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Abstract

Background:

Diaper insecurity is a major financial burden for many families with young children.

Objectives:

We aimed to describe the most frequently occurring stressors among caregivers receiving diaper assistance.

Design:

Caregivers receiving diaper assistance at community-based organizations in North Carolina completed surveys, including a modified Everyday Stressors Index.

Methods:

We conducted a descriptive, cross-sectional study, calculating the number and percent of caregivers reporting that each stressor caused them “a lot of” or “some” stress.

Results:

Conclusions:

Caregivers need support having enough money to meet basic needs and having sufficient time to meet their responsibilities and goals. Potential strategies include repealing the state sales tax on diapers and increasing state and federal tax credits and minimum wage.

Plain Language Summary

Why did we conduct this study?

Diapers represent a significant cost for families with young children. As many as 50% of families with young children report diaper insecurity (also referred to as diaper need), or difficulty affording enough diapers to keep their child clean, dry, and healthy. We wanted to describe the different types of stressors experienced by caregivers with diaper insecurity to understand additional supports these families may need to ensure both caregiver and child wellbeing. What did we find? Among caregivers receiving diaper assistance from local organizations, most had at least one adult in the household working for pay, and most had household incomes <$35,000. More than half reported substantial stress not having enough time to do the things they want, affording diapers, affording rent or mortgage, having too many responsibilities or things to do, and affording utility bills like water and electricity. What do the findings mean? Frequently reported stressors among caregivers receiving diaper assistance revealed two themes: caregivers need more money to meet basic needs and more time to meet their responsibilities and goals. Potential program and policy solutions include directly funding diaper banks, using Temporary Assistance for Needy Families (TANF) funds to cover the cost of diapers, repealing state sales tax on diapers, designating diapers as a medical necessity so they can be covered by Medicaid, allowing diapers to be purchased through health savings or flexible spending accounts, increasing minimum wage, increasing tax credits to families through the Child Tax Credit or Earned Income Tax credit, and increasing benefits in social safety net programs, such as the Supplemental Nutrition Assistance Program, among others.

Keywords

diaper insecurity diaper need diaper bank caregiver stress young children

Introduction

Diapers are a major financial burden for many families with young children.^1,2 Recent estimates indicate that as many as 50% of U.S. families with children under age 4 years experience diaper insecurity.³ Families experience diaper insecurity, also referred to as diaper need, when they are unable to afford a sufficient supply of diapers to keep their child clean, dry, and healthy.² Like other material hardships, diaper insecurity is associated with an increased risk of adverse health and social outcomes, including diaper rash and urinary tract infections among children and depressive symptoms and missed work or school among caregivers.^1,2,4,5 Some states have implemented creative approaches to mitigating diaper insecurity within existing programs.⁶ For example, families with children under age 2 years enrolled in Tennessee Medicaid can receive up to 100 free diapers per month,⁷ and some families with children under age 3 years enrolled in Temporary Assistance for Needy Families (TANF) in Washington state can receive a diaper subsidy to help with the cost of diapers.⁸ However, there are currently no federal or state programs that systematically provide diapers or assistance with the cost of diapers, and many existing policy approaches reach a limited number of families experiencing diaper insecurity, largely due to eligibility restrictions and limited state budgets. Further, diapers are taxed as “discretionary” in many states.⁹ To address this gap, nonprofit diaper banks provide families in need with a supplemental supply of free diapers.¹⁰

Families experiencing diaper insecurity often experience other material hardships, such as food and housing insecurity.^1,11–14 Caregivers struggling to afford a sufficient supply of diapers report cutting back on other essentials, like food and utilities, to purchase diapers.^1,11–14 Further, caregivers lacking a sufficient supply of diapers often experience additional stressors related to their role as caregivers, such as navigating complex health and social service systems and coping with chronic illnesses.^1,11–14 However, the level and types of different stressors experienced among caregivers with diaper insecurity have not been examined. Because caregiver stress has direct implications for both child and caregiver wellbeing,¹⁵ understanding key sources of caregiver stress can identify actionable targets for clinical, programmatic, and policy intervention. Our aims were to describe the demographic and household characteristics among caregivers receiving assistance from a local diaper bank and to determine the most frequently occurring and co-occurring stressors.

Methods

Setting

The Diaper Bank of North Carolina is a nonprofit organization operating four branches that provide families in need with a free, supplemental supply of disposable diapers by distributing diapers to community-based organizations serving families with young children, such as local health departments, Federally Qualified Health Centers, outpatient health clinics, Head Start programs, home visiting programs, and food distribution programs, among others. Currently, the Diaper Bank of North Carolina provides 50 disposable diapers to a family each time they receive assistance, with cloth diapers available upon request. In large surveys, families report that a supplemental supply of 50 diapers per month per child would reduce their diaper insecurity.³

Survey

From November 2021 to April 2022, caregivers who were receiving free diapers from the Diaper Bank of North Carolina at local community-based organizations were approached by trained Diaper Bank of North Carolina staff, community-based organization staff, or volunteers and offered the opportunity to complete the survey. Adults ages 18 years and older receiving diapers for a child in their household were eligible to complete the survey. Caregivers were informed that participation was voluntary, that declining participation would not impact their ability to receive free diapers, and that only approved researchers would have access to their anonymous survey responses. Trained staff and volunteers read each survey question aloud to participants and recorded their responses. Surveys were available in English or Spanish and included questions on the economic impacts of receiving diaper assistance at community-based organizations.

Caregivers self-reported demographic and household characteristics (Supplemental Table S1) and completed a modified Everyday Stressors Index (Supplemental Table S2). The Everyday Stressors Index was developed to assess common, daily stressors experienced by low-income mothers of young children and has good internal consistency among Spanish- and English-speaking women.^16–18 To capture the full range of basic needs families struggle to afford, we added questions assessing difficulty affording clothing, housing, food, healthcare, utility and phone bills, childcare, and diapers.¹⁹ Caregivers indicated whether each stressor causes them “no stress,” “a little stress,” “some stress,” or “a lot of stress.”

Data analysis

We calculated the number and percentage of caregivers by each demographic and household characteristic. To identify the top 15 most frequently occurring stressors, we examined the number and percentage of caregivers reporting that each stressor from the modified Everyday Stressors Index caused them “a lot of” or “some” stress. To identify the top 5 most frequently co-occurring stressors, we examined the number and percentage of caregivers reporting that two stressors caused them “a lot of” or “some” stress. For this descriptive study, we did not conduct statistical tests for comparisons to avoid an overemphasis on p-values and to focus instead on the actual size of observed differences.^20,21

This study was reviewed and approved by the Institutional Review Board at the University of North Carolina at Chapel Hill [#23-0679]. Reporting for this study conforms to the STROBE statement for cross-sectional studies.²²

Results

Of 238 participants, most were women (97.4%) with one child in diapers (62.1%; Supplemental Table S3). In total, 39.2% identified as Black and 26.7% as Hispanic. Forty percent (40.1%) had received diaper assistance every month or almost every month during the past year. Most had at least one adult in the household currently working for pay (79.0%), and one-third (36.8%) had a household income ⩽ $15,999.

More than half of participants reported “a lot of” or “some” stress about not having enough time to do the things they want (58.5%), affording diapers (58.3%), affording rent or mortgage (54.1%), having too many responsibilities or things to do (53.1%), and affording utility bills like water and electricity (51.0%; Figure 1 and Supplemental Table S4). Slightly less than half reported “a lot of” or “some” stress about meeting their own goals for their job or career (48.8%), affording clothes (47.9%), affording phone or internet bills (47.6%), and meeting their own goals for schooling or education (46.1%). On average, participants reported “a lot of” or “some” stress for 9.3 stressors (SD = 6.8).

Figure 1.

Top 15 stressors causing “a lot of” or “some” stress: Diaper Bank of North Carolina participants in the National Diaper Bank Network’s Study of Diaper Insecurity, Health, and Economic Mobility in the United States (N = 238).

The top co-occurring stressors for caregivers were not having enough time to do the things they want and having too many responsibilities or things to do (49.3%), not having enough time to do the things they want and affording diapers (42.7%), affording diapers and affording rent or mortgage (42.2%), affording rent or mortgage and affording utility bills (41.8%), and affording diapers and having too many responsibilities or things to do (40.7%; Table 1).

Table 1.

Top 5 pairs of co-occurring stressors causing “a lot of” or “some” stress: Diaper Bank of North Carolina participants in the National Diaper Bank Network’s Study of Diaper Insecurity, Health, and Economic Mobility in the United States (N = 238).

Co-occurring stressors	N (%)
Not enough time to do the things you want to do and having too many responsibilities or things to do	102 (49.3)
Not enough time to do the things you want to do and affording diapers	87 (42.7)
Affording diapers and affording rent or mortgage	86 (42.2)
Affording rent or mortgage and affording utility bills	86 (41.8)
Affording diapers and having too many responsibilities or things to do	83 (40.7)

Discussion

Among families receiving assistance from a local diaper bank, most had at least one working adult. Despite the presence of a working adult, three-fourths had annual incomes < $35,000, and most reported substantial stress affording basic needs such as rent or mortgage and utility bills. Importantly, when caregivers lack a sufficient supply of disposable diapers, they are often unable to leave young children at childcare, resulting in missed work, lost income, and increased material hardships.^1,11–14,23 Prior research shows that state increases in minimum wage are associated with decreases in material hardship among families with children under age 3 years,²⁴ indicating this may be a promising policy lever to address poverty and material hardships among families with young children.

Frequently reported stressors revealed two themes: caregivers need more money to meet basic needs and more time to meet their responsibilities and goals. Though all participating caregivers were receiving diaper assistance, more than half reported stress affording diapers. While diaper banks provide critical support, these nonprofits alone cannot fill the unmet need for diaper assistance.¹ Potential solutions include directly funding diaper banks, using TANF funds to support TANF-eligible families via the provision of diapers by diaper banks or via diaper stipends or vouchers, repealing state sales tax on diapers, amending the Social Security Act to provide Medicaid coverage of diapers by including diapers as Medical Assistance, allocating funding to Maternal, Infant, and Early Childhood Home Visiting (MIECHV) programs with the requirement that programs contract with and reimburse diaper banks for providing diapers to MIECHV families, allowing diapers to be purchased through health savings or flexible spending accounts, and amending the Family First Prevention Services Act to include the provision of diapers as a concrete support for meeting the material basic needs of a family as a means to create safe, stable, and nurturing environments for children and to prevent child protective services involvement.

Fewer caregivers reported stress affording food than affording other basic needs. Surveys were completed during the height of the COVID-19 pandemic, a period when low-income families received additional food purchasing assistance through the Supplemental Nutrition Assistance Program (SNAP) and additional cash assistance through the 2021 expanded Child Tax Credit (CTC).^25,26 Studies show that the additional food purchasing assistance provided through SNAP and the expanded CTC during the pandemic reduced food insufficiency among households with children.^27,28 Permanent increases in tax credits to families, including through the CTC or refundable or increased state earned income tax credits (EITCs), and increases in social safety net benefits, including food purchasing benefits through SNAP, could help families afford a variety of basic needs, including diapers, and reduce caregiver stress, with implications for both caregiver and child wellbeing.²⁹ In addition, when caregivers are supported in meeting basic needs, they have fewer competing demands and are able to devote time previously spent trying to meet these needs to other responsibilities and goals.^13,30 Notably, during the study period, Medicaid was not expanded in North Carolina. Implementation of Medicaid expansion in North Carolina in 2023 may have provided additional financial support and stress relief to caregivers.^31,32 Given that three-fourths of caregivers reported household income < $35,000, and the poverty threshold was $27,740 for a family of four in 2021,³³ we expect that most families receiving diaper assistance would be eligible for these safety net programs and tax credits, including expanded CTCs, refundable EITCs, SNAP, and Medicaid.

During the COVID-19 pandemic, families with young children experienced unprecedented challenges in balancing work and caregiving responsibilities, given childcare closures and remote schooling. Existing research shows that mothers of young children significantly reduced their work hours during the pandemic,³⁴ and that loss of childcare during the pandemic was associated with an increased risk of unemployment among mothers, but not fathers, of young children.³⁵ Mothers were also more likely to experience parental burnout (e.g., feeling completely run down by their role as a parent) during the pandemic than fathers.³⁶ The added caregiving responsibilities and stress associated with reducing work hours or experiencing unemployment during this time may have influenced caregiver reports of stress around competing demands and not having sufficient time or money to meet their families’ basic needs or their personal goals.

Limitations

This study has limitations. First, the data cross-sectional and thus capture caregiver stressors reported at a single point in time. The types and severity of stressors experienced by caregivers may vary over time. Second, the data were also collected in a single state. Results may not generalize to other state contexts or reflect the characteristics and experiences of caregivers receiving diaper assistance in other communities. Third, surveys were available in English or Spanish, potentially excluding caregivers who speak other languages. However, most caregivers receiving assistance from the Diaper Bank of North Carolina speak English or Spanish. Last, because we did not conduct statistical comparisons, we did not calculate an a priori target sample size.

Conclusions

Clinical, programmatic, and policy efforts to support reduced stress for caregivers of young children by helping them to have enough money to meet basic needs, specifically a basic need for diapers, and have enough time for their responsibilities and to meet their goals are needed to improve caregiver and child wellbeing.

Supplemental Material

sj-docx-1-whe-10.1177_17455057251401753 – Supplemental material for Sources of stress among caregivers receiving diaper assistance

Supplemental material, sj-docx-1-whe-10.1177_17455057251401753 for Sources of stress among caregivers receiving diaper assistance by Anna E. Austin, Yomna Anan, Michelle Schaefer-Old and Kelley Massengale in Women's Health

Footnotes

Acknowledgements

None.

ORCID iDs

Anna E. Austin

Kelley Massengale

Ethical Considerations

This study was reviewed and approved by the Institutional Review Board at the University of North Carolin at Chapel Hill [#23-0679].

Consent to participate

Caregivers were informed that participation was voluntary and that only approved researchers would have access to their anonymous responses. Caregivers provided verbal consent, given that the survey presented no more than minimal risk of harm. A box was included at the bottom of each survey for staff to record that the participant provided verbal consent. Verbal consent was approved by the Institutional Review Board.

Consent for publication

Not applicable.

Author contributions

Anna E. Austin: Conceptualization; Writing – original draft; Formal analysis; Methodology.

Yomna Anan: Writing – review & editing; Formal analysis.

Michelle Schaefer-Old: Conceptualization; Data curation; Writing –review & editing.

Kelley Massengale: Conceptualization; Data curation; Writing – review & editing; Methodology.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Please contact the corresponding author for data and material inquiries.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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