
Victims of violence
Prolonged trauma and distrust
Underutilization of services

103

Table 4.3 Continued

Characteristic Category Description
Time of housing insecurity Non-chronically unhoused
(less than 12 months)
Unable to qualify for housing
Underutilization of services
Chronically unhoused
(more than 12 months)
Health deterioration
Struggle with disabling conditions
Age Elderly Victims of violence
Cope with chronic illnesses
Struggle with disabling conditions
Higher risk of homelessness
Ability status Person with a disability Underutilization of services
Victims of violence
Health deterioration
Higher risk of homelessness
Race Black/African American and
Latinx/Hispanic
Racial discrimination
Overrepresentation
Immigration status Undocumented Language barrier
Unable to qualify for services
Underutilization of services

a
While transgender women and men are a marginalized group among the unhoused as shown in existing
literature, in this study they are not well measured and documented in this study. Of the fifteen providers,
only three highlighted the needs of people that identified as transgender. But it is worth including in this
table as transgender individuals experience stigmatization and high risks of poverty and unstable housing
(Fletcher, Kisler, and Reback 2014).
Note: While these were prominent characterizations of marginalized identities service providers reported,
these are not the only identities unhoused people occupy. Other identities, including sexual orientation,
living conditions, history of incarceration, and other factors not examined are important to also consider
when examining intersectional vulnerability among the unhoused.

104

The first categorization that emerged from the data is demographic differences among the
unhoused community. This refers to the different marginalized identities that unhoused people
occupy. Service providers in particularly, identified gender identity and time a person
experiences homelessness to be the two most prominent factors of marginalization and
vulnerability. In terms of gender identity, majority of service providers (N = 10) report unhoused
women to be the most vulnerable group among the unhoused. Providers argue women are more
vulnerable because they are often victims of abuse and physical violence, both in unsheltered and
sheltered living conditions. Due to the amount of violence and trauma women experience,
providers like LavaMae
x
describes, “it takes a lot to bring women [to use our services] because
there is just less trust, because you know getting naked in the shower trailer and by taking a
shower is a very vulnerable thing to do.” Meaning that based on added trauma women
experience while being unhoused, both their gender identity and lived trauma becomes a barrier
in trusting and utilizing available WaSH services. Similarly, some service providers highlighted
that temporary emergency housing programs are spaces where women also experience high
levels of sexual assault and abuse. The ACLU organization, for instance shares the experiences
of their clients by stating, “when women only are given the option between living unsheltered or
being in a shelter, that puts an enormous amount of power in the hands of shelter staff because
they can always threaten women with eviction, [and] the streets are dangerous so women will put
up with sexual harassment. There is also very little oversight in the shelter system.” Thus these
places that are aimed to serve and provide a safe shelter for unhoused people overnight become
places where trauma and violence is perpetuated and reinforced, particularly for women and
other marginalized groups.

105

While majority of service providers identified women to be a particularly vulnerable
group among the unhoused community, three providers suggest that being an unhoused women
can actually be a protective and advantageous identity. One provider in particularly claims that
when it comes to utilizing services, women have an advantage over men because “sometimes a
male can come off as being intimidating as opposed to a young lady.” Meaning that there often is
less compassion and more stigmatization for an unhoused male compared to a woman. Another
provider argues that women, in particularly women with children are often prioritized in housing
entry systems as opposed to single males, the dominant group among the unhoused community.
Furthermore, the vulnerability and differences of access to services based on gender identity are
not black an d while. Violence between men is commonly seen on the streets, particularly
between territory and intimidation, with men who are new to an area or look less intimidating are
subjected to bullying while being on the streets. This type of violence between male to male is
often seen by Project Ropa provider who discusses:
We do see some men who are either new to certain areas and there's a lot of like people
who are like this is my area, kind of vibe to it, like so someone new we've seen like will
come into an area not aware of like what the situation is with whose area is might be, and
we've seen fights because of that, and it's usually skinnier men, who are being bullied by
just more intimidating looking men.

The other major categorization that service providers identified to be a vulnerability for
unhoused people is the duration a person experiences homelessness. Some service providers
highlight that a person experiencing chronic homelessness also cope with chronic illnesses and
health deterioration. Project Ropa provider, for example explains, “you'll see a deterioration
because we've like at the St Francis location we've been there for four plus years so I've seen
certain people kind of the change in them over the course of four years. Not only mentally but
physically.” The same provider argues that for people who are entering homelessness, it can be a

106

vulnerable point in their lives, in particularly “harder for people who are incarcerated and that are
used to a prison system, as that's kind of a vicious cycle, you could be homeless and not have a
record and then you stay homeless and you're going to get a record, you know just from
something silly. And once that happens, like yes, most people are not going to hire you.”
Meaning that criminalization of homelessness not only reinforces a cycle of poverty but also
prevents people from exiting homelessness and qualifying from services. Furthermore, providers
argued that for people who are not chronically unhoused, it can also become a barrier in terms of
qualifying for housing services and access to other resources. Safe Parking LA provider, for
example explains, “the homeless sector is really made up of a system and it's called the
Coordinated Entry System” mandated through LAHSA. This is a common universal assessment
tool used to triage unhoused people in order to connect the most vulnerable and at risk of dying
on the streets to supportive services, including housing. Safe Parking LA provider describes that
“when you complete the assessment your scaled from you know zero to I think sixteen. The
higher you are, the more vulnerability you have and the more access to resources that exists.
When our clients are assessed with this assessment, they're scoring very low [because] this is the
first time that they're homeless.” Meaning that when people are for the first time experiencing
homelessness and not chronically unhoused (more than a year consecutively), it disqualifies
them from access to supportive services, including housing that can help them exit homelessness.
Other providers like Water Drop LA also argue that for those people first timers, it is an added
vulnerability as they may not know where services are available resulting in an underutilization
of resources.
Another main demographic factor identified by service providers is age. In particularly,
senior adults was a common group identified among all service providers to be a vulnerable

107

group experiencing homelessness. According to Safe Parking LA, “we’re seeing the most of is
seniors, we have a lot of clients that are 70-75 years old and they’re living in their
vehicles…folks don’t have savings and are living on very low income with social security.”
Meaning that the elderly, particularly, low-income seniors are at risk of becoming unhoused, and
once they enter homelessness, may not know where to go to seek for services and experience
chronic health deterioration. In addition, people coping with disabilities is another vulnerable
group among the unhoused. Providers argue that for people with disabilities, it can be
particularly difficult to consistently access WaSH services and engage on personal hygiene
practices. This is exemplified by ACLU’s who describes, “the most vulnerable people are frail
older adults. People dependent adults, which would be people with disabilities, they have to
depend on others to engage like activities of daily living, like toileting or showering.” In other
words, adults struggling with a disabling conditions and chronic illnesses can become a barrier
for them when conducting daily personal activities. Often depending on others to help with
obtaining drinking water or bathing. Additionally, people coping with disabilities also limited by
whether facilities are at close proximity to them and can provide services that are accessible to
meet their basic needs.
Lastly, race and ethnicity, and legal status were other demographic characterizations of
vulnerability among the unhoused. While surprisingly not a major factor reported, five providers
highlight that race becomes a vulnerability factor for specific people, particularly for Black and
Latinx communities that often experience discrimination against on the streets and when trying
to access services. LavaMae
x
provider for instance states, “Black people in LA County are only 8
percent of the [general] population, but they’re 34 percent of people who are homeless, so that’s
a huge disproportion.” This provider alludes to the systemic racism that exist in communities and

108

that plays a role in the access to services available to serve these communities. In other instances,
providers argue that race can be a protective factor depending on the location. For instance, a
provider mentioned that in Skid Row, race can become a protective factor if you are the
dominant race but a vulnerability if you are the minority. At the same time, a person’s legal
status can also become a barrier and vulnerability for unhoused people. Water Drop LA, for
instance explains that undocumented unhoused people have trouble gaining access to housing
stating, “no systems will support you and that no people, no shelters will take undocumented
folks and … the only way that we've been able to support people in those situations is by
connecting them to [our] personal network.” In other words, a person who is both undocumented
and unhoused encounters more barriers in exiting homelessness and in existing in public spaces
that criminalizes them for their citizenship status.
In digging deeper into these demographic vulnerabilities from service providers
perspectives, it was noted that these are not singular, rather unhoused people occupy multiple
intersectional vulnerable identities. These intersectional identities are observed when examining
gender and duration a person experiences homelessness. In particularly, elderly women with a
prolonged time experiencing homelessness is a critical marginalized group among the unhoused.
For example, the Water Drop LA organization states, “single women who struggle with mental
health or with physical disability are especially targeted because they don't have any means of
defending themselves.” Similarly, Project Ropa describes the prolonged duration of people
experiencing homelessness results in higher risk for chronic and disabling health conditions as
one of the few women clients they serve progressively became blind. Project Ropa describes this
added form of vulnerability stating, “being blind is a whole separate thing and being a woman,
you know that's completely vulnerable you're literally dependent on everybody now.” These

109

intersectional identities create further barriers for women, living in unhoused conditions and
coping with disabilities to navigate access to services but also in exiting homelessness because
they are not able to work and pay rent, forcing them to live on the streets exacerbating their
health deterioration.
Other intersectional identities that emerged from the data is duration a person experiences
housing insecurity and coping with a disability or a non-citizen status. Providers such as Safe
Parking LA for example state, “it’s a lot faster if they are chronically homeless and suffering
from mental illness, suffering from substance abuse” to be connected in the coordinated entry
system to access services. In other words, people that have less than two years experiencing
homelessness and that do not have chronic illnesses are less likely to quality and be prioritized in
permanent and supportive housing programs. At the same time, providers like Water Drop LA
shed light to struggles for new arrivals, particularly undocumented unhoused families and
individuals that “don't speak the language, don't know where to go, are fully disoriented and then
there's also a significant amount of anti-Latinx sentiment that's on Skid Row.” Legal status and
first timers experiencing homelessness contributes to added vulnerabilities in accessing services
and surviving living on the streets.
4.4.1.4. Research Question 1: Impacts of WaSH Insecurity
In examining each of the three major themes discussed above, impacts of inaccessibility,
impacts of accessibility, and heterogeneity among the unhoused, different characterizations of
WaSH insecurity impacts emerge. For one, these themes reveal that WaSH insecurity impacts
people’s mental and physical health, exacerbates social exclusion due to the inability to maintain
consistent hygiene practices, and reinforces cycle of poverty. But these impacts are experienced
differently among the community with providers highlighting that vulnerable groups exists

110

among the unhoused and while providers did not explicitly address the multiple intersectional
identities unhoused people occupy, these issues emerged and became obvious during the
thematic analytical process. In particularly, providers identified that elderly women coping
disabilities and undocumented people experiencing homelessness for the first time are the most
vulnerable in accessing services. Second, understanding these three themes also highlight the
importance and need for safe spaces and improved access to services for vulnerable groups that
remain underserved, particularly services catering for the elderly, women, and undocumented
unhoused people. Lastly, from these themes we gather the importance of addressing interim level
services to improve the living conditions and health of unhoused communities while also break a
cycle of poverty that is reinforced with the inaccessibility to essential services.
4.4.2. Improving Access to Services
In the analysis of the data, two additional themes emerged relevant to addressing the
second research question focused on what can service providers do to improve access to WaSH
services. These two major themes includes: (1) service design improvement and (2) impacts of
COVID-19 pandemic. These two themes describe the importance of creating intentional services
that better cater to the different needs of the unhoused community, while also acknowledging
existing challenges in the face of the current global pandemic. Following the description of these
two major themes, this subsection concludes with a summary that connects these themes together
to provide the answer to the second research question.
4.4.2.1. Service Design Improvement
In this study, providers identified service design improvement as a major factor to
integrate in order to improve delivery of service to unhoused communities. Providers in
particularly identified three key areas where improvements are needed including: (a) quality of

111

services, (b) distribution of services, and (c) maintenance of collaborations. The first area
providers highlights needs improvement is the quality of existing programs serving unhoused
communities. Different providers highlight that quality of services can be improved through
community engagement to from relationships, build rapport, and receive input to better know the
types of services people need and will actually utilize. The ACLU organization for example,
argues about the importance of community engagement is to ensure unhoused people utilize the
services that providers can offer. A lack of community engagement results in poorly executed
interventions and ineffective services that people do not end up engaging. Water Drop LA
provider for instance, argues “the City installed fountains, they dropped them across Skid Row in
parts that are not densely populated and then didn’t do outreach to actually tell people that
they’re allowed to use them.” These fountains Water Drop LA describes are also not properly
maintained resulting in people distrusting using these water fountains due to their cleanliness
levels and not located in the proximity of encampments. On the other hand, when the community
is involved in the design of services, it can lead to effective programs exemplified by the success
of the ReFresh Spot, a community based advocacy project that included the voices and opinions
from the community and that now provides access to 24-hour run WaSH facilities.
Improving the quality of services aimed to serve unhoused communities also requires the
re-design and de-institutionalization of existing and future services. Providers highlighted that
improving access to services requires a shift in the design. What this refers to is that in
communities like Skid Row, shelter systems are often times reminiscent of “prisons” and
“institutions” that historically were designed only to service men. According to Lorcan
O’Herlihy Architects provider, some of the shelter systems that provide publicly available WaSH
services are also “consistently are out of service” or have “open shower systems” that lack

112

privacy and reminiscent of institutionalized systems that discourages people from using them
because it may be reminders of places they want to escape.
In contrast, the ReFresh Spot provider explains that involving and engagement with the
community led to a more humane design process of the services they currently provide to the
Skid Row community. For instance, the ReFresh Spot has greeters at the entrance of their
facilities to make their guests feel welcome and “have the option to check their bicycles or large
belongings…so that way they know their things are being held safely, while they’re utilizing the
services.” The ReFresh Spot is also currently working towards developing women-only service
hours to create safer spaces for women, a predominantly vulnerable group as mentioned in the
first research question of this study. This is significant as in Skid Row there is only one
organization (currently Downtown Women’s Center) solely focused in providing women with
services Furthermore, the ReFresh Spot, continues to be intentional with the way they serve the
community by partnering with a ride sharing company to provide free and safe access to
transportation to unhoused people, particularly helpful for people coping with physical
disabilities and that need to constantly visit the doctor or commute to places. Similarly, Laundry
Truck LA acknowledges that WaSH insecurity experiences affect women and families
differently and as such the organization is working towards expanding their services to reach
these vulnerable populations. Other mobile hygiene service providers also acknowledge
language barriers and have modified the design of communicating to the community with some
even translating flyers with information in other languages to break the language barriers that
exist among some unhoused groups, particularly newcomers that are not aware where services
are located.

113

In addition, service providers describe that design improvements are needed in the
distribution of services across communities. In other words, there are service providers that are
predominantly serving the community of Skid Row whereas others shy away from serving
encampment areas and prefer to work in a collaborative manner with established organizations
often located outside Skid Row. The Laundry Truck LA provider, for instance describes, “it's a
little bit challenging at the moment because some of the encampments are dangerous and right
now it's just a little bit, just a lot of things happening in that community [Skid Row] but anyway,
that is my goal for the year and we will we will figure it out. We are right now in mostly on the
east side and in downtown…servicing shelters and a combination of shelters and Project
RoomKey sites.” Thus for providers like Laundry Truck LA and other mobile hygiene providers,
the distribution of their services are facilitated on safety measures, and other logistics including
working with other providers that have already establish operations and can access drainage and
water connections to provide their services.
The building of partnerships is also another pivotal strategy for improving delivery of
services in unhoused communities. Providers such as Project Ropa explains the distribution of
their services is intentional by stating, “with our mobile van, we're always in tandem with mobile
showers, and so that's intentional…if you're taking a shower and you go back into your dirty
clothes it defeats the point of the shower.” In other words, the building of partnerships between
providers is intentional in helping fill gaps in continuum of care services. In particularly, the
provision of WaSH services becomes an additional service, auxiliary service for the community.
Similarly, the ReFresh Spot partners with different organizations on site to fill gaps in services
and to reduce transportation barriers by collaborating with legal clinics, needle exchange
programs, and ride sharing companies. Safe Parking LA is another provider that not only

114

provides people living in vehicles with a safe space to park and sleep overnight, but also works
with mobile hygiene services, libraries, and gyms to connect their guest to WaSH services
overnight. The building of partnerships to distribute and fill gaps in services, however, is often
challenging as experienced by the public Central Library of Los Angeles. Faced with opposition,
the public library employee describes, “the downtown business improvement district was not
happy with having LavaMae
x
at the library. They felt like we were going to draw people in from
Skid Row that they didn't want there. which frankly made me, really, really upset. Very short
sighted that particular group.” This added challenges providers are confronted when trying to
build partnerships alludes to problematic policy of containment and preventing expansion of
services outside of Skid Row boundaries.
Lastly, service providers highlight the importance of maintaining relationships with the
community to improve access to services. This refers to not only engaging with the community
as mentioned earlier, but in preventing disruption of formed relationships. Specifically, providers
describe that encampment sweeps are an example of a disruption of already formed relationships
and connections between services providers and unhoused people. Ten of the fifteen providers
mentioned that encampment street sweeps displaces people, causes people to further distrust
systems, and disrupts people’s access to mainstream services. Project Ropa, as an example
highlights, “the City got rid of the encampments on the [Echo Park] lake, before that, we were
serving 40-50 people…[now] it went down to 25 or so.” In other words, street sweeps disrupts
the formed connections between providers and the community. Additionally, LavaMaex provider
argues, “when people are worried about their belongings and they're worried about people
throwing their stuff away, they don't want to come, have access to showers because they want
their stuff.” This suggests that encampment sweeps disrupts people’s abilities to access services

115

due to induced fear of losing their belongings and needing to constantly protect their living
spaces. In other instances, providers highlight the maintenance of relationships can be improved
by diversifying the workforce and connecting with people at a human level to build rapport with
the community. LavaMae
x
, for instance, recommends for outreach workers and government
agencies to diversity their staff to connect better with the communities they serve by stating,
“that’s really important to have somebody you can trust that looks like you.”
4.4.2.2. Impacts of COVID-19
The recent global pandemic has also attributed to added resource stress and scarcity in
unhoused communities which leads to the last theme in this study, impacts of COVID-19
pandemic. Service providers interviewed indicated both positive and negative impacts of
COVID-19. First, the positive impact attributed to the pandemic has been the increased attention
towards the importance to provide access to WaSH and has even forced organizations to be more
creative in how these services are provided during a pandemic. LavaMae
x
provider reports, “do it
yourself hand washing stations was born out of COVID, so it was an opportunity for us to be
more creative and an opportunity for us to see how we can make access more accessible.” At the
same time, during the pandemic, public health organizations have made it clear that access to
hygiene is a critical way to prevent the spread of the virus, thus important in improving access to
WaSH services across vulnerable communities. These changes of attitude are also reflected in
the Skid Row Housing Trust provider who describes, “the heightened hypersensitivity didn't
come until COVID hit into where we have this concern now of whether folks are getting
adequate water, adequate hygiene.” In other words, WaSH insecurity has existed prior to the
pandemic, but this public health crisis has increased awareness that those communities with less
access to WaSH may have the most acute effects and thus important to address unmet needs of

116

people. The Recreation and Parks department provider also explains that as a result of the
COVID-19 pandemic, they extended their hours of operation to address unmet needs. A similar
expansion of hygiene services was seen in Laundry Truck LA provider that they received added
support from the City to serve shelters and Project Roomkey sites to fill gaps in access to WaSH
services during the pandemic.
While the COVID-19 pandemic raised awareness to the WaSH insecurity experiences of
unhoused people, providers argued that for the most part it negatively them (service providers) in
delivering services and the unhoused community in accessing them. For example, the pandemic
caused a reduction of services available in the community through the closure of spaces such as
libraries, restaurants, gyms, and other facilities that unhoused people typically resort utilizing to
obtain their daily WaSH needs. The Water Drop LA provider states, “the missions [taped off
their] water fountains” at the start of the pandemic to reduce risk of infection transmission. This
severely restricted access to drinking water in a community with already confronted with scarce
facilities. Similarly, LavaMae
x
provider states that at the start of the pandemic, “a lot of them
initially didn't know what was going on. Initially during COVID, they just knew everybody was
off the streets and because we went out and we were like what's going on? Can you get this?
They're like no, we can't even get can we get some water like we can't even get water out here.”
The pandemic resulted is an abrupt disruption of access to WaSH in communities that already
faced with so much deprivation, causing added trauma on top of the trauma experience while
being unhoused. While some services were forced to reduce the capacity of services or shut
down completely, the People Concern provider reported that they had to re-adjust their program
to be able to continue to provide services to the community and was the only hygiene center
available 24-hours in the community of Skid Row at the start of the pandemic.

117

4.4.2.3. Research Question 2: Ways to Improve Access to Services
To answer the second research question of this chapter study, focused on what can
service providers do to improve access to services, two major themes emerged, service design
improvement and impacts of COVID-19. For starters, these two themes reveal that the delivery
and access to services can be improved through community engagement, de-institutionalization
of services, and building of partnerships. Addressing these factors are crucial in facilitating the
process of properly designing services that are both effective and utilized by the community.
Some of the providers interviewed in this study are working to restructuring their services to
allocate to serve vulnerable groups, including allocating women-only hours in order to provide
safe spaces for unhoused women to access services. Providers also highlight that improving
access to services requires creativity during times of a global health crisis and strong partnerships
to work in tandem to fulfill continuum of care services needed in the community. Furthermore,
improving access to services requires for decriminalization of homelessness and shifting away
from encampment sweeps that result in disruptions of community-built networks and access to
fundamental services.
4.5. Interpretation of Findings
In this descriptive qualitative study, the perspective and views of fifteen service providers
are examined to better understand the way WaSH insecurity impacts unhoused communities and
where is room for improvement in the provision and delivery of services. While majority of the
views presented in this study come from private sector providers, the findings remain significant
in raising evidence to support the need to improve access to WaSH services. From the five
themes that emerged from the data, this discussion section begins with a contextualization of the
findings that supports the first research question focused on impacts of WaSH insecurity. This is

118

followed by a discussion on the implications of service improvement. The discussion ends with
informing policy recommendations and addresses the study limitations.
4.5.1. WaSH Insecurity Impacts in Unhoused Communities
In addressing the first research question focused on understanding the impacts of WaSH
insecurity in unhoused communities from the point of view of service providers, three main
themes emerged from the data. These three themes includes, impacts of inaccessibility, impacts
of accessibility, and heterogeneity. In examining these three themes, findings from this study
suggest that impacts of WaSH insecurity experiences among the unhoused may differ greatly
based on individual-level characteristics. These individual level characteristics unveils the
diverse struggles and vulnerabilities of unhoused people. In other words, unhoused people
occupy multiple marginalized identities based on their gender identity, duration a person
experiences homelessness, age, disability status, race, and citizenship status among other
identities of difference. This is seen in existing studies that highlight the intersectional
vulnerabilities of unhoused communities (Goodling 2020; Lurie, Schuster, and Rankin 2015;
Otiniano Verissimo et al. 2021). In Goodling (2020) study, for example, using a national survey
with unhoused community representatives, examines the cycle of criminalization that pushes
unhoused people into hazardous spaces, highlighting that sweeps exposes people to hazards that
are magnified based on people’s identities. Similarly, Otiniano Verissimo et al. (2021) examines
the intersectional vulnerabilities of unhoused communities using national surveys conducted with
housed adults across the US. This study argues that that unhoused communities experience
intersectional discrimination, particularly communities of color including, Black, Indigenous,
and Latinx communities that not only have a higher risk of experiencing homelessness but have
added challenges in accessing services and in exiting homelessness (Otiniano Verissimo et al.

119

2021). While these studies have focused on addressing intersectional vulnerabilities among the
unhoused, this is one of the first to connect these issues with WaSH insecurity experiences in
Los Angeles, an area that remains incredibly underexplored yet has one of the highest counts of
unsheltered unhoused people across the nation (Henry et al. 2021). The findings from this
chapter study also integrates the views and perceptions of service providers that have experience
serving the unhoused community with the community and have seen the added challenges
imposed by experiences of WaSH insecurity in the City.
In further understanding the impacts of WaSH insecurity, it is important to dig deeper
into these intersectional vulnerabilities that impacts the way unhoused communities gain access
to services and impacts their ability to exit homelessness. Goodling’s (2020) work, for example
exposes the exponential burdens for vulnerable groups, including the elderly with disabilities,
women, transgender people, and people of color using the perspective of unhoused community
leaders and grassroot organization. Goodling (2020) findings suggest that street sweeps results in
elderly people with disabilities being at risk of losing their belongings including walkers and
wheelchairs, contributing to added challenges in accessing WaSH services due to limited
mobility (Goodling 2020). Similarly, providers in this chapter study highlight the vulnerability
elderly unhoused people encounter, from risk of physical abuse, health deterioration, and
inability to access services due to physical and mental health disabilities. In San Francisco, a
report by the Coalition on Homelessness found added challenges during the COVID-19
pandemic for unhoused people to access drinking water at grocery stores or restaurants because
of their appearance (Coalition on Homelessness 2021). This report highlights for older adults
coping with physical impairments, fetching for water is a challenge due distance constraints and
fear of losing their belongings in the process of commuting to access WaSH services (Coalition

120

on Homelessness 2021). In Los Angeles, the elderly is a growing group among the unhoused and
addressing impacts of WaSH insecurity can ameliorate the added barriers this vulnerable group
encounter to access services.
In addition to age and disability status vulnerabilities, unhoused people’s access to
services is impacted based on their gender identity. This is also evident in the work of Sommer et
al. (2020) for example, that integrates the perspective of both people with lived experience and
key informants to examine the impacts of inadequate access to WaSH services among unhoused
women in New York City. This study suggests that WaSH insecurity results in women
experiencing added stigmatization, particularly when managing their menstrual cycle, amplifying
social exclusion due to not being able to feel and look clean (Sommer et al. 2020). In reviewing
this study, commonalities are found with this chapter findings. While service providers did not
highlight the challenges for unhoused women to manage their menstrual cycle, providers did
argued that women do encounter added barriers from being victims of sexual assault that results
in a distrust of systems of care, to women developing chronic health conditions that further
impairs their ability to exist homelessness. These vulnerabilities are seen in Hanley et al. (2019)
study that examines the perspectives of unhoused undocumented women in Toronto. Hanley et
al. argues that migrant women with disabilities have a risk of experiencing homelessness, and
once they are unhoused they are faced with added barriers when developing chronic health
conditions that reinforces a cycle of poverty (Hanley et al. 2019). The added trauma and level of
distrust that women develop while experiencing homelessness it is also seen in the work of
Vickery (2018) that argues women coping with mental illnesses are a vulnerable population to
serve due to the extended physical abuse and violence they experienced while living without a
roof, making it difficult for women to seek services. These layers of vulnerability are

121

exemplified in this chapter findings with providers reporting that it takes great efforts for
unhoused women to trust service providers. As a result of this level of distrust, findings from this
chapter study suggests that WaSH insecurity diminishes people's mental and physical health and
can lead to a person experiencing long-term homelessness. The prolongation of homeless is seen
in the work of DeMyers, Warpinski, and Wutich (2017) in Arizona that highlights the views of
people with lived experience and key informants to argue that WaSH insecurity reinforces a
cycle of poverty. Thus it is important to address the multiple marginalized identities of unhoused
people because they unveil the unique disadvantages and disparities in not only exiting
homelessness but also in accessing services compared to people with a single marginalized
identity.
In contrast to the marginalization that unhoused women experience, undocumented men
that are non-chronically unhoused is also another group important to highlight in this discussion.
While unhoused women with multiple marginalized identities are the most vulnerable, men that
are experiencing homelessness for the first time and are undocumented also encounter
challenges. In particularly, undocumented unhoused men have added barriers in accessing and
qualifying for federal subsidized services, including housing. For new arrivals, there is also a
language barrier and lack of knowledge where services are located that results in underutilization
of services. This can be seen in the work Chinchilla and Gabrielian (2020), that integrates the
perspective of service providers in Los Angeles to highlight the compounded marginalization
that unhoused immigrants encounter in seeking services, intersecting with language barrier, fear
of deportation due to their legal status, and discrimination. Vickery (2018) through the lens of
people with lived experience and key informants, also emphasizes the added barrier
undocumented unhoused people encounter in Colorado. In particularly, this study acknowledges

122

undocumented unhoused people underutilize services as a result of fear of deportation, lack of
knowledge of service availability, and discrimination encountered in less diverse cities. In this
chapter study, providers serving unhoused communities also shed light to similar discriminations
that Latinx unhoused communities experience, resulting in race becoming a vulnerable or
protective factor for unhoused people depending on where they reside. For immigrants
experiencing homelessness, Skid Row is a community where they fear violence and experience
discrimination whereas a non-immigrant unhoused person may feel more protective in Skid
Row. Both Goodling (2020) and Otiniano Verissimo et al. (2021), however provide a contrasting
view in their respective studies, arguing that unhoused people of color, particularly Black
unhoused people experience disproportionate levels of discrimination and different forms of
survival mechanism as a result to services available to them. Goodling’s study is the only one
that provides both the perspective of community organizers and grassroot organizations across
the US, whereas Otiniano Verissimo’s study surveys the perspective of housed people across the
US. That being said, depending on the location to which a person finds themselves experiencing
homelessness, race plays a protective role whereas for others, race becomes a marginalized and
vulnerable identity.
All in all, the three themes generated from this study emphasize that WaSH insecurity
impacts unhoused communities through health deterioration, increasing stigmatization, and
reinforcing a cycle of poverty. However, these impacts are experienced differently. Therefore,
taking into consideration an intersectional framework is important in understanding that
heterogeneity exist among the unhoused. Homogenizing unhoused groups erases and obscures
the various converging identities that interact and intersect to create systems of marginalization
or privilege (Crenshaw 1991; Goodling 2020; Vickery 2018).

123

4.5.2. Improving Access to Services
To address the second research question in this study focused on ways service providers
can improve access to services, it is important to highlight the historical design pattern of
services in Los Angeles that are not only increasingly institutionalized facilities but also were
built to predominantly cater a transient male population (Geoffrey Deverteuil 2003; Moore
Sheeley et al. 2021; Stark 1994). As a result, some of the services are not designed to properly
address all of the needs among unhoused community members, including women, families, and
people with disabilities. In thinking of service design improvement, several service providers
stated that engaging with community members has facilitated the process of properly designing
services that are highly utilized and effective. Other providers are working towards breaking
language barriers that exist among some unhoused groups, particularly newcomers that are not
aware where services are located.
Aside from some service providers paying attention to addressing the needs of vulnerable
subgroups among the unhoused, findings from this study also suggest that the distribution of
services plays an important role in improving access to services. The current COVID-19
pandemic has highlighted the importance of having WaSH access to protect people’s health and
disease prevention (McDonald, Spronk, and Chavez 2021). This raised awareness contributed to
the start-up of community driven projects such as Water Drop LA non-profit organization to
provide people with much needed access to potable drinking water, a major scarce resource
throughout Los Angeles’s unhoused community. At the same time, COVID-19 has also impacted
how service providers can deliver essential services to unhoused communities. Therefore,
providers in this study shed light to the importance of partnerships in order to fill gaps of
services in unhoused communities. Providers in this chapter study highlight that the existing
distribution of services is mediated through formed partnerships that allows unhoused people to

124

gain access to multiple services in one place, but these may be limited in number due to funding
constraints and opposition from housed communities. In DeMyers, Warpinski, and Wutich’s
(2017) study in Arizona, for example highlights the constraints service providers have when
serving unhoused communities. This study argues that service providers are limited in the ways
they can operate, being less likely to visit encampment areas that are hidden due to being
perceived as dangerous. This limits the capability of expanding access to essential services in
hard to reach communities that live increasingly further away as a result of encampment sweeps
as seen in Goodling’s (2020) study discussed earlier in this discussion. Goodling’s study also
examines this aspect of accessibility to services, in particularly the author argues that forced
displacement of unhoused people from public spaces and public eye results in people living in
places that may be dangerous and or far from public water fountains and businesses that provide
publicly accessible restrooms and donate water (Goodling 2020). All in all, the redesigning of
services that not only integrates the diverse needs of the community but are also intentional in
the way they operate, can help improve the level of quality and care that is provided to unhoused
communities.
4.5.3. Policy Recommendations
The findings from this study underscores the importance of not only increasing access to
WaSH services in unhoused communities but also in addressing service needs through an
intersectional lens. In thinking of potential policy implications, first it is important to ensure the
is a less fragmented system of care available to unhoused communities. As the findings from this
study demonstrate, access to services can be improved through partnerships and increased
collaborations between providers at both the public and private sectors. Guerrero, Henwood, and
Wenzel (2014), study instance, integrate the perspective of multiple stakeholders in Los Angeles

125

to emphasize the importance of integrated care and access to housing in order to improve health
outcomes in unhoused communities. Similarly, in thinking of redesigning care systems,
particularly focused on providing WaSH services, it is critical encourage collaborations among
service provides and government agencies to transfer knowledge, skillsets, and coordinate of
care to effectively delivery services tailored to the diverse needs of unhoused communities.
It is also critical for continuum of care systems to recognize the right to WaSH. This is
important as it can help fill gaps of existing services and help advocate for the expansion of more
permanent and sustainable solutions, including water infrastructure needed in communities like
Skid Row and across Los Angeles. While majority of the continuum of care in Los Angeles is
focused on the delivery of housing and other specific needs, this study provides evidence that
highlights the importance to also consider WaSH needs of unhoused communities as it
perpetuates a cycle of homelessness and health deterioration. Hale’s (2019) study highlights the
problems with public water infrastructure in cities across the United States. Through integrative
perspective of water experts, activists, and people experiencing homelessness, Hale’s study
suggests that it is not just about the expansion of water infrastructure but also in ensuring that
unhoused people can access these services (Hale 2019). In Los Angeles, water infrastructure in
unhoused communities tends to be temporary, as seen in the provision of public drinking
fountains, often only a few placed in Skid Row and available in the summer time where there is a
spike in temperatures (Hale 2019; Kanbarian 2020; Roy 2016). The problem with such type of
temporary solutions is that there is no accountability, often lacking maintenance, and becoming
unusable for the community. Similarly, unhoused communities lack access to overnight public
restrooms and other sanitation and hygiene services, and this scarcity remains even during the
current global COVID-19 pandemic (The Times Editorial Board 2021). The City instead is

126

considering expanding its Mobile Pit Stop programs (that provides access to restrooms and
shower) so to reduce the cost and risk of vandalization (Ray 2021; The Times Editorial Board
2021). Yet these programs only provide temporary access to services that remain limited in
unhoused communities. Thus, it is critical to invest in more sustainable and permanent solutions
and work towards expanding WaSH services as part of the continuum of care agenda. Successes
can be seen in the ReFresh Spot, LavaMae
x
, and Project Ropa testimonies in this study that
highlight the importance of working in tandem with other systems of care to fill gaps in
provision of services needed in the community at the interim level.
Additionally, findings from this study suggest several other policy recommendations
including the need of redesigning services. Specifically, in speaking with different providers,
findings suggest there is a need for services that tailor to specific sub-groups in unhoused
populations, particularly the most vulnerable. In seeking to expand access to WaSH services, it is
crucial that any interventions engages with people with lived experience in both the design and
implementation process of these program and solutions. In this study, findings demonstrate that
emergency shelters do not adequately serve the community as some of these facilities are
reminiscent of institutions people are trying to escape from, often unsafe for women, families,
and people with disabilities. In the community of Skid Row, the fact that there is only one
organization focused in providing women-only services speaks to the need to expand services to
cater vulnerable groups, including women, elderly, people with disabilities, and undocumented
people. The work of Dickins et al. (2020), for instance highlight the vulnerability of aging
unhoused women, a fast growing group among the unhoused. Through an integrative review of
existing studies, Dickins et al. argue that unhoused women in the US endure a disproportionate
burden compared housed women, facing increased risk for injuries and illness, trauma, and

127

physical abuse (Dickins et al. 2020). In communities like Skid Row, the City should also expand
efforts towards ensuring women the right to adequate living and access to WaSH as recognized
in Article 14 of the Convention on the Elimination of All Forms of Discrimination Against
Women (UN General Assembly 1979). Providers at both the public and private sector, alongside
government agencies need to consider other barriers among unhoused people, including language
barriers among undocumented unhoused people that limits their knowledge and access to
services. This is exemplified in the work of Chinchilla and Gabrielian (2020) that argued Latinx
communities in Los Angeles have distinct vulnerabilities related to their immigration status,
language barriers, and socioeconomic status. Therefore, continuum of care services need to break
language and cultural barriers to better service Latinx communities that are unhoused or at risk
of entering homelessness (Chinchilla and Gabrielian 2020; Speak 2010; Tsai and Gu 2019).
Other considerations includes diversifying the work force in order for unhoused people to be able
to better connect and communicate with providers. Addressing these issues will result in more
utilization and acceptability of existing services because while the number of WaSH facilities is
clearly a key barrier, it is critical making access and use of these services less burdensome and
safe for vulnerable groups.
Furthermore, the study highlights the importance of sustaining connections between
providers and unhoused people. Specifically, this study emphasizes the need for programs that
better serve unhoused communities, shifting away from those that criminalizes homelessness. In
the City of Los Angeles, for example, there are not enough shelter beds for the total number of
unsheltered people residing in the area (LAHSA 2021a). As such, cities should at the interim
level allow for people to live in encampments while also providing them with access to
fundamental services, instead of resorting to forms of intimidation through anti-camping

128

ordinances and encampment sweeps (Zahniser and Oreskes 2021). The National Coalition for the
Homeless, also reports that across the nation, encampment sweeps have increased including in
Dallas, Seattle, San Francisco, and Washington (National Coalition for the Homeless 2016). This
report highlights that sweeps contribute to displacement instead of connections to services.
Therefore, solutions that decriminalize homelessness are needed, particularly at the interim level,
such as providing unhoused people with WaSH services needed and consistent access to
municipal services. Investing in more humane solutions can also facilitate the development of
effective programs such as the ReFresh Spot that is community driven and provide people with
safe access to services that improves people’s health.
4.5.4. Strengths and Limitations
This study has contributed to filling gaps in literature of WaSH insecurity affecting
unhoused communities, particularly by including the perspective of service providers that
directly and indirectly work with these communities. A strength of this study therefore includes
the inclusion from different public and private sector providers in Los Angeles, an area that also
remains underexplored. The issue focused in this study is also timely as the COVID-19
pandemic has changed the landscape of services available. At the same time, it is important to
note some of the study limitations. First, challenges presented during the ongoing COVID-19
pandemic limited recruitment and interviews to be done online, which resulted in a small sample
size. Additionally, the providers interviewed in this study only represent a fraction of the number
of existing providers serving the Los Angeles area. As a result, some of the points of view of
service providers were likely missed. Furthermore, majority of the knowledge generated in this
study comes from the views of private sector providers, with some limited in sharing information
due to depending on City funding to continue providing their services. Of the three public sector

129

service providers interviewed, one was unwilling to share much information due to ongoing
litigations and to maintain their reputation. Therefore, it is important to recognize in this study
the webs of relationships between service providers, with majority of the participating providers
coming from the private and non-profit sector, with some not being comfortable with sharing
criticisms on what the City and County are doing correctly to address WaSH insecurity and the
homelessness crisis.
To further explore the experiences of WaSH insecurity in unhoused communities in Los
Angeles, future studies should consider a longitudinal study design. A longitudinal study design
can better characterize the fast-changing service landscape in the City. This is particularly
important due to changes in laws and expiration of contracts with existing services both at the
public and private sector. Lastly, future research should more explicitly integrate an
intersectionality lens to consider the differing effects of WaSH insecurity to raise awareness to
issues of equity, marginalization, and discrimination that exist at the individual and structural
level. In particularly, it is important to highlight other marginalized identities and groups of
people, including people that identify as transgender, as this study was limited in not capturing in
more detail providers perceptions on this population. Examining the experiences of other
marginalized groups not examined in this study is important as it can help us further understand
and acknowledge the added vulnerabilities people experience in accessing services and in exiting
homelessness.
4.6. Conclusion
The impacts of WaSH insecurity on unhoused communities remain an underexplored
area of study, particularly in Los Angeles, a City with one of the highest unsheltered
homelessness rates across the nation. As the demand for shelter beds and shortage of affordable

130

housing continues to increase, it is necessary to explore interim level services unhoused
communities need to sustain their livelihoods and reduce the risk of infectious diseases in a
COVID-19 pandemic era. As a result, the purpose of this qualitative study was to understand
service providers accounts and perspectives working with unhoused communities to identify
intervention developments to address WaSH insecurity. Main themes generated from these
descriptive interviews included: (1) impacts of inaccessibility, (2) impacts of accessibility, (3)
heterogeneity among the unhoused community, (4) service design improvement, and (5) impacts
of COVID-19. Within these themes, individual-level and structural-level characteristics emerged
that can significantly help better address the differential experiences of unhoused people while at
the same time help improve people’s access to fundamental services.
Overall, the findings from this study shed light on factors that service providers perceive
to be important in addressing WaSH insecurity and the needs of unhoused communities. First,
interview results with service providers confirm that WaSH insecurity does impact unhoused
communities and that as a result of the pandemic, more attention has been given to the provision
of WaSH. Service providers also confirmed that population vulnerabilities exist in among
unhoused groups not only when accessing services but also when surviving living without a roof.
In particularly, women, the elderly, undocumented unhoused immigrants, non-chronically
homeless people are all marginalized groups in the community. Lastly, service providers shed
light on service-level factors that need to be accounted for to improve services, including the de-
institutionalization of services and the importance to engaging with the community to receive
feedback in the design of services. While housing is the end goal in addressing the homelessness
crisis, it is crucial to also advocate for interim level services needed by the community. The
findings from this study aims to provide additional data as to why safe, affordable, and equitable

131

access to WaSH services is essential for human dignity and the maintenance of personal and
public health. At the same time, increasing access to these fundamental services also entails for
providers to be intentional and take into consideration the multiple marginalized identities that
exist among the unhoused. Homogenizing people experiencing homelessness erases the diverse
identities and everyday struggles they are confronted while being on the streets. Thus, improving
access to services requires a better understanding of the lived experiences of unhoused people
and not only expand services but intentionality to accommodate the needs of diverse groups of
people whose needs are not fully represented and being addressed. Incorporating an
intersectional analysis thus challenges the status quo and can help us better understand
underserved populations while also help improve access to fundamental services. That being
said, providers are faced with numerous constrains to which they have to operate, including
funding that restricts their ability to expand services, community opposition that restricts
providers ability to serve communities, and anti-homelessness laws that disrupt connections with
the community. Therefore, changes in the provision of services requires a change in city policies
and County level support to give providers the ability to think more creatively and have the
resources that enables them to accommodate the needs of diverse unhoused communities.

132

Chapter 5 Conclusion
In addressing homelessness, there is no “one size fits all” solution. While expanding access to
permanent and affordable housing is crucial in tackling homelessness, it should not be seen as
the only solution. There must be support at all levels of the spectrum of homelessness, from the
time people are at risk becoming unhoused, to the interim level of when people are experiencing
homelessness, up to point when people are exiting homelessness and are re-entering housing. In
this dissertation, I addressed the interim level service needs as they relate to water, sanitation,
and hygiene (WaSH) services in Los Angeles, which was previously underexplored.
Each section of this dissertation sheds light on how a reinforced cycle of poverty can be
attributed to WaSH insecurity. WaSH insecurity is not phenomenon restricted to the global South
as the literature suggests; it also disproportionally affects marginalized unhoused communities of
Los Angeles, California, USA (Chapter 2). In seeking to understand the importance of WaSH
insecurity, I dig deeper into differences that occur in accessing WaSH between the individual
and service levels (Chapter 3). These barriers to access are validated by the perspectives and
perceptions of service providers, which must also be incorporated when seeking to improve, (1)
WaSH accessibility and (2) the quality and effectiveness of services (Chapter 4). Overall,
findings from these chapter studies suggest that addressing WaSH insecurity plays a pivotal role
in reinforcing the cycle of poverty and homelessness. In other words, WaSH insecurity
exacerbates stigmatization, raises barriers in seeking out services, and negatively affects mental
and physical health. These factors can each play a critical role in a person experiencing long-
term homelessness. In the following sections of this conclusion, I will summarize the
contributions and connections of each study, the broader implications, and future research/policy
directions.

133

5.1. Contributions and Connections
Across these dissertation chapter studies, I identified commonalities that help deepen our
understanding of the WaSH insecurity experiences among the unhoused communities and the
struggles of access and service delivery found in these communities of Los Angeles. In Chapter
2, the study sheds light to coping strategies unhoused people use as a result of WaSH insecurity.
Chapter 3 study digs deeper by examining differences in WaSH insecurity experiences using
sub-populations of different unhoused communities of Los Angeles. Lastly, Chapter 4 recognizes
the impacts of WaSH insecurity outlined in the first two studies from the perspective of
providers, highlighting what improvements are needed to better serve unhoused communities. In
examining these study contributions, four connections emerge including, the importance of
interim-level WaSH services, reinforcement cycle of poverty, diverse needs among the
unhoused, and implications of service design improvements moving forward.
First, each of these studies suggest that WaSH insecurity needs to be part of the
continuum of care agenda in addressing homelessness. Specifically, each of these studies
highlight the importance of providing interim-level WaSH interventions to better meet people’s
basic needs and improve public health, in communities that experience constant deprivations.
This is exemplified in the first two studies (Chapter 2 and 3) in which both examine WaSH
insecurity from the perspective of people with lived experience. Findings from these two studies
suggest that in different unhoused communities across Los Angeles, there is no consistent,
affordable, and safe access to WaSH services. Chapter 4 delves deeper into the issues raised in
the earlier studies by expanding the analytical lens to include the perspective of service
providers. The findings from chapter 4 also come to the same conclusion that WaSH services are

134

needed at the interim level of when people are experiencing homelessness and failure to address
these needs could contribute to prolonged cycle of homelessness.
Second, findings from the three dissertation studies make this connection between WaSH
insecurity and a reinforced cycle of poverty. This is seen through the perspectives of both
unhoused people and service providers. In Chapter 3, for instance, the unhoused community
surveyed reported being forced to spend time and energy trying to find access to WaSH services,
particularly in areas where there are few if any overnight public facilities. All of which
contributed to added barriers for unhoused people to move up the latter, seek other supportive
services, and exit homelessness. Similarly in Chapter 4, service providers argued that unhoused
people have to travel long distances to access WaSH services. Service providers in Chapter 4
also argued that the inability for unhoused people to consistently access services further
marginalizes them by not being able to keep up with daily hygiene practices, look “presentable”
and be employed, overall impeding their ability to exit homelessness. Providers in Chapter 4 also
come to suggest that a cycle of poverty is perpetuated by the lack of investment in water
infrastructure at the County and City level and this is seen in Chapter 2 and 3 with the lack of
services in different parts of Los Angeles beyond the Skid Row community boundaries. The
health deterioration that providers mentioned in Chapter 4 is also explored in the first chapter
study with unhoused people reporting dehydration and other heat stress related illnesses that
create added health deterioration and barriers in exiting homelessness.
Furthermore, the importance of heterogeneity among the unhoused is a recurring theme
among all the three chapter studies, emphasizing that when seeking to effectively address
homelessness, a one size solution will not fit all. This is particularly reflected in the last two
studies (Chapter 3 and 4), that address individual level factors of vulnerability. While these two

135

chapters utilize different perspectives, one examining the experiences of unhoused people
(Chapter 3), whereas the other examining the perspectives of service providers (Chapter 4), they
both come to similar conclusions in that individual characteristics and vulnerabilities shape
access patterns for unhoused people. While Chapter 3 did not find strong statistical evidence to
suggest that gender differences exist in access to WaSH, providers in Chapter 4, do acknowledge
gender differences exist among the unhoused, with women and undocumented unhoused people
being two of the most vulnerable groups highlighted. Both studies do show that length of
homelessness and age are added vulnerabilities when accessing WaSH services. Chapter 4,
however, adds an extra layer of analysis by examining intersectional vulnerabilities among the
unhoused, suggesting that non-chronically undocumented people and elderly women with
disabilities being two major groups that encounter difficulties accessing services and exiting
homelessness.
Lastly, the three chapter studies emphasize the importance of improving access to WaSH
services. In particularly, the three study findings shed light to the need to not only expand
services but also to be intentional in the design and delivery process. Chapter 2 for example,
sheds light to the challenges and survival strategies people embark as a result of inaccessibility
of services. Whereas in Chapter 3 and 4 examines, service level factors are examined more in
depth to understand how to further improve access and delivery of services. In chapter 3, the
findings of the study demonstrates the distribution, quality, and design of WaSH services
perpetuates social inequalities by excluding access to services in public spaces that unhoused
people inhabit (i.e., criminalizing people for their coping strategies in response to unjust
environments). Specifically, the findings suggest that while distance of services plays a role in
the way people choose to access services, it is not the main contributing factor. Other issues play

136

a role including, safety, staffing at the facilities, and affordability. Similarly, services providers
in Chapter 4 study suggest that increasing access to services is only part of the solution. Meaning
that for programs and services to be effective and useful, it requires a more thoughtful and
integrative process with the unhoused community. Both of these chapter studies come to similar
conclusions in that more programs like the ReFresh Spot are effective and needed more because
they are intentional, safe, and involve the community in the development and design process.
While each of the chapters makes a separate contribution and integrate different
perspectives (those of people with lived experience of homelessness and service providers), they
come to similar conclusions in that WaSH insecurity has detrimental impacts in the community.
Overall, findings from all three chapter studies seek to advocate for an investment of water
infrastructure that can provide unhoused communities with safe, affordable, equitable, and
reliable access to WaSH.
5.2. Policy Recommendations
Based on the findings of these three studies, in this section I outline different policy
implications. First, in 2002 the UN’s Committee on Economic, Social and Cultural Rights in
adopted its General Comment 15 that recognizes the right to water, defined as the right to
accessible, affordable, sufficient, and safe water for personal and domestic use (UN Committee
on Economic Social and Cultural Rights (CESCR) 2003). This human right to water is
recognized at the state level with California’s Assembly Bill (AB) 685, which states, “every
human being has the right to safe, clean, affordable, and accessible water adequate for human
consumption, cooking, and sanitary purposes” (The Environmental Law Clinic (ELC) and the
Environmental Justice Coalition for Water (EJWC) 2018). While this bill recognizes this human
right, it does not provide any concrete solutions as to how this can be fulfilled at the county and

137

local level. Specifically, this human right to WaSH remains unfulfilled by unhoused
communities. At the county and city level, there are no clear guidelines and enforcement of this
bill. Therefore, at the State level, there should be clear standards for local governments to
comply with. A starting point could be the UN’s guidelines for WaSH access in refugee camps.
Under these guidelines, Skid Row would have one restroom per 20 persons, one shower per 50
persons, one water fountain per 80 persons, and one trash can per 50 persons. Additionally, the
state and local government should be responsible for investing in permanent WaSH
infrastructure.
Currently, local governments such as the City of Los Angeles, are investing in street
sweeps that are both detrimental to the community and costly. In the fiscal year of 2019-2020,
for example, the City allocated roughly 24 million dollars on street clean-up programs alone
(City of Los Angeles 2019). A major factor that is driving this action is political pressure, as
constituents are opposed to encampments in their neighborhoods. However, forcibly destroying
encampments remains an unsustainable and ineffective solution, as tax payer funds are
effectively paying for criminalization. Community residents, government agencies, businesses,
service providers, and unhoused community members are better served by solutions that do not
marginalize and stigmatize unhoused people, and instead focus on addressing the structural
factors contributing to homelessness (United States Interagency Council on Homelessness
(USICH) 2012). Other forms of anti-homelessness laws and policies (sweeps, Los Angeles
Municipal Code (L.A.M.C.) 41.18(d), which outlaws sitting/sleeping on sidewalks; L.A.M.C.
56.11, limits the number of belongings a person is allowed to have) are costly and do not solve
homelessness or address their service needs. Instead, funds should be invested into expansion of
permanent housing, access to health care, permanent hygiene centers, and other social services

138

needed for people to meet their basic human rights. Specifically, the types of investments in
sanitation services needed by the unhoused communities is the consistent collection of waste,
biohazards, and debris so that residents can keep their own living areas clean. This is important
because while services may be in place (as findings from chapter 4 reveals there are 5,500
receptacles in the City), these may not be equally distributed across communities, particularly in
areas with unhoused people reside and are in need of these services.
Another policy finding from these studies is a problem in service design. In communities
like Skid Row in Los Angeles, the focus has been on the expansion of congregate housing
(shelter systems). In the most recent order by Judge David Carter, the City and County have been
given 90 days to find shelter for unhoused community members on Skid Row, while also
continuing enforcement of anti-camping laws to clear people off the streets (Oreskes and Smith
2021; Oreskes, Alpert Reyes, and Smith 2021). The problem with Judge Carter’s court order,
however, is investing in shelters and placing people in shelters does not address homelessness.
Based on findings gathered from Chapters 3 and 4, there are service-level factors that influence
the way people choose to engage with service providers, including shelter systems. These types
of temporary housing are not only heavily institutionalized places, but are overcrowded, unsafe,
and ineffective at meeting people’s needs. Instead, the design of solutions and services needs to
involve the community and be a collaborative engaging process of communication. This can be
seen in the success of the hygiene center, the ReFresh Spot that is a community driven project
funded by Mayor Garcetti. The ReFresh spot is a one-stop service center providing people with
safe access to restrooms, showers, laundry, drinking water, phone charging stations, free
clothing, ride sharing, health screenings, and other supportive services. Programs like the
ReFresh Spot are successful models designed by the community, for the community.

139

Lastly, better housing policies and immigration reforms are needed to address the unmet
needs of undocumented immigrants. Currently, any federally supported housing program,
specifically permanent housing programs, exclude undocumented people experiencing
homelessness from accessing their services. Additionally, immigrants experiencing homelessness
are unwilling or unable to receive assistance due largely in part to fear of their immigration status
and their perceived risk of deportation (Chinchilla and Gabrielian 2020). As a result of this
exclusion and displacement, undocumented people risk prolonged experiences of homelessness,
which is perpetuated due to an inability to find stable housing, job, and receive federal
assistance.
5.3. Limitations and Future Study Recommendations
In this final section, I will highlight the limitations of my studies and identify future
research directions. First, it is important to note one limitation in each study is sample size. The
small sample size may have influenced the statistical outcome of some of the findings and may
not be representative to the WaSH insecurity experiences of the total unhoused population of Los
Angeles. In the last qualitative chapter study, only fifteen service providers were interviewed
which resulted in five major themes. It should be noted that additional themes or ideas could
have potentially emerged if more interviews were conducted. Future studies should employ a
larger study size in order to confirm or challenge the results in this work.
Another potential source of limitations is the study design. The design of the three
chapter studies was cross-sectional, meaning that participants were interviewed once at a specific
point in time. This research design could be seen as a limitation because unhoused communities
are not only mobile but a fast-paced, changing population. Additionally, the level of
interventions and services can change rapidly over time, especially now in the tail-end of the

140

COVID-19 pandemic. In the third chapter, the closest facility models that measured accessibility
based on distance had a major assumption: that walking was a person’s main mode of
transportation. This may not be completely accurate, as unhoused people are mobile, as some do
report using public transportation. However, the distance between driving and walking to a
location is the same, with the main difference being the travel time. Another major assumption
made in the model was that people only use one main facility, or the one where an exact location
was provided. This may not represent all the daily behaviors people engage in on a recurring,
regular basis. Therefore, future studies should consider a longitudinal design, which would take
into account a temporal scale when examining people’s WaSH insecurity experiences, while at
the same time capturing individual’s daily activity space, patterns, and engagement of services.
Additionally, the format of the survey questions could be improved in order to better
validate certain demographic questions and WaSH insecurity experiences. For instance, in
capturing data on gender and sexual orientation, more transgender inclusive measures of sex and
gender were needed in this dissertation. Bauer et al.’s (2017) study highlights the importance of
inclusive measures for sex and gender, as this kind of error can lead to misclassifications and
degrade the quality of data captured in surveys. Most importantly, inclusive measures of gender
and sex are needed for transgender (trans) persons, as their gender identities differ from their
birth-assigned sex (Bauer et al. 2017; The GenIUSS Group et al. 2014). Furthermore, it is
important that future studies consider incorporating an intersectional and environmental justice
framework in examining experiences of WaSH insecurity among the unhoused. This is important
as findings from these dissertation studies suggest that unhoused people occupy multiple
intersectional vulnerable identities that may exacerbate their access to services and in existing
homelessness.

141

Another limitation during the data collection process is recall bias. In other words,
participants may not remember all of their daily habits and/or the places they visit when carrying
on their personal routines. Lastly, since the population is mobile, there may have been duplicate
interviewees. To mitigate this, duplicate surveys (if identified) were either omitted from final
analyses or used to validate initial survey responses. More extensive mixed methods studies that
include different cohorts are necessary to disentangle these factors and understand how poor
access to WaSH services affects communities differently. That said, one particular strength of
this work is that the willingness of both people who are unhoused and service providers to share
their stories and perceptions. Their inclusion has led to rich and meaningful data, and novel
insights into the WaSH needs of this vulnerable community.
Overall, future studies should measure the time spent in accessing WaSH services and
cost over time. To better understand the temporal aspect of accessibility, studies should compare
and contrast different seasons, not only with respect to the availability of services, but when
more services should be targeted to serve the population (e.g., summer time, increase of mist
stations to reduce heat exposure illness as seen in Demyers, Warpinski, and Wutich 2017;
Popkin, D’Anci, and Rosenberg 2010). Additionally, future studies should consider capturing
water affect experienced in unhoused communities. Specifically, the psychosocial stressors that
result from a lack or poor access to WaSH, as seen in studies that focus on household water
insecurity. Capturing WaSH affect among unhoused communities will shed light to the mental
and well-being impacts of WaSH insecurity. Unfortunately, my dissertation studies could not
measure these and other factors due to the disruption of data collection during COVID-19 stay at
home orders. However, it is important to note that service providers report that gaining access to
fundamental WaSH service motivates people to seek out additional social services, seek out job

142

opportunities, and boosts people’s self-reflection, self-esteem, and confidence. All of these
factors can play a role in reducing length of homelessness, and thus, validates the importance of
WaSH as an effective, immediate intervention.
Lastly, it is important for researchers to acknowledge and document vulnerabilities in the
research process and in studying marginalized populations. This is not a limitation, but rather an
observation based on experiences from this dissertation. In other words, researchers need to be
aware of their positions and their roles in the research process, while also understanding that
there will be challenging and vulnerable situations to maneuver. The difficulty associated with
recruiting hard-to-reach populations also needs recognition in the research process, as these
challenges require researchers to actively seek out certain individuals from the population, which
requires a certain level of trust, safety, comfort level, and the ability to manage conversations. In
their studies, Heller et al. (2011) and Latham (2003) suggest integrating diary journaling as a
practice of reflexivity, which includes noting reflections and moments of struggle. Reviewing
these reflections can strengthen research rigor while also providing a place for the researcher to
vent and document frustrations, fears, and struggles.
5.4. Dissertation Takeaways
To conclude, in this dissertation, I have argued that WaSH insecurity negatively impacts
unhoused communities of Los Angeles, contributing to multiple barriers for people to exit
homelessness. As seen in the introduction, WaSH insecurity is not a phenomenon restricted to
the global South but also invisibly present in the US. Chapter 2 highlights the coping strategies
unhoused people use to survive in spaces and places that lack WaSH services. Chapter 3 expands
the analytical framework by integrating GIS and spatial statistics to measure differences in
access to WaSH while also considering geographic, individual, and service contributing factors

143

to WaSH insecurity experiences. In contrast, Chapter 4 uses qualitative descriptive interviews
from service providers to untangle other factors that play a role in reinforcing WaSH insecurity
experiences in unhoused communities. The findings from this dissertation suggest that WaSH
insecurity is a deeply rooted form of environmental and social injustices would like to highlight
the main takeaways. Providing and expanding access to interim-level WaSH services can
improve unhoused communities' health and living environments while also discontinuing a
reinforcing cycle of poverty.

144

References
Alhassan, Hamdiyah, and Paul Adjei Kwakwa. 2014. “When Water Is Scarce: The Perception of
Water Quality and Effects on the Vulnerable.” Journal of Water Sanitation and Hygiene for
Development 4 (1): 43–50. https://doi.org/10.2166/washdev.2013.140.

Applewhite, Steven Lozano. 1997. “Homeless Veterans: Perspectives on Social Services Use.”
Social Work 42 (1): 19–30. https://doi.org/10.1093/sw/42.1.19.

Avelar Portillo, Lourdes Johanna, Yao-Yi Chiang, Meredith Franklin, Charlene Ko, Angelica
Vasquez, Jimena Gonzalez Orcajo, Diego Jose Avelar, and Nayib Alvarenga. n.d.
“Homeless Encampments and Water, Sanitation, and Hygiene (WaSH) Insecurity in Los
Angeles, CA.”

Badiaga, Sékéné, Samir Benkouiten, Hind Hajji, Didier Raoult, and Philippe Brouqui. 2012.
“Murine Typhus in the Homeless.” Comparative Immunology, Microbiology and Infectious
Diseases 35 (1): 39–43. https://doi.org/10.1016/j.cimid.2011.09.008.

Bauer, Greta R., Jessica Braimoh, Ayden I. Scheim, and Christoffer Dharma. 2017.
“Transgender-Inclusive Measures of Sex/Gender for Population Surveys: Mixedmethods
Evaluation and Recommendations.” PLoS ONE 12 (5): 1–28.
https://doi.org/10.1371/journal.pone.0178043.

Berger, Roni. 2015. “Now I See It, Now I Don’t: Researcher’s Position and Reflexivity in
Qualitative Research.” Qualitative Research 15 (2): 219–34.
https://doi.org/10.1177/1468794112468475.

Bonds, Eric, and Leslie Martin. 2016. “Treating People Like Pollution: Homelessness and
Environmental Injustice.” Environmental Justice 9 (5): 137–41.
https://doi.org/10.1089/env.2016.0021.

Bonilla, Denise L., Charsey Cole-Porse, Anne Kjemtrup, Lynn Osikowicz, and Michael Kosoy.
2014. “Risk Factors for Human Lice and Bartonellosis among the Homeless, San Francisco,
California, USA.” Emerging Infectious Diseases 20 (10): 1645–51.
https://doi.org/10.3201/eid2010.131655.

Capone, Drew, Oliver Cumming, Dennis Nichols, and Joe Brown. 2020. “Water and Sanitation
in Urban America, 2017-2019.” American Journal of Public Health 110 (10): 1567–72.
https://doi.org/10.2105/AJPH.2020.305833.

Capone, Drew, Anna Ferguson, Matthew O. Gribble, and Joe Brown. 2018. “Open Defecation
Sites, Unmet Sanitation Needs, and Potential Sanitary Risks in Atlanta, Georgia, 2017-
2018.” American Journal of Public Health 108 (9): 1238–40.
https://doi.org/10.2105/AJPH.2018.304531.

Center for Disease and Control Prevention (CDC). 2018. “2017 – Outbreaks of Hepatitis A in

145

Multiple States among People Who Use Drugs and/or People Who Are Homeless.” 2018.
https://www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm.

Centers for Disease and Control Prevention (CDC). 2021. “COVID-19: People at Increased
Risk.” 2021. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-
precautions/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronaviru
s%2F2019-ncov%2Fneed-extra-precautions%2Fpeople-at-increased-risk.html.

Chafe, Roger, Debbie Harnum, and Robert Porter. 2016. “Improving the Treatment and
Assessment of Moderate and Severe Pain in a Pediatric Emergency Department.” Pain
Research and Management 2016: 1–6. https://doi.org/10.1155/2016/4250109.

Chinchilla, Melissa, and Sonya Gabrielian. 2020. “Stemming the Rise of Latinx Homelessness:
Lessons from Los Angeles County.” Journal of Social Distress and the Homeless 29 (2):
71–75. https://doi.org/10.1080/10530789.2019.1660049.

City of Los Angeles. 2019. “Budget Summary Fiscal Year 2019-2020.” Los Angeles.
———. 2021. “COVID-19: Keeping Los Angeles Safe.” 2021. https://corona-virus.la.

Clifford, Scott, and Spencer Piston. 2017. “Explaining Public Support for Counterproductive
Homelessness Policy: The Role of Disgust.” Political Behavior 39 (2): 503–25.
https://doi.org/10.1007/s11109-016-9366-4.

Coalition on Homelessness. 2021. “UnH2Oused Water for All Initiative.” San Francisco.
https://drive.google.com/file/d/1OprepTR-JnnH01Chz9n6w9kUtEBsOvec/view.

County of Los Angeles Department of Public Health. 2018a. “Acute Communicable Disease
Control.” 2018. http://www.publichealth.lacounty.gov/acd/vectortyphus.htm.

———. 2018b. “Tuberculosis in Los Angeles County: Surveillance Report 2016.”
http://publichealth.lacounty.gov/tb/docs/SurveillanceReport2016.pdf.

Crawford, Bridget J., and Carla Spivack. 2017. “Tampon Taxes, Discrimination, and Human
Rights.” Wisconsin Law Review 2017 (3): 491–549.

Crenshaw, Kimberle. 1991. “Mapping the Margins: Intersectionality, Identity Politics, and
Violence against Women of Color.” Stanford Law Review 43 (6): 1241.
https://doi.org/10.2307/1229039.

Creswell, John W., and J. David Creswell. 2018. Research Design: Qualitative, Quantitative,
and Mixed Methods Approaches. Fifth edit. Los Angeles: SAGE.

Demyers, Christine, Chloe Warpinski, and Amber Wutich. 2017. “Urban Water Insecurity: A
Case Study of Homelessness in Phoenix, Arizona.” Environmental Justice 10 (3): 72–80.
https://doi.org/10.1089/env.2016.0043.

146

Deverteuil, Geoff. 2019. “Post-Revanchist Cities?” Urban Geography 40 (7): 1055–61.
https://doi.org/10.1080/02723638.2019.1640034.

Deverteuil, Geoffrey. 2003. “Homeless Mobility, Institutional Settings, and the New Poverty
Management.” Environment and Planning A: Economy and Space 35 (2): 361–79.
https://doi.org/10.1068/a35205.

Dickins, Kirsten A., Lisa L. Philpotts, Jane Flanagan, Stephen J. Bartels, Travis P. Baggett, and
Sara E. Looby. 2020. “Physical and Behavioral Health Characteristics of Aging Homeless
Women in the United States: An Integrative Review.” Journal of Women’s Health 00 (00).
https://doi.org/10.1089/jwh.2020.8557.

DiGuiseppi, Graham, Callahan Corcoran, Todd Cunningham, Hoan Nguyen, Monique Noel, Pete
White, and François Bar. 2021. “Mobilizing a Community–Academic Partnership to
Provide DIY Handwashing Stations to Skid Row Residents During COVID-19.” Health
Promotion Practice 22 (1): 9–12. https://doi.org/10.1177/1524839920953092.

Donley, Amy M., and James D. Wright. 2018. “The Health of the Homeless.” Sociology
Compass 12 (1): 1–12. https://doi.org/10.1111/soc4.12550.

Downtown Women’s Action Coaliton. 2020. “Women’s Needs Assessment 2020: A Message of
Love by the Women of Skid Row.” Los Angeles Community Action Network.
https://cangress.org/publications/.

Drake, Robert E., and Michael A. Wallach. 1991. “Substance Abuse among the Mentally Ill.”
Hospital and Community Psychiatry 40 (10): 1041–46. https://doi.org/10.1097/00001504-
199106000-00012.

Durham, Mary L. 1989. “The Impact of Deinstitutionalization on the Current Treatment of the
Mentally Ill.” International Journal of Law and Psychiatry 12 (2–3): 117–31.
https://doi.org/10.1016/0160-2527(89)90003-4.

Felner, Jennifer K, Talia Kieu, Andrew Stieber, Hunter Call, Daniel Kirkland, Amanda Farr, and
Jerel P Calzo. 2020. “‘It’s Just a Band-Aid on Something No One Really Wants to See or
Acknowledge’: A Photovoice Study with Transitional Aged Youth Experiencing
Homelessness to Examine the Roots of San Diego’s 2016–2018 Hepatitis A Outbreak.”
International Journal of Environmental Research and Public Health 17 (13): 4721.
https://doi.org/10.3390/ijerph17134721.

Five Keys Schools and Programs. 2021. “Other Five Keys Programs.” 2021.
https://www.fivekeyscharter.org/other-five-keys-programs.

Flannigan, Shawn, and Megan Welsh. 2020. “Unmet Needs of Individuals Experiencing
Homelessness near San Diego Waterways: The Roles of Displacement and Overburdened
Service Systems.” Journal of Health and Human Aervices Administration 43 (2): 105–30.

147

Fletcher, Jesse B., Kimberly A. Kisler, and Cathy J. Reback. 2014. “Housing Status and HIV
Risk Behaviors Among Transgender Women in Los Angeles.” Archives of Sexual Behavior
43 (8): 1651–61. https://doi.org/10.1007/s10508-014-0368-1.

Foscarinis, Maria. 2012. “Homelessness in America: A Human Rights Crisis.” The Journal of
Law in Society 13 (2): 515.

Frye, Elizabeth A., Drew Capone, and Dabney P. Evans. 2019. “Open Defecation in the United
States: Perspectives from the Streets.” Environmental Justice 12 (5): 226–30.
https://doi.org/10.1089/env.2018.0030.

Gilleland, Jodilyn, Kaya Lurie, and Sara Rankin. 2017. “A Broken Dream: Homelessness &
Immigrants.” SSRN Electronic Journal. https://doi.org/10.2139/ssrn.2776890.

Goodling, Erin. 2020. “Intersecting Hazards, Intersectional Identities: A Baseline Critical
Environmental Justice Analysis of US Homelessness.” Environment and Planning E:
Nature and Space 3 (3): 833–56. https://doi.org/10.1177/2514848619892433.

Gorman, Anna, and Harriet Blair Rowan. 2019. “The Homeless Are Dying in Record Numbers
on the Streets of L.A.” Kaiser Health News, April 24, 2019. https://khn.org/news/the-
homeless-are-dying-in-record-numbers-on-the-streets-of-l-a/.

Green, Carla. 2017. “California City Confiscates Toilets from Homeless Resident –Forcing
Them to Use Buckets.” The Guardian, September 8, 2017.
https://www.theguardian.com/us-news/2017/sep/08/anaheim-homeless-toilets-confiscated-
public-health-crisis.

Guerrero, Erick G, Benjamin Henwood, and Suzanne L Wenzel. 2014. “Service Integration to
Reduce Homelessness in Los Angeles County: Multiple Stakeholder Perspectives.” Human
Service Organizations Management, Leadership & Governance 38 (1): 44–54.
https://doi.org/10.1080/03643107.2013.853009.

Hale, Marcia Rosalie. 2019. “Fountains for Environmental Justice: Public Water, Homelessness,
and Migration in the Face of Global Environmental Change.” Environmental Justice 12 (2):
33–40. https://doi.org/10.1089/env.2018.0031.

Hanley, Jill, Nicole Ives, Jaime Lenet, Shawn-Renee Hordyk, Christine Walsh, Sonia Ben
Soltane, and David Este. 2019. “Migrant Women’s Health and Housing Insecurity: An
Intersectional Analysis.” International Journal of Migration, Health and Social Care 15
(1): 90–106. https://doi.org/10.1108/ijmhsc-05-2018-0027.

Heller, Elizabeth, Julia Christensen, Lindsay Long, Catrina A Mackenzie, Philip M Osano, Britta
Ricker, Emily Kagan, and Sarah Turner. 2011. “Dear Diary: Early Career Geographers
Collectively Reflect on Their Qualitative Field Research Experiences.” Journal of
Geography in Higher Education 35 (1): 67–83.
https://doi.org/10.1080/03098265.2010.486853.

148

Henry, Meghan, Anna Mahathey, Tyler Morrill, Anna Robinson, Azim Shivji, Rian Watt, and
and Abt Associated. 2020. “The 2019 Annual Homeless Assessment Report (AHAR) to
Congress.” Washington D.C. https://files.hudexchange.info/resources/documents/2019-
AHAR-Part-1.pdf.
Henry, Meghan, Tanya de Sousa, Caroline Roddey, Swati Gayen, Thomas Joe Bednar, and and
Abt Associated. 2021. “The 2020 Annual Homeless Assessment Report (AHAR) to
Congress.” Washington D.C. https://www.huduser.gov/portal/datasets/ahar/2020-ahar-part-
1-pit-estimates-of-homelessness-in-the-us.html.

Henwood, Benjamin F., Hsun-Ta Hsu, David Dent, Hailey Winetrobe, Adam Carranza, and
Suzanne Wenzel. 2013. “Transitioning from Homelessness: A ‘Fresh-Start’ Event.” Journal
of the Society for Social Work and Research 4 (1): 47–57.
https://doi.org/10.5243/jsswr.2013.4.

Herring, Christopher. 2016. “Cruel Streets: Criminalizing Homelessness in San Francisco.” PhD
Diss.,. University of California, Berkeley. https://escholarship.org/uc/item/39k7400g.

Holland, Gale, and Christine Zhang. 2018. “Huge Increase in Arrests of Homeless in L.A.—but
Mostly for Minor Offenses.” Los Angeles Times, February 4, 2018.
https://www.latimes.com/local/politics/la-me-homeless-arrests-20180204-story.html.

Howard, Guy, Jamie Bartram, Clarissa Brocklehurst, John M. Colford, Federico Costa, David
Cunliffe, Robert Dreibelbis, et al. 2020. “COVID-19: Urgent Actions, Critical Reflections
and Future Relevance of ‘WaSH’: Lessons for the Current and Future Pandemics.” Journal
of Water Sanitation and Hygiene for Development 10 (3): 379–96.
https://doi.org/10.2166/washdev.2020.218.

Isaacs, AntonN. 2014. “An Overview of Qualitative Research Methodology for Public Health
Researchers.” International Journal of Medicine and Public Health 4 (4): 318.
https://doi.org/10.4103/2230-8598.144055.

Kanbarian, Colette. 2020. “Water Drop LA Brings Water to Unhoused Neighbors on Skid Row.”
Daily Trojan, September 10, 2020. https://dailytrojan.com/2020/09/10/water-drop-la-
brings-water-to-unhoused-neighbors-on-skid-row-2/.

Karlamangla, Soumya. 2018. “L.A. Typhus Outbreak Adds Fuel to the Debates over
Homelessness and Housing.” Los Angeles Times, October 11, 2018.
https://www.latimes.com/local/california/la-me-ln-typhus-outbreak-20181011-story.html.

Katz, Michael B. 2013. The Undeserving Poor: America’s Enduring Confrontation with Poverty:
Fully Updated and Revised. Oxford University Press.

Keene, Danya E., Alana Rosenberg, Penelope Schlesinger, Monica Guo, and Kim M.
Blankenship. 2018. “Navigating Limited and Uncertain Access to Subsidized Housing After
Prison.” Housing Policy Debate 28 (2): 199–214.

149

https://doi.org/10.1080/10511482.2017.1336638.

Keene, Danya E, Amy B Smoyer, and Kim M Blankenship. 2018. “Stigma, Housing and Identity
after Prison.” The Sociological Review 66 (4): 799–815.
https://doi.org/10.1177/0038026118777447.
Kekhtman, Alexander. 2019. “Skid Row Project Highlights Toilets as Harm Reduction and a
Human Right.” Filter, November 25, 2019. https://filtermag.org/sanitation-skid-row-harm-
reduction/.

Kuhn, Randall, Jessica Richards, and Sarah Roth. 2020. “Homelessness and Public Health in Los
Angeles.” UCLA: Campuswide Homelessness Initiative.
https://escholarship.org/uc/item/2gn3x56s.

Kuo, Audrey. 2019. “2019 Los Angeles City Women’s Needs Assessment.” Downtown
Women’s Center. https://www.downtownwomenscenter.org/wp-
content/uploads/2020/01/DWC-2019-Los-Angeles-Womens-Needs-Assessment.pdf.

Latham, Alan. 2003. “Research, Performance, and Doing Human Geography: Some Reflections
on the Diary-Photograph, Diary-Interview Method.” Environment and Planning A:
Economy and Space 35 (11): 1993–2017. https://doi.org/10.1068/a3587.

LavaMaex. 2021. “LavaMaex Media Fact Sheet.” 2021.
https://static1.squarespace.com/static/5dd47e90e2e27e5a2bbcaece/t/603ffa121b603a3c1004
81fe/1614805523158/LavaMaeX_media+fact+sheet_030321.pdf

Leibler, Jessica H., Daniel D. Nguyen, Casey León, Jessie M. Gaeta, and Debora Perez. 2017.
“Personal Hygiene Practices among Urban Homeless Persons in Boston, MA.”
International Journal of Environmental Research and Public Health 14 (8).
https://doi.org/10.3390/ijerph14080928.

Liu, C. Y., S. J. Chai, and J. P. Watt. 2020. “Communicable Disease among People Experiencing
Homelessness in California.” Epidemiology and Infection, 1–10.
https://doi.org/10.1017/S0950268820000722.

Loftus, Alex, and Farhana Sultana. 2020. “Are We All in This Together? COVID-19 and the
Human RIghts to Water and Sanitation.” In Public Water and COVID-19: Dark Clourds
and Silver Linings, edited by David A Mcdonald, Susan J. Spronk, and Daniel Chavez, 49–
60. Municipal Service Project (Kingston), Transnational Institute (Amsterdam) and Latin
American Council of Social Sciences (CLACSO) (Buenos Aires).

Lopez, Steve. 2019. “Column: He Dided Sunday on a West L.A. Sidewalk. He Was Homeless.
He Is Part of an Epidemic.” Los Angeles Times, September 4, 2019.

Los Angeles Central Providers Collaborative. 2017. “No Place to Go: An Audit of the Public
Toilet Crisis in Skid Row.” Los Angeles. https://doi.org/10.1080/02690055.2018.1395158.

150

Los Angeles Community Action Network (LACAN). 2017. “Dirty Divide: ‘Out of Service’ 2017
Update.” Los Angeles. https://cangress.org/publications/.

Los Angeles Congress Action Network (LACAN). 2013. “The Dirty Divide in Downtown Los
Angeles: A Call for Public Health Equity.” https://cangress.org/publications/.

Los Angeles CountyDepartment of Public Health. 2019. “Recent Trends in Mortality Rate and
Causes of Death among People Experiencing Homelessness in Los Angeles County.” 2019.
http://publichealth.lacounty.gov/chie/reports/HomelessMortality_CHIEBrief_Final.pdf.

Los Angeles Homeless Services Authority (LAHSA). 2019. “LAHSA Administered Safe
Parking Sites in Los Angeles.” https://www.lahsa.org/news?article=592-safe-parking.

———. 2020a. “2020 Greater Los Angeles Homeless Count Results: Summary.” 2020.
https://www.lahsa.org/news?article=726-2020-greater-los-angeles-homeless-count-results

———. 2020b. “2020 Greater Los Angeles Homeless Count Results.” Los Angeles.
https://www.lahsa.org/homeless-count/.

———. 2020c. “A Safe Space for the Skid Row Community.”
https://www.lahsa.org/news?article=760-a-safe-space-for-the-skid-row-community-re-
opens.

———. 2021a. “LAHSA Releases 2021 Housing Inventory Count and Shelter Count Results.”
https://www.lahsa.org/news?article=849-lahsa-releases-2021-housing-inventory-count-and-
shelter-count-results

———. 2021b. “Los Angeles Continium of Care (CoC) 2020 Homeless Count: Older Adults
Experiencing Homelessness.” https://www.lahsa.org/news?article=806-2020-los-angeles-
homeless-count-older-adult-homelessness

Los Angeles Municipal Code. 1968. Sidewalks, Pedestrian Subways – Loitering.
https://codelibrary.amlegal.com/codes/los_angeles/latest/lamc/0-0-0-128514#JD_41.18.

———. 2003. Urinating or Defecating.
https://codelibrary.amlegal.com/codes/los_angeles/latest/lamc/0-0-0-128910#JD_41.47.2.

———. 2016. Storage of Personal Property. https://clkrep.lacity.org/onlinedocs/2014/14-1656-
s1_ORD_184182_4-11-16.pdf.

Lurie, Kaya, Breanne Schuster, and Sara Rankin. 2015. “Discrimination at the Margins: The
Intersectionality of Homelessness & Other Marginalized Groups.” SSRN Electronic
Journal. Elsevier BV. https://doi.org/10.2139/ssrn.2602532.

Marr, Matthew D., Geoff DeVerteuil, and David Snow. 2009. “Towards a Contextual Approach
to the Place-Homeless Survival Nexus: An Exploratory Case Study of Los Angeles

151

County.” Cities 26 (6): 307–17. https://doi.org/10.1016/j.cities.2009.07.008.

Maslow, Abraham H. 1943. “A Theory of Human Motivation.” Psychological Review 50 (4):
370–96. https://doi.org/https://doi.org/10.1037/h0054346.

McDonald, David A., Susan J. Spronk, and Daniel Chavez. 2021. “Introduction: Why Public
Water Matters.” In Public Water and COVID-19: Dark Clourds and Silver Linings, edited
by David A Mcdonald, Susan J. Spronk, and Daniel Chavez, 1–24. Municipal Service
Project (Kingston), Transnational Institute (Amsterdam) and Latin American Council of
Social Sciences (CLACSO) (Buenos Aires).

Meehan, Katie, Wendy Jepson, Leila M. Harris, Amber Wutich, Melissa Beresford, Amanda
Fencl, Jonathan London, et al. 2020. “Exposing the Myths of Household Water Insecurity in
the Global North: A Critical Review.” Wiley Interdisciplinary Reviews: Water 7 (6): 1–20.
https://doi.org/10.1002/wat2.1486.

Meehan, Katie, Jason R. Jurjevich, Nicholas M.J.W. Chun, and Justin Sherrill. 2020.
“Geographies of Insecure Water Access and the Housing–Water Nexus in US Cities.”
Proceedings of the National Academy of Sciences of the United States of America 117 (46):
28700–707. https://doi.org/10.1073/pnas.2007361117.

Mitchell, Don. 1997. “The Annihilation of Space by Law: The Roots and Implications of Anti-
Homeless Laws in the United States.” Antipode 29 (3): 303–35.
https://doi.org/10.1111/1467-8330.00048.

Moore Sheeley, Kirsten, Alisa Belinkoff Katz, Andrew Klein, Jessica Richards, Fernanda Jahn
Verri, Marques Vestal, and Zev Yaroslavsky. 2021. “The Making of a Crisis: A History of
Homelessness in Los Angeles.” Los Angeles. https://luskincenter.history.ucla.edu/wp-
content/uploads/sites/66/2021/01/LCHP-The-Making-of-A-Crisis-Report.pdf.

National Coalition for the Homeless. 2016. “Swept Away: Reporting on Encampment Closure
Crisis.” Washington D.C. https://nationalhomeless.org/wp-content/uploads/2016/08/Swept-
Away-2016.pdf.

Nawaz, Gul, and Alan D. Rogol. 2020. “Amenorrhea.” National Center for Biotechnology
Information. https://www.ncbi.nlm.nih.gov/books/NBK482168/.

Neergaard, Mette Asbjoern, Frede Olesen, Rikke Sand Andersen, and Jens Sondergaard. 2009.
“Qualitative Description-the Poor Cousin of Health Research?” BMC Medical Research
Methodology 9 (1): 1–5. https://doi.org/10.1186/1471-2288-9-52.

Oreskes, Benjamin, Emily Alpert Reyes, and Doug Smith. 2021. “Judge Orders L.A. City and
County to Offer Shelter to Everyong on Skid Row by Fall.” Los Angeles Times, April 20,
2021. https://www.latimes.com/homeless-housing/story/2021-04-20/judge-carter-la-city-
county-shelter-skid-row-homeless-fall.

152

Oreskes, Benjamin, and Doug Smith. 2021. “L.A. near Settlement to Create Shelters and Clear
Homeless People off the Streets.” Los Angeles Times, April 12, 2021.
https://www.latimes.com/homeless-housing/story/2021-04-12/la-nears-deal-build-shelters-
clear-homeless-encampments.

Otiniano Verissimo, Angie Denisse, Nicole Henley, Gilbert C Gee, Claudia Davis, and Christine
Grella. 2021. “Homelessness and Discrimination among US Adults: The Role of
Intersectionality.” Journal of Social Distress and Homelessness, 1–15.
https://doi.org/10.1080/10530789.2021.1935650.

Parrillo, Allegra, and Edward Feller. 2017. “Menstrual Hygiene Plight of Homeless Women, a
Public Health Disgrace.” Rhode Island Medical Journal (2013) 100 (12): 14–15.
http://www.ncbi.nlm.nih.gov/pubmed/29190837.

Phelan, J O, Bruce G Link, and Robert E Moore. 1997. “The Stigma of Homelessness : The
Impact of the Label " Homeless " on Attitudes Toward Poor Persons Author (s): Jo Phelan,
Bruce G . Link , Robert E . Moore and Ann Stueve Published by : American Sociological
Association Stable URL : Https://Www.Jstor.O” 60 (4): 324–33.

Popkin, Barry M, Kristen E D’Anci, and Irwin H Rosenberg. 2010. “Water, Hydration, and
Health.” Nutrition Reviews 68 (8): 439–58. https://doi.org/10.1111/j.1753-
4887.2010.00304.x.

Ray, Lexis-Oliver. 2021. “City Reverses Decision to Remove Washing Stations from
Encampments Following L.A. Taco Investigation.” L.A. Taco, August 5, 2021.
https://www.lataco.com/bathroom-stations-encampments-la-city/.

Ray, Lexis-Olivier. 2021. “In Sunny Los Angeles, More Homeless People Die from the Cold
than in SF and NYC Combined.” L.A. Taco, January 19, 2021.
https://www.lataco.com/homeless-la-death-hypothermia/.

Riley, Elise D., Torsten B. Neilands, Kelly Moore, Jennifer Cohen, David R. Bangsberg, and
Diane Havlir. 2012. “Social, Structural and Behavioral Determinants of Overall Health
Status in a Cohort of Homeless and Unstably Housed HIV-Infected Men.” PloS One 7 (4):
1–7. https://doi.org/10.1371/journal.pone.0035207.

Rimawi, Bassam H., Meena Mirdamadi, and Joseph F. John. 2014. “Infections and
Homelessness: Risks of Increased Infectious Diseases in Displaced Women.” World
Medical and Health Policy 6 (2): 118–32. https://doi.org/10.1002/wmh3.95.

Robinson, Tony. 2019. “No Right to Rest: Police Enforcement Patterns and Quality of Life
Consequences of the Criminalization of Homelessness.” Urban Affairs Review. 55 (1): 41-
73. https://doi.org/10.1177/1078087417690833.

Rosengard, Cynthia, Donald B. Chambers, Jacqueline P. Tulsky, Heather L. Long, and Margaret
Chesney. 2001. “Value on Health, Health Concerns and Practices of Women Who Are

153

Homeless.” Women and Health 34 (2): 29–44. https://doi.org/10.1300/J013v34n02_03.

Roudsari, Latifnejad R, and Robab Latifnejad Roudsari. 2019. “Qualitative Description: A Less
Sophisticated Approach for Junior Qualitative Researchers.” Journal of Midwifery and
Reproductive Health 7 (4): 1856–57. https://doi.org/10.1002/nur.21768.9.

Rowe, Stacy, and Jennifer Wolch. 1990. “Social Networks in Time and Space: Homeless
Women in Skid Row, Los Angeles.” Annals of the Association of American Geographers
80 (2): 184–204. https://doi.org/10.1111/j.1467-8306.1990.tb00287.x.

Roy, Jessica. 2016. “DWP Installs Temporary Sidewalk Drinking Fountains in Skid Row.” Los
Angeles Times, July 5, 2016. https://www.latimes.com/local/california/la-me-ln-skid-row-
drinking-fountains-20160701-snap-htmlstory.html.

Sandelowski, Margarete. 2000. “Focus on Research Methods: Whatever Happened to Qualitative
Description?” Research in Nursing and Health 23 (4): 334–40.
https://doi.org/10.1002/1098-240x(200008)23:4<334::aid-nur9>3.0.co;2-g.

———. 2010. “What’s in a Name? Qualitative Description Revisited.” Research in Nursing and
Health 33 (1): 77–84. https://doi.org/10.1002/nur.20362.

Scott, Jan. 1993. “Homelessness and Mental Illness.” British Journal of Psychiatry 162 (3): 314–
24. https://doi.org/10.1192/bjp.162.3.314.

Sebert Kuhlmann, Anne, Eleanor Peters Bergquist, Djenie Danjoint, and L. Lewis Wall. 2019.
“Unmet Menstrual Hygiene Needs among Low-Income Women.” Obstetrics and
Gynecology 133 (2): 238–44. https://doi.org/10.1097/AOG.0000000000003060.

Shelton, Katherine H, Pamela J Taylor, Adrian Bonner, and Marianne Van Den Bree. 2009.
“Risk Factors for Homelessness: Evidence From a Population-Based Study.” Psychiatric
Services 60 (4): 465–72. https://doi.org/10.1176/ps.2009.60.4.465.

Shure, Natalie. 2019. “The Politics of Going to the Bathroom.” The Nation, May 23, 2019.
https://www.thenation.com/article/archive/toilet-urination-disability-access/.

Sommer, Marni, Caitlin Gruer, Rachel Clark Smith, Andrew Maroko, and Kim Hopper. 2020.
“Menstruation and Homelessness: Challenges Faced Living in Shelters and on the Street in
New York City.” Health & Place 66: 102431.
https://doi.org/10.1016/j.healthplace.2020.102431.

Sommers-Dawes, Kate. 2016. “Nonprofit Offering Mobile Showers to the Homeless Is Now
Way More than That.” https://mashable.com/2016/12/13/lava-mae-kind-homeless-
showers/#AeJNAbu_dmqR.

Speak, Suzanne. 2010. “Point of No Return: Exploring the Issues Which Trap Migrants in a State
of Homelessness in the City.” International Development Planning Review 32 (3): 225–43.

154

https://doi.org/10.3828/idpr.2010.07.

Speer, Jessie. 2016. “The Right to Infrastructure: A Struggle for Sanitation in Fresno, California
Homeless Encampments.” Urban Geography 37 (7): 1049–69.
https://doi.org/10.1080/02723638.2016.1142150.
Stark, Louisa R. 1994. “The Shelter as ‘Total Institution.’” American Behavioral Scientist 37 (4):
553–62. https://doi.org/10.1177/0002764294037004008.

Stuart, Forrest. 2015. “On the Streets, Under Arrest: Policing Homelessness in the 21st Century.”
Sociology Compass 9 (11): 940–50. https://doi.org/10.1111/soc4.12324.

Sultana, Farhana. 2011. “Suffering for Water, Suffering from Water: Emotional Geographies of
Resource Access, Control and Conflict.” Geoforum 42 (2): 163–72.
https://doi.org/10.1016/j.geoforum.2010.12.002.

Takahashi, Lois M., Jaime McElroy, and Stacy Rowe. 2002. “The Sociospatial Stigmatization of
Homeless Women with Children1.” Urban Geography 23 (4): 301–22.
https://doi.org/10.2747/0272-3638.23.4.301.

The Environmental Law Clinic (ELC) and the Environmental Justice Coalition for Water
(EJWC). 2018. “Basic and Urgent: Realizing the Human Right to Water and Sanitation for
Californians Experiencing Homelessness.” https://www.law.berkeley.edu/wp-
content/uploads/2018/08/FINAL_EJCW.ELC_.Basic_.UrgentReportonAccesstoWaterandS
anitationbyHomelessCalifornians.8.8.18.docx.pdf.

The GenIUSS Group, M.V. Lee Badgett, Kellan E. Baker, Kerith J. Conron, Gary J. Gates,
Alison Gill, Emily Greytak, and Jody L. Herman. 2014. “Best Practices for Asking
Questions to Identify Transgender and Other Gender Minority Respondents on Population-
Based Surveys (GenIUSS).” In , edited by J.L. Herman, 1–49. Los Angeles.
https://williamsinstitute.law.ucla.edu/publications/geniuss-trans-pop-based-survey/.

The Times Editorial Board. 2021. “Editorial: L.A. Shouldn’t Remove Portable Toilets from
Homeless Encampments.” Los Angeles Times, July 25, 2021.
https://www.latimes.com/opinion/story/2021-07-25/editorial-los-angeles-homeless-
bathrooms.

Tompsett, Carolyn J., Patrick J. Fowler, and Paul A. Toro. 2009. “Age Differences among
Homeless Individuals: Adolescence through Adulthood.” Journal of Prevention and
Intervention in the Community 37 (2): 86–99. https://doi.org/10.1080/10852350902735551.

Truelove, Yaffa. 2011. “(Re-)Conceptualizing Water Inequality in Delhi, India through a
Feminist Political Ecology Framework.” Geoforum 42 (2): 143–52.
https://doi.org/10.1016/j.geoforum.2011.01.004.

Tsai, J., and X. Gu. 2019. “Homelessness among Immigrants in the United States: Rates,
Correlates, and Differences Compared with Native-Born Adults.” Public Health 168 (203):

155

107–16. https://doi.org/10.1016/j.puhe.2018.12.017.

UN Committee on Economic Social and Cultural Rights (CESCR). 2003. “General Comment
No. 15: The Right to Water (Arts. 11 and 12 of the Covenant).”
https://www.refworld.org/docid/4538838d11.html.
United Nations (UN) General Assembly. 1979. “Convention on the Elimination of All Forms of
Discrimination against Women.” New York.
https://www.ohchr.org/en/professionalinterest/pages/cedaw.aspx.

———. 2010. “The Human Right to Water and Sanitation: Resolution Adpted by the General
Assembly A/RES/64/292.” https://www.refworld.org/docid/4cc926b02.html.

———. 2018. “Report of the Special Rapporteur on Extreme Poverty and Human Rights on His
Mission to the United States of America: Note/ by the Secretariat.” Vol. A/HRC/38/3.
Geneva: UN. https://digitallibrary.un.org/record/1629536?ln=en.

United Nations High Commissioner for Human Rights. 2007. “Report of the United Nations
High Commissioner for Human Rights on the Scope and Content of the Relevant Human
Rights Obligations Related to Equitable Access to Safe Drinking Water and Sanitation
under International Human Rights Instruments A/HRC/6/3.”
https://digitallibrary.un.org/record/606139?ln=en.

United States Interagency Council on Homelessness (USICH). 2012. “Searching out Solutions:
Constructive Alternatives to the Criminalization of Homelessness.” Washington D.C.
https://www.usich.gov/resources/uploads/asset_library/RPT_SoS_March2012.pdf.

Verbyla, Matthew E., Jose S. Calderon, Shawn Flanigan, Mireille Garcia, Rick Gersberg, Alicia
M. Kinoshita, Natalie Mladenov, Federick Pinongcos, and Megan Welsh. 2021. “An
Assessment of Ambient Water Quality and Challenges with Access to Water and Sanitation
Services for Individuals Experiencing Homelessness in Riverine Encampments.”
Environmental Engineering Science 00 (00): 1–13. https://doi.org/10.1089/ees.2020.0319.

Vickery, Jamie. 2018. “Using an Intersectional Approach to Advance Understanding of
Homeless Persons’ Vulnerability to Disaster.” Environmental Sociology 4 (1): 136–47.
https://doi.org/10.1080/23251042.2017.1408549.

Wenzel, Suzanne L., Ronald M. Andersen, Deidre Spelliscy Gifford, and Lillian Gelberg. 2001.
“Homeless Women’s Gynecological Symptoms and Use of Medical Care.” Journal of
Health Care for the Poor and Underserved 12 (3): 323–41.
https://doi.org/10.1353/hpu.2010.0797.

Wescoat, James L., Lisa Headington, and Rebecca Theobald. 2007. “Water and Poverty in the
United States.” Geoforum 38 (5): 801–14. https://doi.org/10.1016/j.geoforum.2006.08.007.

Wong, Yi Ling. 2009. “Homelessness in Public Libraries.” Journal of Access Services 6 (3):
396–410. https://doi.org/10.1080/15367960902908599.

156

Wood, D, R B Valdez, T Hayashi, and A Shen. 1990. “Homeless and Housed Families in Los
Angeles: A Study Comparing Demographic, Economic, and Family Function
Characteristics.” American Journal of Public Health 80 (9): 1049–52.
https://doi.org/10.2105/ajph.80.9.1049.

World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). n.d.
“Data Sources.” Accessed May 20, 2021. https://washdata.org/monitoring/methods/data-
sources.

———. 2017. “Progress on Drinking Water, Sanitation, and Hygiene: 2017 Update and SDG
Baselines.” Geneva.
http://apps.who.int/iris/bitstream/handle/10665/258617/9789241512893-
eng.pdf?sequence=1.

———. 2018. “JMP Methodology: 2017 Update and SDG Baselines.” 2018.
https://washdata.org/sites/default/files/documents/reports/2018-04/JMP-2017-update-
methodology.pdf.

Wuerker, Anne. 1997. “Factors in the Transition to Homelessness in the Chronically Mentally
III.” Journal of Social Distress and the Homeless 6 (3): 251–60.
https://doi.org/10.1007/bf02939568.

Yu, Qiang. 2019. “Mobile Pit Stop , Mobile Shower and Skid Row Cleaning Programs.”
https://cao.lacity.org/homeless/HSC20191121c.pdf

Zahniser, David, and Benjamin Oreskes. 2021. “L.A. Finalizes Its Anti-Camping Law, Setting
the Stage for Vote-by-Vote Enforcement.” Los Angeles Times, July 28, 2021.
https://www.latimes.com/california/story/2021-07-28/anti-camping-vote-la-homelessness.

157

Appendix A Survey Tool

Interviewer Instructions: Please read the following statement to participants

My name is ___________ and we are from the Spatial Sciences Institute at USC. We were wondering if
we could have a few minutes of your time to ask you a couple of questions. We are conducting a study
that is trying to understand the ways you cope with water scarcity and how you access water for drinking,
bathing, using a toilet, and laundry services. We are interested in learning about the challenges you face
in finding these basic human needs, as we hope in the future to advocate to increase the access to these
services in public areas in Los Angeles County.

Would you like to participate in this study? [If Yes] Before we begin, I want to remind you that your
participation is based on a survey and that it is completely voluntary. We will not be collecting any
identifiable information and everything in this survey will be kept confidential. If at any point in this
survey there is a question or statement that you do not wish to answer or feel embarrassed to answer,
please let me know and we will skip it and move on to the next question. The survey will take around 15-
30 minutes. Lastly, I want to let you know that handwritten notes will be taken during this survey.

Have you been interviewed by a USC student in the past week?
¨ Yes → STOP interview. Thank them for their time and continue with the next person
¨ No → Continue with Survey

Are you over the age of 18?
¨ Yes → Continue with Survey
¨ No → STOP interview. Participant does not qualify. Thank them for their time and move on to
the next person

Do you consider yourself to be homeless or unstably housed?
¨ Yes → Continue with Survey
¨ No → STOP interview. We want to interview homeless individuals
¨ OtheràDo you have a place to sleep? If the answer is not a home/apartment, then it’s YES,
unstably housed.

Where do you usually stay/sleep?
(Refer to street intersections/ or shelter)

Participant’s ID: Today’s Date:
________________
Survey Completed:
¨ Yes
¨ No

Study Area:
¨ Skid Row
¨ Greater DTLA Area
¨ Freeway/Bridge

Today’s Weather:
_______________
Interviewer:
First Street
Second Street
[DROP PIN IN MAP]

158

OR include name of Sleeping Location/Shelter: ______________________________
Section I. Mobility and Financial Information
This first section contains statements about your living situation, financial support, and personal
constraints accessing basic water resources. Our goal is to get an idea of how far you may have
to walk to access services and your biggest needs and services of value to you. Please answer the
statements to the best of your ability.

1. How many months/years have you been homeless or unstably housed?
¨ ______ months
¨ ______ years
¨ Don’t know
¨ Prefer not to answer

2. In the past 30 days, let me know if you have stayed in any of the following types of
places, even for one night? (Check all that apply)
¨ Tent
¨ Outdoors (not in a tent)
¨ Vehicle
¨ Own house, apt, hotel room
¨ Temporary hotel
¨ Rented room in someone's place
¨ With family, friend
¨ Shelter
¨ Hospital
¨ Jail or prison
¨ Residential treatment
¨ Group home
¨ Other: _________________
¨ Don't know
¨ Not applicable
¨ Prefer not to answer

3. What do you think are some of the main reasons or conditions that led you to you losing
your home?
¨ Unemployment
¨ Divorce, Separation, or Break-Up
¨ Domestic Violence
¨ Sexual Abuse
¨ Conflict with Family/Friends
¨ Family/Spousal Death
¨ Physical Disability
¨ Mental Health Issues
¨ Drug or Alcohol Use
¨ Rising Housing Cost
¨ Eviction or Foreclosure
¨ Other: __________
¨ Prefer not to answer

159

4. In the past 30 days, did you move your tent/belongings to a different location (including
across the street or down the block) and how many times?
¨ Yes, ______________ (number of moves) à Go to PARTS A and B
¨ No/ Not applicable
¨ Don’t know/Remember
¨ Prefer not to answer

If Q.4 is equal to NO, then skip to the next question.
5. In the past 30 days, how many of these moves were because of police, security guards, or
other city/county officials?
¨ _______ (number of moves)
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

6. In the past 30 days, how many of these move were because of sanitation workers and
street clean-ups?
¨ ________ (number of moves)
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

7. In the past 12 months, have you ever been given a citation/ticket and how many times?
¨ Yes, _____________ (times) à Go to PART A-C
¨ No
¨ Don’t Know/Remember
¨ Prefer not to Answer

If Q.5 is equal to NO, then skip to the next question.
8. Do you remember the amount of those citations/tickets?
¨ Yes, _______ ($ amount)
¨ No
¨ Don’t know/Remember
¨ Prefer not to Answer

9. Was the citation/ticket for public urination?
¨ Yes
¨ No
¨ Don’t know/Remember
¨ Prefer not to Answer

10. Did you had to go to jail for this citation and or marked as a sex offender?
¨ Yes
¨ No
¨ Don’t know/Remember
¨ Prefer not to Answer

160

11. Do you receive any public assistance and what is the amount? (DO NOT read options)
¨ Yes, Public Housing
¨ Yes, Food Stamps/Cal Fresh/SNAP: _________ ($ amount)
¨ Social Security: _________ ($ amount)
¨ Medicaid/Medi-Cal
¨ General Relief: _________ ($ amount)
¨ Section 8
¨ Other: ___________
¨ None
¨ Prefer not to Answer

12. Do you have difficulty accessing any of the following services? (Select all that apply)
¨ Restrooms (toilets)
¨ Showers
¨ Drinking Water
¨ Water Fountains
¨ Laundry Services
¨ Sinks for Handwashing
¨ Hygiene supplies (soap, toothpaste, razor, tampons/pads, toilet paper, etc.)
¨ Health supplies (needles, overdose kit, medicine, etc.)
¨ None of the Above – all these resources are easily available to me
¨ Prefer not to Answer

Section II. Discrimination
This brief section contains statements about your perceived experiences in accessing services

13. Have you ever felt discriminated in any way when trying to access any of these
resources?
¨ Yes, when trying to use a restroom
¨ Yes, when trying to use a shower
¨ Yes, when trying to get drinking water
¨ Yes, when trying to wash my clothes
¨ Yes, when trying to wash my hands
¨ Yes, when trying to get hygiene supplies
¨ Yes, when trying to get health/medical supplies
¨ No, never
¨ Prefer not to answer

14. Have you ever felt discriminated because of the following reasons?
¨ Age
¨ Race
¨ Gender
¨ Sexual Orientation
¨ Disability Status
¨ Citizenship Status
¨ Religion
¨ Other/more detail: _______________________________
¨ None of the Above – never felt discriminated
¨ Prefer not to answer

161

Section III. Personal Hygiene
The next series of questions are about your personal hygiene. Some of these questions could be
embarrassing to answer. If at any point in this survey there is a question that you do not wish to
answer, please let me know and we will skip that question or conclude the survey.

RESTROOM ACCESS:

15. When you need to urinate, how easy or hard is it for you to find a toilet? (Mark an X)
Very easy Easy Neither easy or
hard
Hard Very hard Prefer not to
answer

16. When you need to defecate, how easy or hard is it for you to find a toilet? (Mark an X)
Very easy Easy Neither easy or
hard
Hard Very hard Prefer not to
answer

17. Upon waking up in the MORNING, where do you go to use a RESTROOM?
¨ Refresh Spot
¨ Shelters/Missions (include name/s): ______________________________________________
¨ Public Restrooms (PIT Stop, libraries, parks, etc.)
¨ Streets, Sidewalk, or Doorway
¨ In Tent using a bucket or other equipment: ________________________________________
¨ Inside restaurants, stores, etc. (include name/s): ____________________________________
¨ Other/more detail ____________________________________________________________
¨ Prefer not to answer

If Q12. is equal to Shelters/Restrooms/Restaurants, then skip to the next question.
18. What do you do to dispose of the waste? (DO NOT READ OPTIONS)
¨ Dispose in drainage
¨ Dispose in trash bin/can
¨ Dispose in bag
¨ Dispose in the street
¨ Other: ____________________________
¨ Prefer not to Answer

19. In the MORNING, how many blocks does it take you to walk to find a RESTROOM?
¨ 1-2 blocks
¨ 3-4 blocks
¨ 5-6 blocks
¨ Other: _________ (estimated number of blocks)
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

20. In the MORNING, how long does it take you to walk to find a RESTROOM?
¨ 1-2 minutes
¨ 3-5 minutes
¨ 6-10 minutes
¨ 11-15 minutes

162

¨ Other: ___________________ (estimated number of minutes)
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

21. In the MORNING, how long do you have to wait to use a RESTROOM?
¨ No wait
¨ 1-2 minutes
¨ 3-5 minutes
¨ 6-10 minutes
¨ 11-15 minutes
¨ Other: ___________________ (estimated number of minutes)
¨ Don’t Know/Remember
¨ Prefer not to answer

22. Why do you go to these places in the MORNING, rather than somewhere else?
¨ It’s free/affordable
¨ It’s open when I need it
¨ It’s not crowded/I don’t have to wait a long time
¨ It’s close to where I stay
¨ It’s clean
¨ I feel safe there
¨ It’s wheelchair accessible
¨ It’s child/pet friendly
¨ The staff/security guards are friendly and welcoming
¨ Other/more detail: ____________________________________________________________
¨ Prefer not to answer

23. In the AFTERNOON, where do you go to use the RESTROOM?
¨ Refresh Spot
¨ Shelters/Missions (include name/s): ______________________________________________
¨ Public Restrooms (PIT Stop, libraries, parks, etc.)
¨ Streets, Sidewalk, or Doorway
¨ In Tent using a bucket or other equipment: ________________________________________
¨ Inside restaurants, stores, etc. (include name/s): ____________________________________
¨ The same place/s as in the morning
¨ Other/more detail ____________________________________________________________
¨ Prefer not to answer

24. In the AFTERNOON, how many blocks does it take you to walk to find a
RESTROOM?
¨ 1-2 blocks
¨ 3-4 blocks
¨ 5-6 blocks
¨ Other: __________ (estimated number of blocks)
¨ Same as the morning-time
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

163

25. In the AFTERNOON, how long does it take you to walk to find a RESTROOM?
¨ 1-2 minutes
¨ 3-5 minutes
¨ 6-10 minutes
¨ 11-15 minutes
¨ Other: ___________________ (estimated number of minutes)
¨ Same as the morning-time
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

26. In the AFTERNOON, how long do you have to wait to use a RESTROOM?
¨ No wait
¨ 1-2 minutes
¨ 3-5 minutes
¨ 6-10 minutes
¨ 11-15 minutes
¨ Other: ___________________ (estimated number of minutes)
¨ Same as the morning-time
¨ Don’t Know/Remember
¨ Prefer not to answer

27. Why do you go to these places in the AFTERNOON, rather than somewhere else?
¨ It’s free/affordable
¨ It’s open when I need it
¨ It’s not crowded/I don’t have to wait a long time
¨ It’s close to where I stay
¨ It’s clean
¨ I feel safe there
¨ It’s wheelchair accessible
¨ It’s child/pet friendly
¨ The staff/security guards are friendly and welcoming
¨ Other/more detail:____________________________________________________________
¨ Prefer not to answer

28. During the middle of the NIGHT, where do you go to use the RESTROOM?
¨ Refresh Spot
¨ Shelters/Missions (include name/s): ______________________________________________
¨ Public Restrooms (PIT Stop, libraries, parks, etc.)
¨ Streets, Sidewalk, or Doorway
¨ In Tent using a bucket or other equipment: ________________________________________
¨ Inside restaurants, stores, etc. (include name/s): ____________________________________
¨ The same place/s as in the morning time
¨ Other/more detail ____________________________________________________________
¨ Prefer not to answer

29. At NIGHT, how many blocks does it take you to walk to find a RESTROOM?
¨ 1-2 blocks
¨ 3-4 blocks
¨ 5-6 blocks

164

¨ Other: __________ (estimated number of blocks)
¨ Same as the morning-time
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

30. At NIGHT, how long does it take you to walk to find a RESTROOM?
¨ 1-2 minutes
¨ 3-5 minutes
¨ 6-10 minutes
¨ 11-15 minutes
¨ Other: ___________________ (estimated number of minutes)
¨ Same as the morning-time
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

31. At NIGHT, how long do you have to wait to use a RESTROOM?
¨ No wait
¨ 1-2 minutes
¨ 3-5 minutes
¨ 6-10 minutes
¨ 11-15 minutes
¨ Other: ___________________ (estimated number of minutes)
¨ Same as the morning-time
¨ Don’t Know/Remember
¨ Prefer not to answer

32. Why do you go to these places at NIGHT, rather than somewhere else?
¨ It’s free/affordable
¨ It’s open when I need it
¨ Other facilities are closed/out of service
¨ It’s not crowded/I don’t have to wait a long time
¨ It’s close to where I stay
¨ It’s clean
¨ I feel safe there
¨ It’s wheelchair accessible
¨ It’s child/pet friendly
¨ The staff/security guards are friendly and welcoming
¨ Other/more detail: ____________________________________________________________
¨ Prefer not to answer

33. Have you ever been denied access to use a BATHROOM service, and if so, where did
this happened?
¨ Yes, _________________________________________________________(locations)
¨ No, I have never been denied access to use a bathroom
¨ Prefer not to answer

34. Why were you denied access to a RESTROOM?
¨ I have to be a customer

165

¨ It cost too much and could not afford it
¨ It was closed [out of service/outside hours of operation/in use/other
¨ I was turned away by staff, a guard, etc. because of my appearance
¨ It wasn’t child/pet-friendly
¨ Other/more detail: _________________________________________________
¨ None of the Above/ Not Applicable
¨ Prefer not to answer

35. Do you ever have to hold your pee at any time of the day because of a lack of public
restrooms available and how often?
¨ Yes, all the time
¨ Yes, sometimes
¨ Yes, rarely
¨ No, never
¨ Don’t know/Remember
¨ Prefer not to answer

SHOWER ACCESS:

36. In the last week, how often have you changed your clothes?
¨ 1-2 times
¨ 3-4 times
¨ 5-6 times
¨ Everyday
¨ When I can wash my clothes
¨ Don’t Know/Remember
¨ Prefer not to Answer

37. How many times have you had a BATH/SHOWER in the week?
¨ 1-2 times
¨ 3-4 times
¨ 5-6 times
¨ Everyday
¨ Don’t Know/Remember
¨ Prefer not to Answer

38. Do you prefer to shower in the morning, day, or night-time?
¨ Morning
¨ Day/Afternoon
¨ Night
¨ Not applicable
¨ Prefer not to Answer

39. At that time of the day is it more difficult to use take a SHOWER?
¨ Morning
¨ Day/Afternoon
¨ Night
¨ None
¨ Prefer not to answer

40. What places do you visit regularly to SHOWER?
¨ Refresh Spot

166

¨ LAMP/People’s Concern
¨ Lava Mae/Other Mobile Showers
¨ Shelters/Missions (include name/s): ______________________________________________
¨ Public Restrooms (PIT Stop, libraries, parks, etc.)
¨ In Tent (using a bucket or other equipment:________________________________________
¨ Inside restaurants, stores, etc. (include name/s):_____________________________________
¨ Church/Religious organizations (include name/s):___________________________________
¨ Other/more detail_____________________________________________________________
¨ Not Applicable
¨ Prefer not to answer

41. How many blocks does it take you to walk to find a SHOWER?
¨ 1-2 blocks
¨ 3-4 blocks
¨ 5-6 blocks
¨ Other: ___________ (estimated number of blocks)
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

42. How long does it take you to walk to find a SHOWER?
¨ 1-2 minutes
¨ 3-5 minutes
¨ 6-10 minutes
¨ 11-15 minutes
¨ Other: ___________________ (estimated number of minutes)
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

43. How long do you have to wait to use a SHOWER?
¨ No wait
¨ 5-10 minutes
¨ 15-30 minutes
¨ 60-90 minutes
¨ Other: ___________________ (estimated number of minutes/hours, please specify)
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

44. Are these places available 24 hours or at what time do these places stop running/close for
the day?
¨ Yes, available 24 hours
¨ No, _____________ (time)
¨ Don’t know/Remember
¨ Prefer not to answer

45. Why do you go SHOWER in this place/these places rather than somewhere else?
¨ It’s free/affordable
¨ It’s open when I need it

167

¨ It’s not crowded/I don’t have to wait a long time
¨ It’s close to where I stay
¨ It’s clean
¨ I feel safe there
¨ It’s wheelchair accessible
¨ It’s child/pet friendly
¨ The staff/security guards are friendly and welcoming
¨ Other/more detail:____________________________________________________________
¨ Prefer not to answer

46. Have you ever been denied access to use a SHOWER service, and if so, where did this
happened?
¨ Yes,_______________________________________________________________(locations)
¨ No, I have never been denied access to use a shower
¨ Prefer not to answer

47. Why were you denied access to a SHOWER?
¨ I have to be a customer
¨ It cost too much and could not afford it
¨ It was closed [out of service/outside hours of operation/in use/other
¨ I was turned away by staff, a guard, etc. because of my appearance
¨ It wasn’t child/pet-friendly
¨ Other/more detail: _________________________________________________
¨ None of the Above/ Not Applicable
¨ Prefer not to answer

48. Of the places you frequent to shower or use the toilet, do they provide the following?
(Mark each box that applies)

Supply Yes No Sometimes Maybe
Prefer not to
answer
Toilet Paper
Soap
Hand Sanitizer
Seat Cover
Paper Towels/Air Dryer
Trash Can
Feminine Hygiene Products
(Females only)

Toilet that flushes
Functioning Sink
Doors with Working Locks
Well-Lit
Toothpaste/Toothbrush
Towel
Other: ___________________

168

DRINKING WATER ACCESS:

49. What places do you visit regularly to get DRINKING WATER in the MORNING?
¨ Donations
¨ Public Water Fountains
¨ Fire Hydrant
¨ Supermarket/Liquor store (self-purchase)
¨ Restaurant, stores etc. (include name/s):___________________________________________
¨ Shelters/Missions (include name/s):______________________________________________
¨ Public Restrooms (PIT Stop, libraries, parks, etc.)
¨ Church/Religious organizations (include name/s): __________________________________
¨ Other/more detail:____________________________________________________________
¨ Not Applicable
¨ Prefer not to answer

50. In the MORNING, how many blocks does it take you to walk to find DRINKING
WATER?
¨ 1-2 blocks
¨ 3-4 blocks
¨ 5-6 blocks
¨ Other: __________ (estimated number of blocks)
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

51. In the MORNING, how long does it take you to walk to find DRINKING WATER?
¨ 1-2 minutes
¨ 3-5 minutes
¨ 6-10 minutes
¨ 11-15 minutes
¨ Other: ___________________ (estimated number of minutes)
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

52. What places do you visit regularly to get DRINKING WATER in the NIGHT?
¨ Donations
¨ Public Water Fountains
¨ Fire Hydrant
¨ Supermarket/Liquor store (self-purchase)
¨ Restaurant, stores etc. (include name/s)___________________________________________
¨ Shelters/Missions (include name/s):______________________________________________
¨ Public Restrooms (PIT Stop, libraries, parks, etc.)
¨ Church/Religious organizations (include name/s): __________________________________
¨ Other/more
detail:______________________________________________________________________
¨ Not Applicable
¨ Prefer not to answer

169

53. During the NIGHT, how many blocks does it take you to walk to find DRINKING
WATER?
¨ 1-2 blocks
¨ 3-4 blocks
¨ 5-6 blocks
¨ Other: __________ (estimated number of blocks)
¨ Same as the morning-time
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

54. During the NIGHT, how long does it take you to walk to find DRINKING WATER?
¨ 1-2 minutes
¨ 3-5 minutes
¨ 6-10 minutes
¨ 11-15 minutes
¨ Other: ___________________ (estimated number of minutes)
¨ Same as the morning-time
¨ Don’t Know/Remember
¨ Not Applicable
¨ Prefer not to answer

55. Why do you go to these places to get DRINKING WATER, rather than somewhere
else?
¨ It’s free/affordable
¨ It’s available when I need it
¨ It’s not crowded/I don’t have to wait a long time
¨ It’s close to where I stay
¨ The water is clean
¨ I feel safe there
¨ It’s wheelchair accessible
¨ It’s child/pet friendly
¨ The staff/security guards are friendly and welcoming
¨ Other/more detail:________________________________________________________________
¨ Prefer not to answer

56. What is your MAIN source of drinking water?
¨ Bottled water from shelters/missions
¨ Bottled water from street donations
¨ River/Creek
¨ Water Fountains (from parks and libraries)
¨ Fire Hydrant
¨ Neighborhood Sprinkler/Water hose
¨ Free Water from Restaurants
¨ Other: _____________________
¨ Not Applicable
¨ Prefer not to answer

57. Have you ever been denied access to DRINKING WATER, and if so, where did this
happened?
¨ Yes,_________________________________________________________(locations)
¨ No, I have never been denied to drinking water

170

¨ Prefer not to answer

58. Why were you denied access to DRINKING WATER there?
¨ I have to be a customer
¨ It cost too much and could not afford it
¨ It was closed [out of service/outside hours of operation/in use/other
¨ I was turned away by staff, a guard, etc. because of my appearance
¨ It wasn’t child/pet-friendly
¨ Other/more detail: _________________________________________________
¨ None of the Above/ Not Applicable
¨ Prefer not to answer

59. Do you think you drink sufficient water throughout the day?
¨ Yes
¨ No
¨ Other: _______________________
¨ Prefer not to answer

60. On a daily basis, on average, how much drinking water do you actually consume?
¨ 0-3 bottles
¨ 4-6 bottles
¨ Greater than 6 bottles
¨ Don’t Know
¨ Prefer not to answer

LAUNDRY SERVICES

61. What places do you visit regularly to do LAUNDRY?
¨ Refresh Spot
¨ LAMP/People’s Concern
¨ Public Sink (PIT Stop, parks, libraries, etc.)
¨ Sinks in restaurants, stores, etc. (include name/s): ___________________________________
¨ Shelters/Missions; include name/s:_______________________________________________
¨ Private Laundromat (self-pay); include name/s:_____________________________________
¨ Other/more detail:____________________________________________________________
¨ Prefer not to answer

62. Why do you go to WASH YOUR CLOTHES in this place/these places?
¨ It’s free/affordable
¨ It’s open when I need it
¨ It’s not crowded/I don’t have to wait a long time
¨ It’s close to where I stay
¨ It’s clean
¨ I feel safe there
¨ It’s wheelchair accessible
¨ It’s child/pet friendly
¨ The staff/security guards are friendly and welcoming
¨ Other/more detail:____________________________________________________________
¨ Prefer not to answer

171

63. How often do you WASH YOUR CLOTHES? (Mark an X)
Everyday Twice a
Week
Once a Week One a Month None Other Prefer not to
Answer

64. Have you ever been denied access to WASH YOUR CLOTHES, and if so, where did
this happened?
¨ Yes,_________________________________________________________(locations)
¨ No, I have never been denied to laundry services
¨ Prefer not to answer

65. Why were you denied access to WASH YOUR CLOTHES there?
¨ It cost too much and could not afford it
¨ It was closed [out of service/outside hours of operation]
¨ I was turned away by staff, a guard, etc. because of my appearance
¨ It wasn’t child/pet-friendly
¨ Other/more detail: _________________________________________________
¨ None of the Above/ Not Applicable
¨ Prefer not to answer

HANDWASHING / SINKS

66. How often do you wash your hands? (Check box that applies for each category)

Situation
Soap or
Sanitizer
Always Often Sometimes Rarely Never
Prefer not
to answer
Before Preparing Food

Before Eating Food

After Using The Toilet

67. Where do you go to WASH YOUR HANDS, when possible?
¨ Refresh Spot
¨ LAMP/People’s Concern
¨ Public Sink (PIT Stop, parks, libraries, etc.)
¨ Sinks in restaurants, stores, etc. (include name/s): ______________________________________
¨ Shelters/Missions; include name/s:__________________________________________________
¨ Church/Religious Organizations (include name/s): _____________________________________
¨ Other/more detail:________________________________________________________________
¨ Prefer not to answer

68. Why do you go to these places to WASH YOUR HANDS, rather than somewhere else?
¨ It’s free/affordable
¨ It’s open when I need it
¨ It’s not crowded/I don’t have to wait a long time
¨ It’s close to where I stay
¨ It’s clean
¨ I feel safe there

172

¨ It’s wheelchair accessible
¨ It’s child/pet friendly
¨ The staff/security guards are friendly and welcoming
¨ Other/more detail:
______________________________________________________________________
¨ Prefer not to answer

HYGIENE SUPPLIES

69. What HYGIENE SUPPLIES do you need the most but are difficult to obtain?
¨ Supplies needed:____________________________________________________________
¨ None, I can easily access everything I need
¨ Don’t know/Remember
¨ Prefer not to answer

70. Where do you obtain HYGIENE SUPPLIES when possible?
¨ Shelters/Missions; include name/s:__________________________________________________
¨ Church/Religious Organizations (include name/s):______________________________________
¨ Self-bought in stores/pharmacies
¨ Non-profits (include name/s):_______________________________________________________
¨ Clinics (include name/s):__________________________________________________________
¨ Other/more detail:________________________________________________________________
¨ Prefer not to answer

Section IV. Demographics
In this section, you will be asked basic demographic questions. If at any point in this section there is a
question that you do not wish to answer, please let me know and we will skip the question.

71. What is your age? ______________ (Write actual age)
¨ Prefer not to answer

72. What is your gender identity? (DO NOT read options)
¨ Female
¨ Male
¨ Transgender female
¨ Transgender male
¨ Do not identify with any
¨ Other: ___________________________
¨ Prefer not to answer

73. What is your sexual orientation? (DO NOT read options)
¨ Heterosexual
¨ Bisexual
¨ Homosexual
¨ Asexual
¨ Queer
¨ Not Sure/Questioning
¨ Other: ____________________________
¨ Prefer not to answer

173

74. Are you a U.S. citizen/permanent resident?
If you do not feel comfortable answering them, we would skip these questions.
¨ Yes
¨ No
¨ Prefer not to answer

75. What is your nationality? _________________________
¨ Prefer not to answer

76. What race/ethnicity do you identify yourself with? (DO NOT READ OPTIONS)
¨ White/Caucasian
¨ Black/African American
¨ Latino/Hispanic
¨ Asian
¨ American Indian/Alaska Native
¨ Native Hawaiian/Pacific Islander
¨ Other _____________________________
¨ Prefer not to answer

77. What is your preferred language? ____________________________
¨ Prefer not to Answer

78. What is your current marital status? (DO NOT READ OPTIONS)
¨ Single
¨ Married
¨ Separated
¨ Divorced
¨ Widowed
¨ Prefer not to answer

79. What is your highest level of education completed? (DO NOT READ OPTIONS)
¨ No Education
¨ 8
th
Grade or Less
¨ Some High School, Did Not Graduate
¨ High school diploma or GED
¨ Technical or vocational school
¨ Some college
¨ 4-Year college degree (Undergraduate)
¨ More than 4-year college graduate degree (Master’s, Doctoral, M.D. degree)
¨ Other _______
¨ Prefer not to Answer

80. Are you currently employed?
Yes à Go to PART A
No à Go to PART B
Prefer not to answer
If “YES,” complete the following question

80A. What is your current estimated monthly income? (Refer back to Q.6 Public Assistance)

174

¨ Answer: _____________________________ ($ monthly income)
¨ Prefer not to answer
¨ If “NO” complete the following question
¨ What is your current status?
¨ Retired
¨ Disabled
¨ Other___________
¨ Prefer not to answer

81. Have you ever served in the military?
¨ Yes à Go to PART A
¨ No
¨ Don’t Know
¨ Prefer not to answer
If “NO,” skip and move on to the next question (DO NOT READ OPTIONS)

81A. What is your status?
¨ Active
¨ Reserve
¨ Honorable Discharge
¨ Dishonorable Discharge
¨ General Discharge
¨ Other Than Honorable Discharge
¨ Retired/Disabled
¨ Prefer not to answer

Section V. Health
The next questions are about your health conditions and access to health services. We understand that
these questions could be embarrassing. If at any point in this survey there is a question or statement that
you do not wish to answer, please let me know and we will go on to the next question.

82. In the past 12 months, have you visited the Emergency Department and how many
times?
¨ Yes: ______________________________ (times in the past year AND reason for visit)
¨ No
¨ Prefer not to Answer

83. How often do you access health care services?
¨ Not Often
¨ Rarely
¨ Sometimes
¨ All the time
¨ Do not access health services
¨ Other: __________________________________
¨ Prefer not to answer

84. What is your biggest health concern at the moment? __________________________

175

85. In the past MONTH (30 days), have you ever experienced or been diagnosed or any of
the following health conditions? (Check all that applies)
¨ Dehydration
¨ Migraines/Headache
¨ Difficulty having bowel movement
¨ Skin infections (including staph, cellulitis)
¨ Urinary tract infections
¨ Head and or body lice
¨ Diarrhea/Loose stool
¨ Scabies
¨ Fungus
¨ Typhus
¨ Hepatitis A
¨ Other: __________________________________
¨ None of the above
¨ Prefer not to answer

86. In the past YEAR (12 months) have you ever experienced or been diagnosed with any of
the following health conditions? (Check all that applies)
¨ Dehydration
¨ Migraines/Headache
¨ Difficulty having bowel movement
¨ Skin infections (including staph, cellulitis)
¨ Urinary tract infections
¨ Head and or body lice
¨ Diarrhea/Loose stool
¨ Scabies
¨ Fungus
¨ Typhus
¨ Hepatitis A
¨ Other: _________________________________
¨ None of the above
¨ Prefer not to answer

87. In the past 30 days, how often have you had a bowel movement (able to poo)?
¨ 2 or more times a day
¨ Once a day
¨ 2 or more times a week
¨ Once a week
¨ 1-3 times a month
¨ Never
¨ Don’t know/Remember
¨ Not applicable
¨ Prefer not to answer

88. Have you ever received the Hepatitis A vaccine (it is a vaccine usually given to children
and consist of 2 doses, administered 6 months apart)?
¨ Yes
¨ No
¨ Don’t know/Remember

176

¨ Prefer not to answer

89. In the past MONTH (30 days), have you ever stopped taking any prescribed medications
because of the inability to cope with side effects (such as diarrhea, frequent urination,
etc.) and difficulty accessing restrooms and other water services?
¨ Yes
¨ No
¨ Not applicable, not taking any medications
¨ Prefer not to answer

90. In the past MONTH (30 days), did you stopped you stopped taking any psychiatric
medications because of the inability to cope with side effects?
¨ Yes
¨ No
¨ Not applicable, not taking any medications
¨ Prefer not to answer

91. In the past 30 days have you taken hormonal therapy?
¨ Yesà GO TO PART A
¨ No
¨ Prefer not to answer
If “YES” answer the following question

91A. Did you had access to a restroom and proper hygiene services when taking
hormonal therapy?
¨ Yes, how so: ____________________________
¨ No
¨ Not Applicable
¨ Prefer not to Answer

FOR FEMALE STUDY PARTICIPANTS.
92. Do you still experience your menstrual cycle?
¨ Yes à Answer Questions A-C
¨ No
¨ Not Applicable, Male Participant
¨ Prefer not to Answer
If “NO” skip the following questions

92A. Do you have concerns or difficulties regarding hygiene during your periods? If so,
what are your concerns?
¨ Yes, Answer: ___________________________________
¨ No
¨ Prefer not to Answer

92B. Do you ever have issues acquiring feminine hygiene products? (For example:
tampons, pads, wipes, etc.)?
¨ Yes, Answer: ___________________________________

177

¨ No
¨ Prefer not to Answer

92C. Do you take birth control?
¨ Yes, which kind: ___________________________________
¨ No
¨ Prefer not to Answer

93. In the past 30 days, where have you obtained your meals and what kind of foods did they
served/did you purchased?
¨ Market (self-bought)__________________________________________________________
¨ Sit down Restaurant___________________________________________________________
¨ Fast-food Restaurant__________________________________________________________
¨ Mission/Soup kitchen_________________________________________________________

94. On average, do you sleep in the day or night and how many hours of sleep?
¨ Morning, __________hours
¨ Night, _____________ hours
¨ Prefer not to answer

95. Have you ever been arrested/incarcerated?
¨ Yes, _____________________________________ (number of times AND reason)
¨ No, never
¨ Prefer not to answer

96. Do you have solid waste piles near your living area?
¨ Yes
¨ No, never
¨ Prefer not to answer

97. How frequently is trash collected in the area?
¨ Everyday
¨ Once a week
¨ Twice a week
¨ Rarely/Not Enough
¨ Other: ______________
¨ Prefer not to answer

98. How often do you drink alcoholic beverages?

Don’t Drink Monthly or less 2-4 times per
month
2-3 times per
week
4+ times per
week
Prefer not to
Answer

99. Have you ever used drugs other than those required for medical reasons? (such as,
marijuana, cocaine, heroin, hallucinogens, and inhalants, as well as the misuse of opioids,
prescription pain relievers, tranquilizers, stimulants, and sedatives)
¨ Yes, which ones:_______________________________________________________

178

¨ No, never
¨ Prefer not to answer

99A. How long has it been since you last used these drugs, in any form?
¨ Last used: ______________________________ (enter number of days, weeks,
months, or years)
¨ Not applicable, do not uses drugs
¨ Don’t Know/Remember
¨ Prefer not to Answer

99B. Did you started using drugs when you became homeless or before?
¨ Started before I became homeless
¨ Started after I became homeless
¨ Not applicable, do not uses drugs
¨ Don’t Know/Remember
¨ Prefer not to answer

99C. How expensive is it to get these drugs?
¨ Price: ___________________________ (insert $ amount)
¨ Not applicable, do not uses drugs
¨ Don’t Know/Remember
¨ Prefer not to answer

100. If you had the opportunity, would you consider moving into permanent housing?
¨ Yes
¨ No
¨ Don’t Know/Remember
¨ Prefer not to answer

101. Is there anything else that you would like to share with us?
Answer:________________________________________________________________________________________

179
Appendix B Closest Facility Analysis Tables
Table 3.4. Closest restroom facility model results for morning time of the day (N=186, not all responses shown)

Morning time restroom Factors driving usage
a
Facility
Closest to n
people
Total actual
use
Total
facilities
skipped
Total
distance
traveled (mi)
Median
distance
traveled (mi) Distance (n)
Free/
affordable
(n)
Accessible
b
(n)
Tent 0 91 0 .00 .00 38 13 51
Refresh spot 13 32 349 17.31 .22 10 10 35
The People Concern 1 8 54 2.19 .20 5 2 8
Midnight mission 8 6 57 1.64 .30 2 2 4
St. Francis center 9 6 117 5.76 .66 4 2 3
Los Angeles mission 2 4 34 .77 .17 0 0 4
Union station 2 4 68 2.51 .51 3 2 1
Placita Olvera 11 4 19 1.25 .25 3 0 5
Grand park 1 4 46 2.08 .52 3 1 4
Union Rescue mission 0 3 7 .06 .01 1 1 2
City hall 6 3 9 .46 .15 1 0 3
McDonalds #3 1 3 8 .73 .21 1 0 3
Downtown women’s
center 4 2 9 .18 .10 0 1 1
Weingart 10 2 2 .05 .02 1 0 2

a
Factors included in this model based on people’s responses as to why they utilized these specific services.
b
Accessibility is an aggregated factor measured in terms of safety, open, ADA accessible, friendly staff, pet friendly, and clean.

180
Table 3.5. Closest restroom facility model results for afternoon time of the day (N=163 not all responses shown)

Afternoon time restroom Factors driving usage
a
Facility
Closest to
n people
Total
actual use
Total
facilities
skipped
Total
distance
traveled
(mi)
Median
distance
traveled
(mi)
Distance
(n)
Free/
affordable
(n)
Accessible
b
(n)
Tent 0 45 0 .00 .00 16 8 36
Refresh spot 11 29 309 17.34 .22 13 10 31
Midnight mission 7 12 135 3.54 .32 2 2 12
The People Concern 1 9 117 4.10 .29 0 1 7
Union station 2 8 249 17.08 1.48 4 1 5
LA Central library 1 7 283 15.78 1.16 0 3 6
Los Angeles mission 2 6 88 3.01 .22 2 0 7
Grand park 0 6 130 4.54 .62 6 1 5
Union Rescue
mission 0 5 20 .35 .03 1 1 4
Placita Olvera 11 5 61 2.19 .24 2 1 6
McDonalds #3 1 4 67 3.96 .20 3 0 3
St. Francis center 7 3 49 1.31 .10 2 1 1
Downtown
Women’s center 3 1 37 7.22 7.22 2 1 2
Weingart 11 2 2 .05 .02 1 0 1

a
Factors included in this model based on people’s responses as to why they utilized these specific services.
b
Accessibility is an aggregated factor measured in terms of safety, open, ADA accessible, friendly staff, pet friendly, and clean.

181
Table 3.6. Closest restroom facility model results for evening time of the day (N=191, not all responses shown)

Night time restroom Factors driving usage
a
Facility
Closest to
n people
Total
actual use
Total
facilities
skipped
Total
distance
traveled
(mi)
Median
distance
traveled
(mi)
Distance
(n)
Free/
affordable
(n)
Accessible
b
(n)
Tent 0 114 0 .00 .00 50 12 87
Refresh spot 13 32 272 15.29 .18 14 12 31
Midnight mission 6 10 86 3.00 .20 2 3 11
Union Rescue
mission 0 7 24 .38 .01 1 1 3
The People Concern 1 6 36 1.47 .20 2 0 5
Union station 2 6 91 6.54 .31 3 1 4
PIT Stop #4 22 2 17 .42 .21 2 1 2
Los Angeles mission 2 2 8 .76 .38 0 0 2
Weingart center 11 2 2 .05 .02 1 0 2
McDonalds #3 2 2 42 1.24 .62 1 0 1
Grand park 2 2 11 .73 .36 0 0 2
Downtown women’s
center 4 1 2 .05 .05 1 0 0
Little Tokyo mall 2 1 21 .47 .47 1 0 1
Police department 4 1 27 3.29 3.29 1 1 1

a
Factors included in this model based on people’s responses as to why they utilized these specific services.
b
Accessibility is an aggregated factor measured in terms of safety, open, ADA accessible, friendly staff, pet friendly, and clean.

182
Table 3.7. Closest shower facility model results (N=203, not all responses shown)

Shower Factors driving usage
a
Facility
Closest to n
people
Total actual
use
Total
facilities
skipped
Total
distance
traveled
(mi)
Median
distance
traveled
(mi) Distance (n)
Free/
affordable
(n)
Accessible
b
(n)
Tent 0 8 0 .00 .00 2 1 5
Refresh spot 14 84 844 93.10 .36 26 24 81
St. Francis center 26 26 183 41.44 .51 11 4 20
Midnight mission 6 22 183 14.87 .37 8 4 22
The People Concern 2 19 113 14.43 .24 6 4 22
LavaMae
x
32 11 112 25.6 .70 2 1 8
Downtown women’s
center 19 8 72 10.71 .32 3 3 10
Los Angeles mission 4 8 42 3.60 .28 1 3 8
Union Rescue mission 6 7 41 3.07 .25 1 2 7
Weingart center 6 3 6 .21 .05 1 0 3
Grand park 5 2 4 .51 .36 2 2 0
YMCA gym 1 1 14 .85 .85 0 1 0
Planet Fitness 3 1 7 1.28 1.28 0 1 1
Shower of Hope 0 1 29 2.82 2.82 0 0 2

a
Factors included in this model based on people’s responses as to why they utilized these specific services.
b
Accessibility is an aggregated factor measured in terms of safety, open, ADA accessible, friendly staff, pet friendly, and clean.

183
Table 3.8. Closest laundry facility model results (N=133, not all responses shown)

Laundry Factors driving usage
a
Facility
Closest to n
people
Total actual
use
Total
facilities
skipped
Total
distance
traveled
(mi)
Median
distance
traveled
(mi) Distance (n)
Free/
affordable
(n)
Accessible
b
(n)
Tent 0 16 0 .00 .00 4 6 14
Refresh spot 18 81 503 65.21 .34 24 56 41
The People Concern 2 22 99 18.43 .33 8 7 11
Weingart center 12 3 9 .27 .05 2 2 3
Downtown women’s
center 20 2 6 .31 .15 1 1 1
Laundromat 1 0 2 39 8.28 4.14 1 0 3
St. Francis center 11 1 1 .33 .33 0 0 1
Grand park 24 1 1 .66 .66 0 0 1
Laundromat 2 3 1 16 2.25 2.25 0 0 1
Burbank aid center 0 1 22 12.95 12.95 0 1 0
Laundromat 3 2 1 15 2.17 2.17 0 0 0
Union Rescue mission 3 0 0 .00 .00 NA NA NA
Midnight mission 1 0 0 .00 .00 NA NA NA
Los Angeles mission 16 0 0 .00 .00 NA NA NA

a
Factors included in this model based on people’s responses as to why they utilized these specific services.
b
Accessibility is an aggregated factor measured in terms of safety, open, ADA accessible, friendly staff, pet friendly, and clean.

184
Table 3.9. Closest drinking water facility model results (N=91, not all responses shown)

Drinking water Factors driving usage
a
Facility
Closest to n
people
Total actual
use
Total
facilities
skipped
Total
distance
traveled
(mi)
Median
distance
traveled
(mi) Distance (n)
Free/
affordable
(n)
Accessible
b
(n)
Refresh spot 9 13 113 5.33 .12 5 2 6
Midnight mission 4 9 115 7.80 .37 2 2 4
St. Francis center 8 9 111 14.82 .03 5 2 3
Hippie soup kitchen 9 5 13 .87 .16 3 2 2
Placita Olvera 7 5 16 1.45 .22 1 4 6
Downtown women’s
center 6 4 51 3.81 .24 1 0 4
The People Concern 2 4 15 .65 .20 1 0 1
LA Central library 1 4 84 17.00 .97 2 1 5
Los Angeles mission 3 3 20 .63 .25 1 1 2
McDonalds #1 1 3 95 4.60 1.50 0 0 4
Gladys park 0 3 19 .70 .20 1 0 2
San Julian park 1 3 23 .95 .33 1 0 0
Daiso store 0 3 84 4.71 .96 0 2 2
Weingart center 7 2 2 .05 .02 1 0 3

a
Factors included in this model based on people’s responses as to why they utilized these specific services.
b
Accessibility is an aggregated factor measured in terms of safety, open, ADA accessible, friendly staff, pet friendly, and clean.

185

Appendix C Interview Tool Guide
Homelessness and Water Insecurity in Los Angeles
Service Provider Interview

Interviewer Instructions: Please read the following statement to study participants

My name is ___________ and we are from the Spatial Sciences Institute at USC. We are
conducting a study that aims to better understand the lives of homeless people in our
communities. Specifically, we wish to study the forms of water, sanitation, and hygiene
(WaSH) insecurity experienced by homeless people on a daily basis in your community.
The purpose of this meeting is to learn from you about the services your organization
provides to the community. We are also interested in learning about your perspectives on
this matter of water security and exchange knowledge in what policies and solutions are
needed to better address homelessness in our communities.

I want to remind you that this interview is completely voluntary and your answers will be
kept confidential. If at any point in this interview, you have a question or statement you
do not wish to answer, please let me know and we will go on to the next question. The
interview will take about 30-60 minutes. With your permission, we would like to audio-
record this interview for transcription purposes to analyze the common themes generated
in the answers. If you do not want to be recorded, handwritten notes will be taken.

Are you over the age of 18?
¨ Yes → Continue with Survey
¨ No → Stop interview. Participant does not qualify. Thank them for their time and move
on to the next person

Interview Recorded:
¨ Yes
¨ No

Address of Service Provider/Organization:

___________________________________________________

Participant’s Study ID: Today’s Date: ___________
Interviewer Initials:
Interview Completed:
¨ Yes
¨ No

186

1. Name of study participant: ____________________________ (if participant feels comfortable
disclosing)

2. Name of organization participant work: _______________________________

3. How many years have you been working in [name of organization]?
__________________

4. Can you tell me about the specific services provided by your organization?

5. How does your organization prioritize the delivery of services to homeless members of
your community?

6. Can you describe models of community engagement within your organization? In other
words, are homeless people involved in the decision/planning process?

WaSH Access

7. How does your organization decides where services are allocated?

[Note: if this is a WaSH service provider, then services specify, where WaSH services
are allocated (e.g., water = drinking water; sanitation = restrooms; hygiene = showers,
laundry and handwashing stations)

8. To what extent do you believe increasing access to water, sanitation, and hygiene
services is part of the current homeless crisis agenda? Can you say a little bit more about
that?

9. Where do you believe the biggest shortage is across the different types of water,
sanitation, and hygiene facilities? In other words, which is/are in shortest supply in the
community? (e.g., restrooms?, laundry services?, showers? or public fountains?)

10. What do you believe are the main barriers that prevent people experiencing
homelessness from gaining access to safe and equitable water, sanitation, and hygiene
services?

11. What do believe are the main obstacles to providing water, sanitation, and hygiene
(WaSH) services to the community at all times of the day?

12. What do you believe is one of the best thing the City has done to address the water needs
of the community of Skid Row? Why is that?

13. What do you believe has been an unsustainable/detrimental way in which the City has
addressed the needs of people experiencing homelessness? Why is this a bad example to
follow? What positive learning can we take from this?

187

Prevention

14. How might the access of water, sanitation, and hygiene services help reduce the cycle of
poverty/homelessness or does it sustains it?
[Note: Criticism that I have received is that if we were to provide these services, people
will not want to transition to permanent housing]

15. What are different types of immediate strategies/interventions that can be provided to
increase access to water, sanitation, and hygiene services in the community?

16. Who do you believe has the responsibility or is best placed to address the scarcity of
water services in the community?

17. Are there other organizations that would be more appropriate to carry out this type of
work?

Vulnerability Among Homeless Populations

18. Who do you believe are the most vulnerable groups within the homeless community in
accessing WaSH services?

19. What role do you think race plays in gaining access to different types of water services in
the community of Skid Row?

20. How about gender identity and sexual orientation, how do you believe it impacts one’s
access to water services in Skid Row?

Health

21. How has COVID-19 impacted the way your organization provides services to the
community?

22. How has COVID-19 pandemic impacted access to WaSH services in the community as a
whole? Have you noticed the impact?

23. With the current pandemic, have you seen if there are any new temporary or
permanent WaSH facilities set up for the homeless community?

24. In what ways can the access of water services impact people’s health and well-being?

25. How have you seen lack of restrooms and hygiene services impacts women’s health?

26. What is the most commonly reported health condition by people experiencing
homelessness?

188

Criminalization

27. Are there any criminalization strategies that you consider detrimental in addressing
homelessness in Los Angeles? (e.g., street clean-ups, public urination, encampments
ticketing, loitering)

General
28. How do you believe we can break the stigma of homelessness?

29. Who do you believe bears the cost of both the provision of homelessness services and for
homelessness crisis?

30. Is there anything else that you would like to share with us today?

31. Are there any service providers that you would recommend us reach out that may be
interested in helping us with this project?

Other:
32. [To LAPD only] As a result of the COVID-19 pandemic, are there any new protocols to
address emergency calls in Skid Row?

33. [To LAPD only] How are homeless outreach police officers critical to connecting people
experiencing homelessness to services?

Housing Services
34. [To Housing Services only] How long does the process take for a housing project to be
completed? From start to finish?

35. [To Housing Services only] What are the roadblocks in speedy the development process
and get housing approved?

Abstract (if available)

Abstract Access to water, sanitation, and hygiene (WaSH) are fundamental human needs. However, global water reports estimate that 2 billion people worldwide live without safely managed access to these WaSH services. The absence and inadequate access to WaSH result in WaSH insecurity experiences that increase individual exposure to preventable water-related health risks and illnesses. While most of the existing research focuses on WaSH insecurity experiences in the global South, this dissertation shifts the attention to the global North, specifically Los Angeles, California, USA. This dissertation aims to better understand how unhoused communities of Los Angeles navigate spaces and places that do not have safe, sufficient, accessible, and affordable access to WaSH services. The following work presents three studies that detail the difficulties unhoused communities encounter, each making a case for interim-level WaSH services that would help address people’s unmet fundamental needs. The first study, integrates survey data from people with lived experience to identify the coping mechanisms people use to survive in places lacking access to WaSH. The second study uses spatial statistics and geographic information systems (GIS) to measure differences in accessibility based on individual and service-level factors that contribute to experiences of WaSH insecurity. The final study incorporates service providers' perspectives using qualitative descriptive interviews to understand the impacts of WaSH insecurity during the SARS-CoV-2 (COVID-19) global pandemic. Together the findings from these studies identify the critical needs of unhoused communities, and meeting these needs presents important policy implications. The findings suggest that addressing WaSH insecurity is crucial because WaSH insecurity reinforces a cycle of homelessness. In other words, WaSH insecurity exacerbates stigmatization, raises barriers in seeking out mainstream services, and negatively affects people's mental and physical health. Therefore, interim-level services, specifically WaSH services, are needed to address the immediate unmet needs of unhoused residents of Los Angeles.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Implementation of peer providers in integrated health care settings

PDF

Modeling patient access to point-of-care diagnostic resources in a healthcare small-world network in rural Isaan, Thailand

PDF

A mixed-methods examination of transgender and gender nonbinary students’schooling experiences: implications for developing affirmative schools

PDF

Incomplete data & insufficient methods: transgender population health research in the US

PDF

Exploring the social determinants of health in a population with similar access to healthcare: experiences from United States active-duty army wives

PDF

The impact of childhood trauma on substance use and mental health during the SARS-CoV-2 pandemic among young adults

PDF

Spatiotemporal studies of out-of-hospital cardiac arrests and bystander cardiopulmonary resuscitation in Los Angeles

PDF

Understanding the role of population and place in the dynamics of seasonal influenza outbreaks in the United States

PDF

Smoke-free housing policies and secondhand smoke exposure in low income multiunit housing in Los Angeles County

PDF

At the intersection of lifelong learning, aging, technology, and brain sciences: the future for Latin-America

PDF

Urban green space accessibility and environmental justice: a GIS-based analysis in the city of Phoenix, Arizona

PDF

Homelessness and substance use treatment: using multiple methods to understand risks, consequences, and unmet treatment needs among young adults

PDF

The environmental and genetic determinants of cleft lip and palate in the global setting

PDF

Food is medicine: the intersection of food insecurity and chronic disease management

PDF

Adolescent mental health services in Nevada: assessing the perspectives of families

PDF

Exploring the practices and experiences of food resource manager in managing food resource rooms to address food insecurity at two-year community colleges

PDF

Service-learning and character development: an analysis of Up with People resulting in a model of global citizens for servant leadership

PDF

Engaging homeless men and shelter providers to adapt an existing evidence-based HIV prevention intervention

PDF

The role of dyadic and triadic factors on psychosocial wellbeing and healthcare interactions among childhood cancer survivors, parents, and medical providers

PDF

Mapping uniformity of park access using cadastral data within Network Analyst in Wake County, NC

Asset Metadata

Creator Avelar Portillo, Lourdes Johanna (author)

Core Title Homeless encampments and access to Water, Sanitation, and Hygiene (WaSH) services in Los Angeles, CA

School College of Letters, Arts and Sciences

Degree Doctor of Philosophy

Degree Program Health and Place,Population

Degree Conferral Date 2021-12

Publication Date 10/06/2021

Defense Date 06/02/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag GIS,Global North,Homelessness,Hygiene,Los Angeles,mixed-methods,network analysis,OAI-PMH Harvest,sanitation,unhoused communities,urban WaSH insecurity,WaSH insecurity,water insecurity

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Chiang, Yao-Yi (committee chair), Franklin, Meredith (committee chair), Ferguson, Laura (committee member), Henwood, Benjamin (committee member), Pastor, Manuel (committee member)

Creator Email avelarpo@usc.edu,ljavelar@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC16022359

Unique identifier UC16022359

Legacy Identifier etd-AvelarPort-10128

Document Type Dissertation

Format application/pdf (imt)

Rights Avelar Portillo, Lourdes Johanna

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu