Navigating water, sanitation and hygiene (WaSH) access at the intersections of poverty, substance use, sex work and gender: A qualitative analysis of Vancouver, Canada's washroom trailer program

Although substantial disparities in access to Water, Sanitation and Hygiene (WaSH) facilities persist in high-income countries (HICs), few studies have explored the WaSH experiences of marginalized and criminalized communities in HICs. Our study assessed how the Washroom Trailer Program (WTP), a municipal response to large-scale closures of public washrooms during the COVID-19 pandemic, shaped experiences of health (in)equity among unhoused/precariously housed people, sex workers and people who use substances in Vancouver, Canada. Specifically, we examined how WTP interventions shaped access to WaSH services, overdose prevention, risks of gender-based violence (GBV), and connections to health care and social services. We analyzed 47 semi-structured interviews (2023–2024) with WTP users, peer staff and site operators and drew on a structural determinants of health framework and an intersectional feminist lens to delineate how structural inequities intersect and compound to shape access to and engagement with WaSH infrastructure. Our results indicate that unhoused/precariously housed women, sex workers and people who use substances face heightened gender safety concerns in their attempts to carry out regular WaSH activities, with unique gendered vulnerabilities to physical and sexual violence. We found that WTP interventions have the potential to reduce health and drug-related vulnerabilities, including risks of GBV, primarily through the integration of low-barrier gender-responsive anti-violence and harm-reduction supports alongside WaSH infrastructure. The findings of this study highlight the potential benefits of scaling and evaluating similar WaSH interventions in other urban settings in HICs as a pragmatic means of improving overall safety, health and well-being among marginalized and criminalized populations.