Modular decentralized water system associated with improved child health and increased in-home water use in remote Alaska Native communities Open Access

Safe and accessible water services for hand hygiene are critical to human health and well-being, yet a little under half of the entire world's population (3.6 billion people) lack adequate access to sanitation and hygiene services (World Health Organization & United Nations Children's Fund 2021). Worldwide there are 2.2 billion people who do not have access to handwashing facilities within their homes to wash their hands with soap and water (World Health Organization & United Nations Children's Fund 2021). Within the United States, more than 2 million people live without access to running water as well as basic indoor plumbing and sanitation services, including 1.4 million Americans who lack hot and cold running water, a sink to wash up or wash hands in, a shower and/or bath, as well as a flushing toilet (Dig Deep & US Water Alliance 2019).

The physical health implications due to inadequate access to safe drinking water, sanitation, and sufficient hygiene practices have been established in the literature (Howard et al. 2020; Wolf et al. 2023). Those most vulnerable to the health impacts include young children, with global estimates that suggest annually more than 800,000 children die from preventable diseases caused by inadequate quantities and quality of safe drinking water, lack of sanitation, and poor hygiene practices (Mills & Cumming 2016). The World Health Organization estimates that 7.6% of all deaths among children under 5 are attributed to inadequate WASH including 273,000 childhood deaths from diarrhea and 112,000 deaths from acute respiratory infections (WHO 2023).

This water disparity in America is predominantly visible in Indigenous households where they are 19 times more likely than non-native households to lack indoor plumbing (Dig Deep & US Water Alliance 2019). Nationally, the state of Alaska has the highest percentage of households that lack access to complete indoor plumbing (Census Bureau 2022). This problem is concentrated in remote Alaska Native communities, where over 3,300 households across 37 remote communities do not have access to complete plumbing systems (Indian Health Service 2021; Census Bureau 2022).

Researchers in Alaska have begun to document the connection between inadequate water and sanitation services and their health impacts. These water access inequities correlate with an increased prevalence of water-washed illnesses, especially for young children (Hennessy et al. 2008; Sohns et al. 2019). Within many of these water-insecure communities, the incidence of acute respiratory illnesses, skin, and gastrointestinal infections are significantly higher compared to households with access to in-home plumbing (Gessner 2008; Hennessy et al. 2008; Wenger et al. 2010; Thomas et al. 2016; Mosites et al. 2020). These homes are overwhelmingly in smaller rural villages off the road system occupied by people of Alaska Native descent (Bressler & Hennessy 2018). Compared to Alaska communities with piped water, the hospitalization rates for pneumonia are 11 times higher for Alaska Native children who live in villages without plumbed water. In addition, one in every three infants is hospitalized for respiratory syncytial virus, five times higher than the national rate (Atwell et al. 2023). These higher rates of illnesses are partly due to a household's inability to collect enough water to meet their most basic hygienic needs (Bressler & Hennessy 2018).

The COVID-19 pandemic highlighted the ongoing health disparities and water inequities that exist within the United States, as well as the risks they posed for SARS-CoV-2 infection (Eichelberger et al. 2021). At the beginning of the pandemic, it was recognized that Alaska Natives and American Indians in communities lacking in-home plumbing were suffering from disproportionate rates of COVID-19 (Rodriguez-Lonebear et al. 2020). This spurred a new urgency to implement prevention strategies that would allow individuals and communities to follow Centers for Disease Control and Prevention (CDC) recommendations, such as frequent handwashing (Eichelberger et al. 2021). The Alaska Native Tribal Health Consortium (ANTHC) received funding from the Centers for Disease Control and Prevention Foundation (CDCF) to rapidly develop a solution, ultimately leading to the development and installation of the Miniature Portable Alternative Sanitation System (Mini-PASS).

To date, a total of 373 HWSs and 349 VHBs have been installed in 14 communities served by the Norton Sound Health Corporation (NSHC) in Northwest Alaska (3 communities), the Tanana Chiefs Conference (TCC) in Interior Alaska (8 communities), and the Yukon Kuskokwim Health Corporation (YKHC) (3 communities). One of the major objectives of the Mini-PASS project was to reduce disease by enabling handwashing with clean, free-flowing water. In this paper, we report our findings focused on how the Mini-PASS has affected the health of children 12 years old and younger, changes to water hauling and usage, and changes to handwashing and hygiene practices.

This work is part of a larger evaluation study of the Mini-PASS. To evaluate the effectiveness and acceptability of the Mini-PASS, ANTHC conducted a study over 2 years (April 2021–March 2023), specifically looking at water use and quantity, hygiene and handwashing practices, user assessment and satisfaction, perceived health impacts, and changes in skin, gastrointestinal, and respiratory symptoms in children 12 and younger. All 373 households with Mini-PASS installed were contacted during each data collection period; however, not every household was available and/or interested in participating in the evaluation.

We interviewed 179 individuals from 147 unique households throughout the evaluation. Interviewees were members of a household who self-identified as being knowledgeable about water use, sanitation, and health within their home. Interviewees were counted if they answered the phone, gave consent, and were a part of at least one interview. Due to the timing of the COVID-19 pandemic and the urgency to focus on the installation of the systems, only 41 interviews occurred prior to installation. Households participated in 1–5 interviews across the follow-up periods defined by time since installation (3–5, 6–9, 11–14, and 15–24 months). Interviews corresponded with seasons since this was known to affect water use, availability, and quality. Interviews in the fall occurred between September and November and were timed as much as possible, to correspond with freeze-up, the time of year when rivers transition to being frozen over and precipitation is mostly snow. Winter interviews occurred from December to February, the coldest months of the year when frozen pipes and weather often impede water access. Spring interviews occurred during the season known in Alaska as ‘break-up’, the transition from frozen substrate back to liquid, usually between April and May. During July and August, which are the warmest months, we conducted summer interviews.

The interview questions we explored and described in this paper were related to water quantity measured in gallons of water per capita per day (g/c/d), sources of hauled water, changes to water use, handwashing and bathing practices, and child symptoms related to skin, gastrointestinal, and respiratory infections. Interviews lasted 30–45 min and answers were manually entered into either Excel or a REDCap form during the interviews to maintain accuracy of data collection. Due to COVID-19 pandemic restrictions, most interviews were conducted by phone.

One measure of the Mini-PASS's efficacy was children's illness rate as determined by the report of symptoms the child experienced during the last 2 weeks. This measure is reliable in other studies (Nair et al. 2011; Thomas et al. 2016). Interviewers asked about three symptoms of respiratory illness: ‘cold or runny nose’, ‘cough between colds’, and ‘wheezy, whistling chest’. A ‘yes’ to one or more of these symptoms was coded as a positive ‘respiratory symptom’. Interviewers also asked about symptoms of gastrointestinal illness or skin disease: ‘diarrhea’ and ‘skin infection’. A ‘yes’ answer to one or more of these symptoms or a ‘yes’ to one or both of these questions was coded as a positive ‘any symptom’.

A comparison of symptoms pre- and post-installation of the Mini-PASS could not be done since few households were interviewed before the system was installed. In addition, because of social distancing and other public health measures instituted during the height of the COVID pandemic, the rates of non-COVID illnesses dropped below normal levels throughout Alaska (Kadambari et al. 2022). Also, only 30% (n = 21) of households with children were interviewed more than once and repeated interviews were often conducted in different seasons. Symptom rates are highly dependent on the season of the year, with rates of symptoms typically being highest during the winter (Nair et al. 2011).

Therefore, we decided to restrict our symptom analysis to interviews conducted during the winter of 2023. We compared the rate of ‘any respiratory symptoms’ or ‘any symptoms’ among children in households that reported using the Mini-PASS HWSs to rates among children in households that reported using basins of water to wash hands or both basins and the HWS. It is well-established that rates of respiratory disease are inversely related to the age of the child (Monto & Ullman 1974). We grouped children in this study to <1, 1–4, and 5–12 years of age. We also included the gallons of water per capita per day (g/c/d) available in the household in our analysis as we thought very low levels might influence whether or not a basin of water was used to wash hands, as opposed to running water from the HWS.

Our analysis used descriptive statistics such as measures of central tendency (mean, median, and mode) and measures of dispersion or variation (range, standard deviation, variance, and quantile ranks) to describe the characteristics of households. We conducted the univariate analyses comparing household reports of the hand wash method (HWS vs. basin or mixed users) for g/c/d, age group of children, and rate of symptoms. Differences in linear variables were compared using medians and interquartile range (IQR) with Kruskal–Wallis tests of significance. Categorical variables were compared by count and percentage, and significance was determined using a Chi-square test of independence.

In addition, we conducted a generalized linear mixed model to examine the likelihood of any respiratory symptoms in a household by the hand wash method (HWS vs. basin or both), accounting for multiple children by household cluster and adjusting for the age group of children and g/c/d. p-values less than 0.05 were considered significant, allowing no more than a 5% chance that observed relationships were due to chance.

We interviewed 48 unique households during the winter of 2023, which contained a total of 109 children 12 years old and younger (69% of all Mini-PASS households with children 12 years old or younger). More than half (n = 61, 56%) of the 109 children in these households were between 5 and 12 years old, 43 (39%) were less than 5 years old, and 5 (5%) were less than 1 year of age. Children were not interviewed for this study; interviewees, who were usually primary caretakers, had to be at least 18 years of age and were asked to provide verbal informed consent before continuing with the interview process. Participants were compensated with a $50 gift card for their time after any interview was completed. This study was approved by the Alaska Area IRB protocol #2018-03-009 as well as the ANTHC Health Research Reviewee Committee, YKHC, NSHC, and TCC.

There were 109 children 12 years of age or less residing in the 48 households in this analysis. More than half (n = 61, 56%) of them were between 5 and 12 years old, 43 (39%) were less than 5 years old, and 5 (5%) were less than 1 year of age. Most households (n = 34; 71%) reported using only HWSs for washing their hands. Households also reported a median water use of 1.1 (IQR = 1.3) gallons of water per person per day. During the 2-week period prior to the interview, 45% (n = 49) of children experienced respiratory symptoms, 16% (n = 17) gastrointestinal, and 11% (n = 12) skin infections. Overall, interviewees reported that 51% (n = 56) of children experienced a symptom of any kind (Table 1).

When we examined household characteristics by the handwashing method (‘HWS only’ vs. ‘wash basin only’ or ‘mixed use’ (basins and HWS)), we found no significant differences in the age groups of children. However, households that used HWS reported a significantly greater amount of gallons of water per person per day as compared with households that used basins. Households that reported using HWS also reported significantly fewer respiratory symptoms or symptoms of any kind as compared to households that used basins (Table 2).

Generalized linear mixed models that accounted for multiple children in a household and adjusted for the age group of children and g/c/d showed that households using HWS still had significantly fewer respiratory symptoms than households using basins (Table 3). Differences in ‘any symptoms’ between HWS households and basin households lost significance after accounting for the number of children in the household (Table 4).

Previous studies in Alaska have established the association between inadequate access to in-home plumbing and elevated rates of respiratory, skin, and gastrointestinal infections (Gessner 2008; Hennessy et al. 2008; Mosites et al. 2020). However, these studies primarily measured clinic and/or hospital visits and were limited in their ability to establish any causal relationships between water, sanitation, and health as well as define any mechanism related to in-home water use (i.e. frequent handwashing) that could help decrease infection risk. One recent study explored the relationship between having access to adequate quantities of water and the influence this has on health. Their results showed a significant decrease in rates of acute respiratory, skin, and gastrointestinal infections before and after the installation of in-home plumbing and hygiene education among rural Alaskan households in four different communities in Western Alaska (Thomas et al. 2016). Although the use of clinical data has demonstrated clear connections between running water and health, we also know that within the Arctic very few water-washed diseases are properly documented and reported to public health authorities (Bressler & Hennessy 2018), ultimately making it unclear how this lack of reporting has potentially missed the larger picture of water and health within these communities.

Many of the prospective studies on disease outcomes and sanitation have been conducted in low- and middle-income countries and are primarily focused on the reduction of diarrheal illnesses (Waddington et al. 2009; Darvesh et al. 2017; Wolf et al. 2018). Limited studies have explored acceptability and behavior changes surrounding communal HWS interventions, often combined with a hygiene curriculum, and focused minimally on measurable health outcomes (Biran 2011; Hulland et al. 2013; Pasewaldt et al. 2019; Wichaidit et al. 2019; Sutherland et al. 2021), and very few studies have assessed the impact of handwashing and hygiene interventions on the reduction of water-washed infections (Patel et al. 2012; Boubacar Maïnassara & Tohon 2014; Kamm et al. 2014; Willmott et al. 2016).

Our evaluation contributes to the limited number of studies that have explored water, sanitation, and health in Alaska. This study does not provide clinical evidence; instead, we rely on caregiver reports of the primary handwashing method and symptoms experienced by children 12 years old and younger within a household. Instead of relying on medical records that may not have recorded the entire picture of wash-disease symptoms experienced within a household, we use caregiver-reported data to capture some of the underreported experiences within these homes. Self-reported data has its own limitations, such as recall bias, but this study attempts to identify the daily life impacts that an intervention designed to provide a more sanitary hand hygiene method has on caregiver-reported wash-disease symptoms. These findings contribute to the growing body of literature and provide evidence that handwashing with free-flowing water is an important mechanism that contributes to the reduction of wash-disease symptoms. To our knowledge, our study is the first prospective cohort study in Alaska that evaluated a hygiene intervention and the direct impact that handwashing in free-flowing water has on caregiver-reported skin, respiratory, and gastrointestinal symptoms of children 12 years old and younger living within the home.

The COVID-19 pandemic spurred the rapid development and installation of the Mini-PASS units within Alaska communities. Due to the urgency of this public health response, the intervention took priority over research efforts, which ultimately impacted the evaluation. We were unable to compare health symptoms among children in households pre- and post-installation of the Mini-PASS due to a small number of households that completed pre-installation interviews. Also, only 30% (n = 21) of households with children were interviewed more than once and repeated interviews were often conducted in different seasons. Symptom rates are highly dependent on the season of the year, with rates of symptoms typically being the highest during the winter (Monto & Ullman 1974).

Further research activities will expand on our findings and address these limitations by recruiting a larger sample size from a cohort of households in rural Alaska who use different types of water and sewer services and systems including the PASS, the Mini-PASS, piped, and unpiped households. These households will be matched by community and household demographics to assess health outcomes over time, with a piped community serving as our control. We will interview these households across several different seasons to understand more thoroughly household water storage, use, water reliability, health indicators, and the prevalence of symptoms of water-washed diseases to better assess how each of these variables differs by each water and sanitation service type or lack thereof. Collecting this information will help to better inform public health and tribal organizations on the impact water and sanitation service types have on health and well-being. By utilizing a piped community as a control, we will be able to assess in greater detail how the PASS and Mini-PASS impact health outcomes and water-washed disease symptoms over time.

One major objective of the Mini-PASS was to reduce disease by enabling handwashing with clean, free-flowing water. In this paper, we described our findings focused on household hand hygiene practices and how that has affected the caregiver-reported symptoms of children 12 years old and younger. Our results showed households with children 12 years old and younger who used the HWS as the primary handwashing method (n = 34, 71%) were significantly less likely to report respiratory symptoms. These households also reported hauling significantly larger amounts of water compared with households who reported using primarily wash basins only or mixed users (1.5 vs. 0.8 gallons of water per person per day; p < 0.0001). These findings indicate that the Mini-PASS HWSs are an effective intervention for improving hand hygiene as well as reducing caregiver-reported symptoms within a home. Although we are unable to conclude the long-term impacts the Mini-PASS has on the health of young children, our findings demonstrate that when the system is used as the primary handwashing method, especially during the winter season when respiratory symptoms are generally at their peak, the systems have been successful in the reduction of these symptoms and mitigating the spread of disease within these homes, suggesting the potential for long-term benefits. Furthermore, previous findings indicated a shift in the primary handwashing method from the use of primarily wash basins in 100% of homes at the baseline, to the use of free-flowing Mini-PASS water in 70% of homes at follow-up (Harmon et al. 2024). These findings are critical as they demonstrate the acceptability of the transition from wash basins to the Mini-PASS HWSs within these homes.

In the current work, we demonstrate that a simple plumbing system such as the Mini-PASS HWS can help decrease reusing water in a wash basin for handwashing and provide a more sanitary hand hygiene method within a home. Replacing the wash basin with the Mini-PASS ultimately reduces pathogen exposure from handwashing water reuse and provides an effective handwashing strategy that ultimately helps mitigate the risk and spread of disease. The Mini-PASS units have also contributed to an increase in a household's water storage capacity by 20 gallons with a system that is specifically designated for handwashing. Overall, these systems appear to enable effective use of small amounts of water to promote a more hygienic handwashing method in the home. When used as the primary hand hygiene method, the Mini-PASS enables handwashing with free-flowing water, reduces wash basin water reuse, and protects household health. Together, these findings suggest that providing free-flowing water for washing hands via the Mini-PASS HWS is an effective intervention that can provide a low-cost practical solution to improve hand hygiene and reduce caregiver reports of water-washed disease symptoms for households without running water.

These results are significant because they illuminate the impact that access to running water has on hand hygiene practices and childhood health in rural Alaskan communities. Lack of running water plays a critical role in the spread of disease and is particularly important in rural Alaskan communities where geographic isolation and lack of infrastructure exacerbate health vulnerabilities. There is an urgent need to prioritize infrastructure that ensures reliable access to water. Childhood symptoms are less likely when HWSs and increased water quantity are available in their household, which not only increases the quality of life of children but also reduces the burden on the healthcare system (which usually consists of small, rural clinics staffed by a health aide). By sharing our results, this research supports the necessity for increased funding, advocacy, and interventions directed toward water and sanitation infrastructure in rural Alaska. The results of our evaluation will inform the broader community about the potential health benefits of an affordable, responsive, decentralized water system solution for communities that lack piped water and sewer.

Data cannot be made publicly available; readers should contact the corresponding author for details.

The authors declare there is no conflict.