Diaper Need as a Measure of Material
Hardship During COVID-19
Emma Shaffer
▼ Sallie Porter
▼ Peijia Zha
▼ Eileen Condon
Background: Diaper need is a lack of reliable access to a sufficient quantity of diaper supplies. It is an essential pediatric social
determinant of health measure that is useful for exploring the effects of the COVID-19 pandemic on families of young children.
Objective: This study aimed to identify the predictors of diaper need and the associations between diaper need and psychosocial
outcomes among underresourced families with neurodiverse children.
Methods: This cross-sectional study included 129 caregivers of children aged 0–36 months who completed an online survey in
early 2021, during the height of the COVID-19 pandemic. Participants completed a diaper need assessment, the Hunger Vital
Signs Food Insecurity Screener, the Perceived Stress Scale, and the Infant Behavioral Questionnaire subscale. Relationships
were explored using independent-samples t-tests, chi-square tests, and multiple regression analyses.
Results: Seventy-six percent of caregivers reported some diaper need, and 87.6% reported food insecurity. Greater than one
third (39.5%) reported high diaper need. Common mitigation strategies included using a towel or other cloth like a diaper, not
using a diaper, and keeping the child in the same diaper for longer than usual. In multivariate modeling, food insecurity,
household size, and parent age were significantly associated with high diaper need. Families experiencing food insecurity were
4.24 times more likely to experience high diaper need than food-secure families. High diaper need compared to low or no diaper
need was associated with increased parent perceived stress.
Discussion: We found high levels of diaper need and food insecurity for families during the COVID-19 pandemic. The association
of high diaper need and stress indicates an inadequate supply of diapers adversely affects parent stress. Nurses may consider
including diaper need in social determinants of health screening and prioritize connecting families to appropriate resources.
Key Words: birth to 3 years developmental delay diaper need material hardship social determinants of health
Nursing Research, March/April 2022, Vol 71, No 2, 90–95
A
ffording basic necessities is a challenge for 1 in 10 U.S.
families with young children (Coleman-Jensen et al.,
2019; Gross et al., 2019; Ouellette et al., 2004). Approximately 20% of families with a child with a disability live
below 200% of the U.S. federal poverty line (Zablotsky et al.,
2019). Diaper need is a measure of material hardship that is especially important for families with young children. Diapering
supplies are expensive goods that are critical for the care of infants and toddlers. Before the COVID-19 pandemic, one in
three U.S. families could not afford the diapers required to
keep an infant dry, clean, and healthy (Raver et al., 2010).
The COVID-19 pandemic further strained families’ available
resources. Greater than 50 million U.S. families experienced
Emma Shaffer, PhD, CPNP, is PhD Graduate, Division of Nursing Science,
School of Nursing, Rutgers, The State of University of New Jersey, Newark.
Sallie Porter, DNP, PhD APN, PED-BC, CPNP, FNAP, is Associate Professor, Division of Advanced Nursing Practice, School of Nursing, Rutgers, The State of
University of New Jersey, Newark.
Peijia Zha, PhD, is Assistant Professor, Center for Technology and Chronic Disease Management, Division of Nursing Science, School of Nursing, Rutgers,
The State of University of New Jersey, Newark.
Eileen Condon, PhD, APRN, FNP-BC, is Postdoctoral Associate, Yale University
School of Nursing, New Haven, Connecticut.
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/NNR.0000000000000572
90
www.nursingresearchonline.com
a loss of employment income during 2020 (U.S. Census
Bureau, 2021), and food insecurity has also increased (Dondi
et al., 2020; Niles et al., 2020; Wolfson & Leung, 2020). Within
this new landscape, diaper banks also reported a surge in demands for supplies (National Diaper Bank Network, 2020).
Diaper need is defined as an inability to obtain supplies
required to keep an infant dry, clean, and healthy without
decreasing spending on food or other essential goods
(Massengale et al., 2020; Porter & Steefel, 2015). Delayed diaper changing or reusing soiled diapers are common mitigation
strategies (Feeding America, 2013; Massengale et al., 2017).
Prolonged exposure to feces and urine erodes skin integrity,
leading to dermatitis and increased risk of urinary tract infections (Blume-Peytavi et al., 2016; Porter & Steefel, 2015). Diaper
need is associated with increased pediatric medical visits for
dermatitis and urinary tract infections (Sobowale et al., 2021).
For caregivers, diaper need has a psychological toll. Mothers
experiencing diaper need have significantly higher depressive
symptoms than their peers (Austin & Smith, 2017). Furthermore, as childcare attendance can be contingent on the provision of diapers, an inadequate supply prohibits parents from attending school or working to earn wages to purchase more diapers (Massengale et al., 2017; Porter & Steefel, 2015). The two
Nursing Research • March/April 2022 • Volume 71 • No. 2
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Nursing Research • March/April 2022 • Volume 71 • No. 2
primary federal programs for underresourced families with
young children, the Supplemental Nutrition Assistance Program
and the Special Supplemental Nutrition Program for Women, Infants, and Children, do not allow for diapers as a covered benefit.
The consequences of diaper need are particularly detrimental to families because of developmental timing. The early
years of a child’s life are foundational for later health and family
function (Brazelton & Greenspan, 2000; National Scientific
Council on the Developing Child, 2007; Russell & Gleason,
2018). Early childhood, especially birth to 3 years, is a sensitive
period of rapid growth and development. Brain plasticity is
highest in young children. The groundwork of brain circuitry is
based on early life exposures and environmental stress. This time
is a particularly critical window of opportunity for children with
a developmental disability. Bronfenbrenner and Ceci (1994) created the bioecological model, and they propose that human development occurs through complex, reciprocal interactions between the external environment and the individuals. These interactions are called proximal processes. The external environment
transforms individuals, and individuals change the setting.
Grounded in the bioecological model, this study examines individual and environmental variables as predictors of diaper need
and the interaction between an environment of diaper need
and individual psychosocial outcomes. Previous work identified
some diaper need associations, but the literature is limited primarily related to child outcomes. The purpose of this study
was to (a) examine the family and socioeconomic predictors of
diaper need and (b) examine associations between diaper need
and parent stress and child irritability among an underresourced,
neurodiverse COVID-19 pandemic point in time sample.
METHODS
This was a cross-sectional study of families with children aged
birth to 36 months. Parents were recruited online by informational e-mails with attached flyers and responded to survey
questions in January and February 2021. The sample was recruited through a public university in the northeastern United
States with a purposeful sampling of families connected to early
child support, home visiting, and disability programs. The participants completed an online questionnaire addressing family
characteristics, child developmental disability, and developmental concerns. The developmental conditions question was
based on a birth-to-3 age range modification of the National
Health Interview Survey (Zablotsky et al., 2019).
The diaper need assessment and classification of high and
low diaper need was based on a previous work by Massengale
et al. (2017) and National Diaper Bank Network recommendations (J. S. Goldblum, personal communication, 2020). Participants also completed the Hunger Vital Signs Two-Question
Screener for Food Insecurity (Hager et al., 2010), the Perceived
Stress Scale 10-item version (Cohen et al., 1983), and a subscale
of an infant or child behavior questionnaire. Based on the
child’s age, parents of a child aged 17 months or younger
Diaper Need
91
completed the distress to limitations subscale of the Infant Behavior Questionnaire (Gartstein & Rothbart, 2003), and parents of children aged 18 months or older completed the frustration subscale of the Early Childhood Behavior Questionnaire (Putnam et al., 2006). The distress to limitations and
frustration subscales were used to measure irritability. The survey was available in English and Spanish. A bilingual early childhood specialist translated the Spanish version. The translation
was reviewed by a bilingual parent of an infant and a Spanishspeaking pediatric nurse practitioner. Parents were offered a
$15 gift card for participation. Each participant provided consent before starting the survey. The protection of human subjects was approved by the institutional review board at
Rutgers, The State University of New Jersey.
Statistical Analysis
Descriptive statistics of the family characteristics, diaper need,
food insecurity, and parent-reported diaper need mitigation
strategies were calculated for the entire sample. High diaper
need was defined as not having enough diapers to last the
month. Low diaper need was defined as needing diapers occasionally (once a year or a few times a year) but typically having
enough supplies to last the month. Missing items constituted
<5% of the data from enrolled participants. Respondents with
missing items for a variable were not included in models that
included the said variable. Because of the limited number of
participants with children 18–36 months (n = 29), the Early
Childhood Behavior Questionnaire results, young child irritability scores were excluded from statistical analysis. Infant
(0–17 months) irritability scores (n = 99) were included.
The study’s first aim was to identify family and socioeconomic predictors of diaper need among the sample. Bivariate
analyses with chi-square and Fisher’s exact tests were used to
assess the associations between predictors (family characteristics and socioeconomic factors) and high diaper need. Logistic
regression was used to identify and model predictors of high
diaper need. The second aim was to assess the associations between high diaper need and family psychosocial outcomes
(parent stress and child irritability) among the sample. Bivariate independent t-tests were also used to explore the relationship between diaper need and psychosocial family outcomes
(parent stress and child irritability). To ensure that we did
not exclude relevant covariates, we performed exploratory bivariate analysis with an alpha value set at less than .05. Multiple
linear regression was used to explore the relationship between
diaper need and each outcome while controlling for significant socioeconomic and family variables.
RESULTS
Sample Description
Of the 129 included parent participants, 76% (n = 98) were female. Greater than half, 62% (n = 80), identified as White.
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
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Diaper Need
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Fourteen percent (n = 18) identified as Latinx, and 7.7%
(n = 10) identified as Black/African American. The majority,
59.7% (n = 77), were between 25 and 34 years. Twenty-eight
TABLE 1. Characteristics of Study Participants
Response sample
n (%)
Characteristics (N = 129)
Caregiver-level and family-level characteristics
Respondent language
English
Spanish
Female gender
Age, years
18–24
25–34
35–44
45–54
55–64
Income for 2019, USD (n = 125)
<10,000
10,000–20,000
20,000–35,000
35,000–50,000
50,000–70,000
70,000-100,000
>100,000
Race
Latinx
Native American
Asian
Native Hawaiian or other Pacific Islander
Black/African American
White
Two or more races
Geographic region (n = 128)1
Northeast
Midwest
South
West
Household members, median (IQR), mean (SD)
Child-level characteristics
Child’s age in months, median (IQR), mean (SD)
Prematurity
Female gender
Developmental concerns
Developmental disability
Autism spectrum disorder
Blindness
Cerebral palsy
Intellectual disability
Seizures
Developmental delay
Hearing loss
Any
121 (94)
8 (6)
98 (76)
5 (3.9)
77 (59.7)
44 (34)
2 (1.6)
1 (0.8)
5 (4)
5 (4)
23 (18.4)
35 (28)
27 (21.6)
20 (16)
10 (8)
18 (14)
9 (7)
6 (4.6)
5 (3.9)
10 (7.7)
80 (62)
1 (0.8)
26 (20.3)
25 (19.5)
36 (28.1)
41 (32)
4 (3–5), 4.2 (1.4)
4 (2–16), 9.4 (9.6)
30 (23.3)
57 (44.2)
61 (47.3)
7 (5.4)
2 (1.6)
4 (3.1)
3 (2.3)
3 (2.3)
16 (12.4)
7 (5.4)
42 (32.6)
TABLE 1. Characteristics of Study Participants, Continued
Material hardship
Food insecure
Diaper need
High
Low
113 (87.6)
51 (39.5)
47 (36.4)
Note. Northeast includes CT, ME, MA, NH, NJ, NY, PA, RI, and VT. Midwest includes IL, IN, IA, KS, MI, MN, MO, NE, ND, OH, SD, and WI. South includes AL,
AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, and WV. West
includes AK, AZ, CA, CO, HI, ID, MT, NV, NM, OR, UT, WA, and WY.
percent (n = 35) had an annual income of $35,000–$50,000
in 2019. The average household size was 4.2 (SD = 1.4) individuals. The average child age was 9.4 months (SD = 9.6). Twentythree percent (n = 30) of the children were born prematurely.
Almost half of the parents had concerns about their child’s development (n = 61), and one third of the children had a diagnosed developmental disability (n = 42). Developmental delay
was the most common disability (n = 16). Over 87% of the
sample was food insecure. Descriptive statistics are shown
in Table 1.
Diaper Need Prevalence and Mitigation Strategies
Three in four (n = 98, 76%) of the participants reported some
diaper need. Greater than one third (n = 51, 39.5%) reported
high diaper need, defined as not having enough diapers to last
the month. The most frequently reported consequences and
mitigation strategies were child used a towel or other cloth
as a diaper (n = 41, 39%), child did not wear a diaper
(n = 36, 34%), and child used an ill-fitting diaper (n = 29,
27%). Other cited consequences were child got a rash
(n = 21, 20%), child was unhappy (n = 21, 20%), child got sick
(n = 17, 16%), child could not go to childcare (n = 16, 15%),
and an adult missed work (n = 12, 11%).
Predictors of Diaper Need
Table 2 shows bivariate analysis between child and family characteristics and diaper need. A chi-square test showed a significant association between high diaper need and adult age
( p < .001). Using bivariant analysis (Fisher’s exact test), we
did not find a significant association between income and high
diaper need ( p = .496) nor between diaper need and disability
and high diaper need (χ2 = 0.55, p = .457). The predictor variables of household size, adult age, and food insecurity were
examined for their effect on high diaper need in the binary logistic model. After adjusting for household size and adult age,
food-insecure families had 4.24 higher odds of experiencing
high diaper need than food-secure families (OR = 4.24, 95% CIs
[1.07, 16.77], p = .039). After adjusting for food insecurity and
household size, older parents (age = 35–64 years) were less likely
to report diaper need than younger parents less than 35 years
(OR = 0.23, 95% CI [0.08, 0.64], p = .005). After adjusting for
food insecurity and parent age, smaller households were more
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
Nursing Research • March/April 2022 • Volume 71 • No. 2
Diaper Need
TABLE 2. Family and Child Characteristics and High Diaper Need
High diaper need
(N = 129)
Yes
Variable
Prematurity
Premature
Term
Child gender
Female
Male
Developmental
concerns
Yes
No
Disability
Yes
No
Adult gender
Female
Male
Food security
Secure
Insecure
Adult age
18–34 years
35–64 years
Incomec
<$10,000
$10,000–$20,000
$20,000–$35,000
$35,000–$50,000
$50,000–$70,000
$70,000–$100,000
>$100,000
Race/ethnicity
Black/African
American
Latinx
Othere
White
Child agef
Household size
n
12
39
25
26
25
26
n
9.30 18
30.23 60
19.38 32
20.16 46
19.38 36
20.16 42
%
Coefficient
p
0.004a
.953
0.80a
.371
0.10a
.750
0.55a
.457
0.01a
.914
3.30a,b
.069
13.95
46.51
24.81
35.66
27.91
32.56
12
39
9.30 23
30.23 55
17.83
42.64
39
12
30.23 59
9.30 19
45.74
14.73
3
48
2.33 13
37.21 65
10.08
50.39
42
9
32.56 40
6.98 38
31.01
29.46
<.001
.502d
1.60
2.40
10.40
10.40
6.40
5.60
4.00
3
2
10
22
19
13
5
2.40
1.60
8.00
17.60
15.20
10.40
4.00
.374d
6
4.65
4
3.10
5
3.88 13
10.08
7
5.43 14
10.85
33
25.58 47
36.43
Mean SD Mean SD
9.22 8.83 9.58 10.13
3.86 1.28 4.36 1.37
High diaper need was associated with increased parentperceived stress scores in t-testing and linear regression modeling ( p < .001, p < .001). Controlling for food insecurity, child
age, and developmental concern, parents who reported high
diaper need to score an average of 2.72 points higher on the
perceived stress test than did families with low or no diaper
need (β = 2.45, p = .001). The model explained 22% of the variability in perceived stress scores (Adj R2 = .22, F = 9.85,
p < .001). In the second model, in which we controlled for disability instead of developmental concern, parents experiencing high diaper need to be scored 2.91 points higher than parents with no or low diaper need (β = 2.91, p < .001). We did
not find a significant association between high diaper need
and infant irritability either in t-tests or regression models, respectively ( p = .167; β = 0.23, p = .053).
DISCUSSION
12.85a
2
3
13
13
8
7
5
likely to experience high diaper need (OR = 0.72, 95% CI [0.53,
0.98], p = .035).
Diaper Need and Psychosocial Variables
No
%
93
0.21g
2.07g
.836
.041
Note. High diaper need is defined as an insufficient supply of diapers to get
through the month. Participants reported current (2021) diaper need.
a
Chi-square test.
b
Fisher’s exact p = .10.
c
2019 Annual income.
d
Fisher’s exact test.
e
“Other” includes Asian, Native American, Native Hawaiian or other Pacific Islander, and two or more races.
f
Age in months.
g
Independent t-test.
This study provided an updated COVID-19 pandemic time assessment of underresourced families through the lens of diaper need. In this cross-sectional analysis of 129 U.S. families,
76% (n = 98) of parents reported some diaper need and
39.5% (n = 51) parents reported high diaper need. This sample’s prevalence of diaper need was greater than among
prepandemic studies of underresourced families (Belarmino
et al., 2021). An increase in any diaper need during the
COVID-19 pandemic is consistent with case reports of a rise
in demand for resources at diaper banks (National Diaper
Bank Network, 2020).
Caregivers reported using a cloth-like diaper or not using a
diaper as primary consequences of a deficit. Less commonly
cited consequences included asking a friend or family member
for money/diapers. This finding differs from previous studies
(Belarmino et al., 2021; Massengale et al., 2017). The change
suggests a possible shift in primary mitigation strategies during
the pandemic from leveraging support networks of family and
friends to using alternate supplies or forgoing a diaper. More
serious secondary consequences of diaper need, including
child unhappiness, rash, sickness, inability to attend childcare,
or inability of adults to attend work/school, were similar to
Massengale et al. (2017). Higher levels of diaper need may indicate that more children and families are experiencing secondary consequences. Participants were asked about 2019 income
and 2021 diaper need. Our results also showed that 2021 diaper need occurred across all 2019 income brackets; 2019 income was not protective against 2021 diaper need, a finding
that may be partially related to the changing economic landscape from 2019 to 2021.
In the regression analysis, younger parent age was a risk
factor for high diaper need. This finding differs from Smith
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94
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et al.’s (2013) finding of an association between older parental
age and diaper need. However, in Smith et al. (2013), the age
category associated with diaper need was older, above 45 years,
and was used as a proxy for grandparent caretakers. Our findings on the positive relationship between food insecurity
and any diaper need are similar to the findings of Belarmino
et al. (2021). A positive relationship between food insecurity
and diaper need is an expected finding because both food insecurity and diaper need are types of material hardship and
poverty measures.
Our findings of the positive relationship between diaper
need and parent stress are congruent with qualitative literature
on diaper bank clients. Mothers reported a key benefit of diaper receipt was decreased stress (Massengale et al., 2017). Disability and developmental concern uniquely contributed to
parent stress in the model. A finding suggests the role of both
disability status and developmental crisis in parent stress
among underresourced families. We did not find a relationship between diaper need and infant irritability among this
sample. This differs from parent reports of child unhappiness
related to insufficient diapers in this study and previous work
(Massengale et al., 2017). In this sample, many of the children
had developmental disabilities or developmental concerns,
contributing to irritability. Disability was significantly associated
with infant (age = 0–17 months) irritability in the multiple linear
regression model. Future research could assess the relationship
between high diaper need and irritability among samples of
neurotypical children. Because of insufficient power, we could
not analyze the relationship between diaper need and young
child (age = 18–36 months) irritability. Future research is needed
to measure the relationship between irritability and diaper need,
especially among children aged 18–36 months.
These results have implications for material hardship screening. The Council on Community Pediatrics (2016) and the Council
on Community Pediatrics and Committee on Nutrition (2015) recommended screening for basic and social needs and connecting
families to resources. Screening for food insecurity may serve as
a proxy for diaper need among families with young children.
After a positive screen for food insecurity—especially with a
history of diaper dermatitis—clinicians should consider providing information on diaper banks or other diaper resources.
However, it should be noted that food security does not exclude the possibility of diaper need, as seen in Belarmino
et al. (2021). When families are particularly at risk, screening
specifically for diaper need may be beneficial.
Furthermore, in the current climate, families who were
previously economically stable may be experiencing diaper
need. Our study revised the diaper need assessments by incorporating previous literature with current expert opinion. Clinicians may consider asking families if they have enough diapers
to last the month. Insufficient supplies to last the month indicate high diaper need. Identifying high diaper need and
connecting at-risk families to resources may be especially
useful as our data suggest a relationship between high diaper
need and parent stress.
This research also has implications for the prioritization of
patient education on toilet training. Decisions about toilet
training timing are likely affected by economic pressures
(Horn et al., 2006; Howell et al., 2010), and families experiencing diaper need may attempt training before a child is developmentally ready (Porter & Steefel, 2015). For children with developmental disabilities, toilet training support may include referrals for behavioral therapy or the utilization of specialized
toilet training toolkits. Timely toilet training education could
provide families experiencing diaper need with information
that promotes appropriate development while possibly lessening the child’s time in diapers.
Currently, most safety net programs do not allow for diapers
as a covered benefit. This research contributes to our knowledge
of diaper need risk factors and possible consequences. This
knowledge could aid in creating, modifying, and sustaining programs to address diaper need at a structural, policy level.
Limitations
This cross-sectional study identified meaningful relationships but
cannot determine causation. Survey responses were parentreported and may be subject to social desirability and recall
bias. Although the sample was neurodiverse and racially inclusive, it was a nonprobability sample and not representative of
all populations. We did not measure or control for all possible
variables (e.g., personal support, marital/relational hostility,
neighborhood risk, and acculturation) that have been associated
with parental stress among underresourced families. Finally, we
do not have pre–post pandemic data for this sample, limiting
the comparison to trends among nonpandemic samples.
Conclusion
The findings of this study add to our knowledge about diaper
need among families with neurodiverse young children during
the COVID-19 pandemic. Nurses can use this information to assess families and connect clients to diaper resources, especially
during economic and social upheaval. Diapers are important
care items that are used daily during the foundational early
childhood years. Diaper need is a potentially modifiable factor
that influences parent stress and the health of their children.
An adequate diaper supply is likely significant among households with children with a developmental disability because
these parents are at risk for increased stress. There is a need
for further research on child behavioral outcomes of diaper
need and the relationship between material hardship and
developmental disability.
Accepted for publication October 8, 2021.
The authors would like to thank Kelley Massengale, PhD, MPH, National
Diaper Bank Network, for generously sharing her expertise; Claudia Patricia
Burnham, Certified Interpretation Services, for her excellent translation
work; and the families and family advocates who made this work possible.
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
Nursing Research • March/April 2022 • Volume 71 • No. 2
The study was approved by the institutional review board of Rutgers, The
State University of New Jersey. Consent was obtained prior to survey
completion.
The authors have no conflicts of interest to report.
Corresponding author: Emma Shaffer, PhD, CPNP, Rutgers, The State
University of New Jersey, 180 University Ave, Newark, NJ 07102
(e-mail: es951@sn.rutgers.edu).
ORCID iDs
Emma Shaffer https://orcid.org/0000-0002-2762-8493
Sallie Porter https://orcid.org/0000-0002-2077-640X
Peijia Zha https://orcid.org/0000-0003-4864-692X
Eileen Condon https://orcid.org/0000-0001-7747-5870
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