Reusable nappies: research

5 Findings: Interventions to support use of reusable nappies

This section of the report examines existing evidence on schemes or interventions intended to support uptake of reusable nappies. This draws on evidence from the academic and grey literature reviewing, the desk-based investigation of schemes in Scotland, and focus group discussions with parents.

5.1 Overview of types of schemes to support use of reusable nappies

Based on the rapid evidence assessment, we identified the following categories of schemes to support reusable nappy uptake:

• Nappy libraries
• Reusable nappy kit provision
• Voucher schemes
• Cashback or grant schemes
• Nappy laundry services
• Provision of reusable nappies on maternity wards
• Other (including events, campaigns and information resources)

These different types of scheme are discussed in detail in section 5.2. Where schemes were mentioned in the literature, this was often relating to speculation on the potential for schemes to address identified barriers, or case studies providing descriptions of schemes only. The 13 sources providing some evaluation of schemes are summarised in Appendix C, with several sources pertaining to the same scheme. There were few examples of robust evaluation of scheme impacts. The quality of evidence from the studies was limited by:

• Lack of insight into behavioural outcomes in scheme evaluations, beyond broad headline figures on uptake (e.g. number of vouchers redeemed, number of kits supplied). This means it was often not possible to identify the extent to which parents who redeemed a voucher or requested a nappy kit switched to reusables after having tried them out initially.
• General lack of evidence on the added value of schemes in stimulating adoption of reusables beyond those that would have used reusables in the absence of the scheme. Whilst a few studies adopted experimental or quasi-experimental methods to compare outcomes in trial groups to control groups most studies did not. At the same time, scheme participants were largely self-selected.
• Absence of follow-up on long-term behavioural maintenance. Those studies that did explore behavioural changes among participants were short-term time limited studies, limiting understanding of how changes may or may not have persisted in the long-term.
• Few of the sources evaluating schemes reported economic, environmental or social impacts. In the cases where economic and environmental impacts were estimated the assumptions upon which these were based were not always clear.

5.1.1 Interventions operating in Scotland

The desk-based activity collating information on schemes in Scotland identified 20 schemes operating at a local or regional level. These are detailed in Appendix D. Some of the evidence available is more than five/ten years old and so it was not always clear whether the schemes are still active. Other active schemes and activity promoting the use of reusable nappies may also exist across Scotland, but further research is required to determine the scale of this. The majority (16 out of 20) of the schemes identified were nappy libraries. Nappy libraries allow parents to hire reusable nappies usually for a small price, to try out different types of reusable nappies before buying them upfront. Usually, nappy kits can be rented through messaging the Facebook group or emailing the nappy library and then are collected or can also be delivered in some communities with some offering courier services. Reusable nappy kit provision schemes (2), and cashback or grant schemes (3) were also identified. It is noted that one of the initiatives operated multiple scheme types. The majority of nappy libraries appear to be run by volunteer-based community groups, with other schemes operated by local authorities and charities. We found limited evidence evaluating the impacts of these schemes.

5.2 Evidence on scheme types and their impacts

In this section we outline evidence from the international literature on the impacts of reusable nappy schemes falling under the categories set out above in section 5.1. Additionally, insights from the focus groups on parents’ attitudes to and awareness of such schemes in Scotland are noted.

5.2.1 Nappy libraries

Nappy libraries offer families the opportunity to borrow reusable nappies/nappy kits or hire for a small fee. This allows families to gain hands on experience of reusables before committing the upfront costs to buy their own kit, and to try out different types and brands to see what might best for them and their babies. Nappy libraries were the most common scheme identified in our mapping activity of interventions operating in Scotland, and are mentioned in the literature as an intervention that reusable nappy users report having found useful in supporting their own positive attitude to reusable nappies (Watson et al., 2023). Despite this, the evidence review found almost no published evidence on the impact of nappy library schemes. Kok’s (2018) evaluation of a pilot scheme ran across three Dutch municipalities included only a very small number of participants (3) who took part in a nappy leasing scheme. In a wider survey as part of the same study, leasing or renting was very unpopular with respondents – ‘nearly all’ of the more than 100 respondents who used disposables stated a perception that leasing or renting would be unhygienic (Kok, 2018).

Insights from focus groups – nappy libraries:

None of the focus group participants had heard of nappy libraries, but they were broadly supportive of the idea. This was particularly the case in comparison to nappy laundering services (see section X below), but also as a favourable alternative to the high upfront costs of purchasing reusable nappies.

5.2.2 Free reusable nappy kit provision

The evidence review highlighted a number of schemes focusing on the provision of free reusable nappy kits to families. One source highlighted North Ayrshire Council’s Birth to Potty Scheme, reported to be the first scheme in the UK to provide free reusable nappy packs from birth to potty, launched in October 2019. Parents can request a trial pack of reusable nappies, and can then choose to progress to a free birth to potty pack (see Appendix C for more details of contents). The Council reported that the scheme has been used by >200 families and is estimated to save families up to £1300 per child (North Ayrshire Council, n.d.). No evidence on the behaviour of families after having accessed the scheme, or that would allow quantification of the uptake of reusables attributable to the scheme itself was available.

Other examples of nappy kit provision schemes in the literature tended to engage smaller groups of participants in trials or pilot projects, involving follow up with participants to understand the impact of accessing a nappy kit on subsequent use of reusables. The results of these projects, conducted in the USA (Renkert & Filippone, 2023), Australia (Siemensma & Hunter, 2007) and the Netherlands (Kok, 2018) are shown in Appendix C. Overall these studies showed that the majority of participants reported continuing to use reusables for the full length of the trial period (the duration of which was not always reported) and intended to continue using them. Across these studies, those who continued to use reusables tended to do so in combination with disposables, rather than exclusively relying on reusables. Together the studies suggest that free reusable nappy kit provision can be an effective intervention to promote uptake of reusable nappies, however the findings of the studies are generally limited by a lack of follow-up beyond the trial period, self-selection of participants onto projects, as well as a lack of assessment against appropriate control or comparator groups. Assessment of overall economic, environmental and social benefits was variable across the studies. Positive impacts highlighted were cost savings by families (Renkert & Filippone, 2023). Negative impacts noted included higher water use (Siemensma & Hunter, 2007), greater time spent on nappy care work (Renkert & Filippone, 2023; Siemensma & Hunter, 2007), more nappy rashes (Renkert & Filippone, 2023), and leaks (Siemensma & Hunter, 2007).

Whilst not evaluating impacts of a scheme per se, it is worth highlighting that in Scotland it was originally proposed that the Baby Box scheme included a single free reusable nappy, rather than a voucher as is currently included. Focus group testing of this proposal indicated that parents did not appreciate the inclusion of the reusable nappy (Scottish Government, 2017a) and a subsequent pilot in which 160 boxes were distributed and feedback sought from parents found that these were seen as a wasted item that should not be included (Scottish Government, 2017c).

5.2.3 Voucher schemes

Voucher schemes offer parents the opportunity to save money on purchases of reusable nappies. Overviews of good practice in reducing disposable nappy waste in Europe highlight that in the UK more than 70 local authorities offer economic incentives including voucher schemes, examples of voucher and money off schemes operating in Italy and Spain are also given (Arnold et al., 2023; Copello, 2021).

Evaluations of the Real Nappies for London scheme (Warner et al., 2015, 2017, 2018), introduced in 2007, offers insight into the potential impacts of such schemes. In this scheme, registered residents of participating London boroughs are able to request a voucher towards the costs of reusable nappies. Between 2007 and 2016 13,845 vouchers were issued, around three-quarters of which were redeemed. Estimations of the impact of the scheme across this time period suggested that the scheme was extremely cost effective, with local authority cost savings for waste disposal estimated to total more than 10 times the cost of administering the scheme. Over the course of 2007-2017, it was estimated that the scheme prevented 10,903 tonnes of disposable nappy waste. Impact estimations assumed that parents redeeming vouchers used reusable nappies from birth to toilet training at 2.5 years, in combination with disposable nappies, resulting in an average saving of 4.7 disposable nappies per day over this period (Warner et al., 2015). No monitoring of behaviour after redeeming the voucher was conducted to ascertain whether families redeeming the voucher continued to use reusables in the long-term, so estimations of impact may have inflated actual environmental and economic savings to local authorities.

Evaluation of Scotland’s Baby Box scheme (Scottish Government, 2017b; Scottish Government et al., 2021) included investigation of the attitudes of parents and healthcare professionals regarding the inclusion of specific items in the box, including a reusable nappy voucher for one reusable nappy wrap and five washable nappy pads. Earlier prototype versions of the baby box included a free reusable nappy in the contents, which was removed in response to early pilot evaluations (Scottish Government, 2017a, 2017c). Further research on the baby box indicated an appetite for inclusion of a voucher towards reusable nappies, and this was introduced in 2019. A 2021 evaluation of the Baby Box scheme indicated that midwives and health visitors perceived the voucher to be the least useful item included, although this view was not matched by parents’ perceptions. Some parents on lower incomes appreciated the voucher as without it they would not have had the opportunity to try reusables (Scottish Government et al., 2021). Information given in response to a parliamentary question in 2022^[1] indicated that between June 2019 and April 2022, a total of 19,258 reusable nappy vouchers were redeemed, with a cumulative saving of over £249,000 for families. It is also stated that families who use the voucher were offered a discounted package if they wished to continue using reusables, with 224 families (from June 2020 to April 2022) using this discount.

Overall, there is a need for more evidence on the effectiveness of reusable nappy vouchers, particularly regarding the adoption of reusable nappies in the long term by those who redeem vouchers, and investigation into the extent to which voucher schemes provide an incentive for uptake by those who would not have considered reusables otherwise.

Insights from focus groups – voucher schemes:

In our focus groups, only one participant had been motivated to try reusable nappies as a result of the voucher in the Baby Box. Some participants did not recall having seen a voucher in the Baby Box, and others had dismissed it, either because they were not interested in trying reusables, or because it involved actively sending away for the supplies.

5.2.4 Cashback or grant schemes

Similar to voucher schemes, a number of examples of cashback, grant or other subsidy schemes to encourage reusable nappy use were mentioned in the literature. These included examples of cashback schemes in London (Warner et al., 2015), other local authority areas in England including Derbyshire, Milton Keynes and Leeds (Copello, 2021), Belgium (Arnold et al., 2023; Copello, 2021), Austria (Salhofer et al., 2008) as well as in Scotland (Inverclyde council & Barnes, 2009). In Scotland, the Inverclyde Real Nappy Campaign offered an £80 incentive to use reusables, with uptake by 23 families in 2008-2009 (Inverclyde council & Barnes, 2009). Salhofer et al. (2008) reported overall low uptake of subsidy schemes in Austria, ranging from 1.4% to 3.3% depending on region, with higher uptake (up to 10.5%) in some communities. No evidence on the economic, social and environmental impacts of cashback, grant or other subsidy schemes was found.

5.2.5 Nappy laundry services

Commercial nappy laundries provide users with freshly laundered reusable nappies. Once used, nappies are returned for laundering. This type of nappy product service system (where users purchase the service, rather than owning their own nappies) is discussed as offering a potential advantage of more energy efficient laundering (United Nations Environment Programme et al., 2021), however the recent UK-based nappy life cycle assessment commissioned by Defra (2023) did not analyse potential gains due to the fact that use of laundry services is not common practice. Others note that laundry services may have the potential to help overcome the barriers to do with time and labour in particular (Pendry et al., 2012; Short & Harvey, 2008), however costs of commercial services may be prohibitive or off-putting (Pendry et al., 2012; Plotka-Wasylka et al., 2022). Some authors argue for incentivisation and subsidisation of laundry services (Pendry et al., 2012; United Nations Environment Programme et al., 2021) due to these potential advantages. Nappy laundry services operating as social enterprises can also offer the potential for positive social impacts through supporting people into employment (Delgadillo et al., 2021).

Husaini et al. (2007), in a review of case study waste reduction schemes, profiled the West Sussex Real Nappy Initiative, a scheme providing free laundry services to families (see Appendix C) was assessed as ‘good’ in terms of effectiveness. Five hundred families participated in 1999-2000, with an estimated cost saving of around £20,000 for the local authority due to reduced waste management costs associated with the 8000 tonnes of disposable nappies (1600 kg/family/year) that were estimated to have been avoided. No information was available on the methodology or assumptions used to estimate these impacts.

Uzzell & Leach (2003) trialled a free laundry service, in combination with an intervention in a maternity unit in England (see also section 5.2.6 below). Uptake of the 6-week home laundry trial was higher amongst those that experienced reusable nappies on the maternity ward, and those motivated to reduce waste through their nappy choices. While parents who already intended to use reusable nappies were more likely to agree to take part in the scheme, the majority of scheme participants had originally intended to use disposables.

Of the 44 parents who took part in the home trial and returned a questionnaire 6 weeks later, more than half had continued to use the laundry service for the full length of the trial, with 5 using exclusively reusables during the trial period. At the end of the trial, 20 of the 44 participants intended to continue to use reusables, around half of which had originally planned to use disposables with their baby. Intentions to continue to use reusables was higher amongst participants who had also had reusables available to them in the maternity ward, compared to the control group. Reasons for not continuing at the end of the free trial included smells from the nappy bin (collected weekly) and costs of continuing the laundry service, as well as challenges of using reusables in general (e.g. time and convenience, nappy performance issues).

Overall the evidence suggests that free nappy laundry service schemes have the potential to encourage use of reusable nappies, but more research is required on the cost effectiveness, environmental and social impacts of such schemes and different models for their operation.

Insights from focus groups – nappy laundry services:

None of the focus group participants had either used, or even heard of, nappy laundering services. When we explored how participants felt about potentially using a nappy laundering service there was a generally negative reaction, with participants voicing major hygiene concerns and disliking the idea of not receiving their baby’s ‘own’ nappies back. They were concerned about where they might store a week’s worth of dirty nappies (with one participant commenting that they wouldn’t ever have a dirty disposable in their inside bin, let alone a week’s worth of used cloth nappies waiting to be picked up), about the house smelling, and expressed feeling that they might have to do a ‘pre-clean’ of the nappies (analogous to the ‘clean the house before the cleaner comes’ mentality). One participant raised concerns about the environmental impact of having delivery vans driving to and from multiple households, picking up and dropping off nappies. With respect to the cost of such a service, another participant commented that eventually the cost might encourage one to start laundering them at home. A possible underlying reason to such strongly negative reactions to the concept of nappy laundering services is stigma and lack of control over the condition of the nappies that would be delivered.

“I think it’s just a stigma. I think most folk, certainly for younger children especially, you are very – you want to wrap them in cotton wool, and it’s not somebody else’s dirty cotton wool you want it to be.” (Focus group participant).

5.2.6 Provision of reusable nappies in maternity wards

As noted above in section 5.2.5, Uzzell & Leach (2003) evaluated the impact of providing reusable nappies in a maternity unit, so that new parents were freely able to use these during their stay following the birth of their baby, or they could use disposables they supplied themselves. Previous to this, the policy had required parents to supply their own disposables. Groups of parents staying on the ward before and after the policy change were compared. The research found that no significant difference in eventual nappy choices between the before and after groups, although interviews with those in the after group indicated that these parents were more open to trying reusable nappies. Issues with training of staff on the ward to use reusables were noted, which may have impacted on the effectiveness of the scheme.

Insights from focus groups – provision on maternity wards:

Participants in our focus groups suggested that provision of reusable nappies in maternity wards would be a good way of increasing awareness and experience of them, and that confidence in trying them out at home might be boosted through having tried them in the hospital first.

5.2.7 Other types of reusable nappy interventions

Other types of reusable nappy interventions highlighted in the evidence review included real nappy events and campaigns (Sharp et al., 2010), ‘nappucino’ events for reusable nappy users (Pendry et al., 2012), partnerships between local authorities and independent private sector reusable nappy agents in promotions and social support for users (Askins & Bulkeley, 2005), online communities and social media groups (Watson et al., 2023), and website information interventions (Miller et al., 2011). While there is a lack of evidence on the impact of such interventions on adoption of reusable nappies, the literature discussing such interventions highlights the importance of social support and trusted actors in promoting reusable nappy use.

5.3 Parents’ recommendations for interventions

One of the key findings from the focus groups was that using disposables rather than reusables was often not an explicit, considered choice. It was simply that reusable nappies were not on participants’ radar when they were expecting their babies, and so disposables were automatically bought and used when the babies were born. In recognising this, the participants generated ideas for how the profile of reusable nappies could be raised, and how and where more information/support on using them could be provided.

There was general agreement that currently information on reusables nappies is something that has to be actively sought. Disposable nappies are advertised heavily on television and dominate in the supermarkets. Although Boots does sell a few different reusable nappies in its stores, these are placed on the top shelf or, as one participant highlighted, are often out-of-stock online. Aldi and Lidl occasionally sell them in their middle aisles, but this presence is not consistent. Although there are multiple makes and types of reusable nappies available online, this information requires time and effort to sift through in order to make an informed decision on which brand to purchase.

But before that stage is reached, it is important to increase visibility and awareness of reusable nappies through multiple points of contact during pregnancy and beyond. Some ideas generated within the focus groups include:

• Posters/information at the doctor’s surgery/waiting for antenatal scans. Early on in pregnancy would be best, as reusable nappies require more active research than disposables, and the intention to use reusables is often a decision that requires consultation and discussion with a partner.
• Information about reusable nappies in the NHS’s ‘Ready Steady Baby’ / other pamphlets/booklets about pregnancy, childbirth and raising babies. Information sources should include tips on how to use, how to clean, how many one is likely to need.
• Demonstration/information at antenatal classes. At least one focus group participant had never seen a reusable nappy and had no frame of reference for the terminology that goes along with their use e.g. liner, insert, wrap. Since antenatal classes demonstrate disposable nappies, it was felt that they could also demonstrate reusables.
• Information/advice from midwife/health visitor, and not just pre-birth or in the early weeks. As some of the focus group participants had used reusables at the potty-training stage, it was felt that this was something that could be more broadly encouraged, that reusable nappies could be promoted for different stages within the overall birth-to-potty stage. Also seen as important was the promotion of the idea that even using reusables for some of the time is better than using them for none of the time.
• Inclusion of an actual reusable nappy in the baby box, rather than the voucher.
• Reusables as an option in the maternity ward. Many maternity wards have spare nappies available under the cot. Focus group participants felt having reusables as an option would encourage them to give them a go.
• TV adverts particularly endorsed by The Scottish Government (seen as a reliable source), possibly combined with more information on what currently happens to disposables nappies, tackling both the perception that disposables are biodegradable, and that nappies end up in landfill. Focus group participants thought that presenting actual statistics on carbon savings with relatable examples would be valuable.
• Adverts/information on social media/TikTok/YouTube would be appreciated (while recognising that the algorithms of some of these platforms might mean that not everyone would see the adverts).
• Greater presence of reusables in supermarkets, next to disposables (and not just on the top or bottom shelf).

5.4 Data to support future evaluations of scheme impacts in Scotland

The limited evidence on the economic, environmental and social impacts of reusable nappy schemes, both in Scotland and in the international academic and grey literature, points to a need for more robust evaluation. Evaluations should ideally measure impacts on behaviour, rather than just scheme participation numbers, including long-term maintenance of use of reusables and the extent to which reusables are used in combination with disposables. Critically, evaluations should consider ways in which to assess the extent to which schemes have encouraged uptake of reusables over and above those who would have chosen to use them in the absence of the scheme (e.g. through the use of control or comparator groups).

More accurate data on the behavioural impacts of schemes could help to ground models estimating their economic and environmental impacts, particularly given that evidence from Life Cycle Assessments emphasises that the impact of reusables versus disposables depends heavily how they are laundered, which may be subject to variation due to climate, weather and energy costs. At the same time, the environmental impact associated with laundering reusables could depend highly on the grid energy mix (Sandison et al., 2023). Although Defra's (2023) LCA offers a useful data to ground calculations of scheme impacts, Scotland-specific assessments of impacts of reusables, taking into account the energy mix and context-specific assumptions about laundering could improve estimations of impacts of reusable nappy schemes in the future. Economic assessments should also strive to incorporate up-to-date data on costs to local authorities associated with managing waste from disposable nappies.