Rising rates of people experiencing homelessness in rural areas call for increased WASH-access, particularly among women

In the United States, 2.3 to 3.5 million people experience homelessness every year. While homelessness is often considered an urban issue, it’s a problem that is growing in rural areas, where substance use can serve as a catalyst for homelessness. New research led by investigators at the Rollins School of Public Health at Emory University highlights the substantial barriers to accessing water, sanitation, and hygiene (WASH) services among people experiencing homelessness in rural areas.

To help combat this significant—and growing—public health issue, the authors call for developing place-based, stigma-free access to WASH facilities in rural areas, with specific focus placed on meeting the sanitary needs of women and people who inject drugs. April M. Ballard, MPH, was lead author on the article. Additional authors include Hannah L. F. Cooper, ScD, and Bethany A. Caruso, PhD, MPH, both from Rollins; and April M. Young, PhD, from University of Kentucky. 

“Limited WASH access is not only concerning from an infectious disease transmission standpoint, but also from a dignity and human rights standpoint,” says Ballard. “WASH, when sufficient, provides us the space to care for ourselves and have dignity, to feel human. This is acutely true during a global pandemic and as many Americans are newly experiencing homelessness.”

The investigators conducted exploratory research on people experiencing homelessness in five counties in rural Appalachian Kentucky to better understand barriers to WASH resources and unique challenges facing this population, particularly in relation to substance use. Interviews with research participants revealed the complex and interrelated impacts of unmet WASH needs on self-esteem, self-worth, and drug usage.

“The important link between WASH and substance use is rarely recognized, despite the fact that harm reduction approaches to injection drug use ask people to use clean water to mix or dilute drugs and clean their skin and hands prior to injecting,” says Ballard. “Our findings reveal nuances that researchers and practitioners should consider. For example, how can we ask people to perform these behaviors when they may not even have access to clean drinking water or a shower to clean their body?”

The authors recommend that rural areas build onto the new public WASH infrastructure established during the COVID-19 pandemic and to provide public sanitation facilities equipped with showers, restrooms, and laundry access, as well as free hygiene and menstrual products. They also recommend that these services be spread throughout rural communities and for access to facilities to be made available unconditionally (i.e. no ID requirements or felony or drug background checks) alongside harm reduction services.