"Gives us peace of mind for keeping our hands clean": targeted handwashing intervention increases water use and hand hygiene in rural Alaska.

Lack of in-home water service remains a persistent challenge in rural Alaska due to underfunding, high construction and operating costs, extreme cold, and environmental change. Alaska has the highest proportion of households in the U.S. lacking complete plumbing, resulting in self-hauling of water and waste, reuse of limited supplies, and higher rates of water-washed disease than in plumbed homes. During the COVID-19 response, the Alaska Native Tribal Health Consortium (ANTHC) and Silverline LLC developed and installed the Miniature Portable Alternative Sanitation System (Mini-PASS) in 14 unplumbed Alaska Native communities. To evaluate its impact on hand hygiene, water-hauling behaviors, and system use, we conducted seasonal interviews with 147 households. Among 139 households reporting handwashing methods, 63% (n=93) used the in-home handwashing station (HWS) as their primary method. Longer ownership was associated with greater HWS use and increased water hauling. Analysis of 163 interviews from 52 households showed a monthly rise of 0.08 gal/c/d (0.30 L/c/d) in water use following installation. These findings indicate that in-home HWS interventions such as the Mini-PASS improve hand hygiene, reduce wash-basin water reuse, and modestly increase household water use over time. Longitudinal monitoring is critical to assess sustained behavioral and WASH outcomes in unpiped communities.