Less than a quarter of people experiencing unsheltered homelessness (PEUH) in Los Angeles report access to a toilet, and about one-third eat less than one meal per day. Access to showers, safe drinking water and medical care is also limited. The findings were just published in the Journal of Primary Care and Community Health.
The study was conducted by the USC Street Medicine team, which delivers on-the-ground primary care to PEUH, and includes responses from 665 adults across Los Angeles County.
Most studies of homelessness look collectively at unsheltered individuals and those living in temporary shelters. Instead, the present study focused specifically on people living in places not intended for habitation, such as a car, tent or sidewalk, in order to gain detailed insights about this group's needs.
"Among this population, we found pervasive unmet needs for the most basic things, which are access to a toilet, meals, water and hygiene," said lead author Alexis Coulourides Kogan, PhD, assistant professor of family medicine and geriatrics at the Keck School of Medicine of USC and director of research for USC Street Medicine.
"If someone cannot meet those very basic needs, there is likely no way to do things like look for a job, get on housing lists or even go to a doctor's office—hunger and thirst supersede all else," she said.
The study also revealed geographic differences in how PEUH access food, water and bathroom facilities, such as purchasing water from a business versus using public sources. Kogan said these findings can help tailor support efforts so that urgent needs can be addressed while longer-term solutions are implemented.
"Solutions for housing are in the works, which is fantastic," she said. "In the meantime, people have basic needs that must be met—or they're not going to be able to utilize those other services."
Urgent unmet needs
USC Street Medicine dispatches small teams—typically consisting of a physician assistant, nurse, community health worker, and nursing aid—to offer medical care to PEUH in the places they call home. During a series of visits in 2022 and 2023, they surveyed 665 adults, aged 18 and older, using the HOUSED BEDS assessment tool.
The HOUSED BEDS survey was specifically designed to assess social determinants of health among PEUH. It was developed at the Keck School of Medicine by Brett Feldman, MSPAS, PA-C, clinical associate professor of family medicine and director of USC Street Medicine, and Corinne Feldman, MMS, PA-C, clinical assistant professor of family medicine.
Among those surveyed, 22.5% of participants reported access to a toilet, and 43.9% had access to a shower. Participants ate an average of 8.25 meals per week, with 32.7% of them eating less than one meal per day. While 72.4% had access to clean drinking water, 35.4% reported having concerns about unsafe water. Just 7% of participants had seen a primary care provider in the past year.
The researchers found significant geographic differences on multiple factors, including participants' primary source of food, water and bathroom facilities. For example, PEUH in Hollywood relied heavily on local businesses to purchase water or use a toilet. In other parts of the city, public parks were more likely to provide a source of safe drinking water.
"Given the geographic variation in how needs are met, there's not one solution that fits all," Kogan said. "We really need to be thoughtful about how we target solutions and triage resources to different areas."
Finding targeted solutions
Kogan applauds the efforts of Los Angeles County and the state of California to build both temporary shelters and long-term housing for people experiencing homelessness.
"At the same time, if people cannot eat or drink today, they're not going to be well or alive to get into those housing solutions, which will take some time to develop," she said.
The study shows that urgent help is needed to ensure PEUH across Los Angeles can access basic resources. It also points to the effectiveness of a street medicine approach in reaching people who are unable to visit a doctor's office.
The street medicine model, as well as the HOUSED BEDS survey, can both be applied outside of Los Angeles to help PEUH in other states or countries, Kogan said.
She and her team have several related studies underway. One effort aims to develop profiles of PEUH to determine which groups face the most urgent unmet needs. Another involves analyzing whether people who receive care from USC Street Medicine have better access to essential resources than those who are not engaged in care.
"When going without the basics for survival like food, showers, or healthcare, it's almost impossible to self-resolve your own homelessness. This underscores the need to take resources to the people through programs like street medicine," said Brett Feldman, who was one of the study's coauthors.
About this research
In addition to Kogan, Feldman and Feldman, the study's other authors are Camilo Zaks and Jehni Robinson from the Department of Family Medicine and Geriatrics, Keck School of Medicine of USC, University of Southern California; and Jersey Chen from Rutgers Robert Wood Johnson Medical School.
