Poor Disposal of Soiled Diapers in Sub-Saharan Africa: A Gap in Environmental Health Literacy in Rural Communities

Abstract

Disposable diapers are designed to absorb and retain a baby’s urine and fecal matter whilst keeping their skin dry and healthy. Although they are convenient and a huge benefit in today’s busy life-style, their impact on the environment is becoming unbearable due to poor handling and disposal practices. Disposable diapers are known to reduce the burden of domestic chores for many care-givers. However, the threat to environmental and public health due to its ability to contaminate water and land cannot be ignored. These practices show a serious gap in Environmental Health Literacy (EHL) within the communities of Sub-Saharan Africa (SSA). Seemingly, more than 95% of these communities use disposable diapers with limited knowledge on how to dispose of them and protect the environment. Apparently, there are no programs in place to transfer knowledge to care-givers on how to prevent an impact on the environment after use. On the other hand, there is no regulation or procedure in place focusing on practices and disposal. As a result, inappropriate handling and disposal continue to be a public health risk to communities, with less appropriate measures to prevent environmental and health risks.

1. Introduction

Environmental Health Literacy (EHL) is a concept that integrates environmental and health literacy, with the aim of developing self-empowering skills and the competency required to make an informed choice to reduce health risks and enhance environmental protection [1]. The use and disposal of soiled diapers in rural areas represent a lack of Environmental Health Literacy. This is usually observed in disadvantaged communities with low socio-economic status, and lack of environmental health risks awareness programs [2]. In Sub-Saharan Africa (SSA), especially in the rural areas, waste management has become a serious challenge. This is evident in most areas where communities lack appropriate services and find their own means of managing waste, which has left these communities with serious environmental health risks [3].

It has been reported that the annual waste generated increased to 174 million tonnes per year in 2016 [4]. However, in 2018, only 44% received municipal solid waste collection [4]. The high volume of waste generated in SSA is attributed to rapid growth and industrialization [5]. Furthermore, projections indicate that by 2050, globally, waste will have doubled, particularly in Africa and Asia. Moreover, while waste generation continues to increase, it is reported that approximately 50% of urban waste remains uncollected [6]. In the Southern African Development Community and many other similar countries, waste management problems stem from the lack of management, high costs of service delivery, lack of infrastructure and poor enforcement from the authorities [7]. Purportedly, in rural areas, the situation is worse as the majority do not receive waste management services [8]. Hence, rural communities have resorted to alternative ways of managing waste, whereby indiscriminate dumping has become more evident, symbolizing a lack of or poor EHL [9].

Subsequently, the indiscriminate disposal of waste remains the biggest challenge in many SSA countries, as the dumping of waste, including soiled diapers, is observed along roadsides, marketplaces and other public spaces, proving this to be a common practice [10]. Subsequently, the lack of waste removal services in many rural communities in SSA countries continues to be a concern for the environment and public health [10]. These behavior indicate a lack of knowledge and environmental literacy amongst the communities. Furthermore, in a report by the United Nations International Children’s Emergency Fund conducted in 2020, it was estimated that 1.7 billion people lacked access to basic sanitation services, with 494 million people practicing open defecation [11]. Open defecation is defined as the disposal of human feces in an open environment such as fields, forests, water bodies, and with municipal waste [11]. Consequently, the dumping of soiled nappies becomes a proxy of open defecation due to fecal matter found in soiled diapers that contaminates the environment.

The concept of open defecation extends to the disposal of feces contained in materials such as plastic bags, which has the potential to become exposed to the open environment irrespective of the pathway [12]. Open defecation poses a risk to environmental and public health as it is associated with the increased prevalence of diarrhea diseases, particularly in children [12]. According to the World Health Organization (WHO), diarrhea disease is the second greatest cause of mortality for children under 5 years of age worldwide, and accounts for 800,000 deaths a year primarily in the developing countries of Africa [13]. Children’s fecal matter is more likely to contain enteric pathogens than adults’, and open defecation by children contaminates the household environment, which may cause the transmission of diarrhea and cholera [11]. Consequently, this could happen as a result of poor or unsafe disposal of fecal waste, especially in low-income countries with fewer waste management resources. This then represents a gap in EHL [14].

2. The knowledge, attitude and behavior regarding diaper disposal in Sub-Saharan Africa

Over the last decades, there has been an increase in the global usage of disposable diapers, which was a huge transition from the use of cloth diapers [15]. Sales of nappies have grown rapidly, mostly in Africa and other Asian countries. The growth is expected to continue to increase, especially in low- middle income African countries. For instance, Nigeria is expected to see a 117% rise by 2026 [12]. Jesca et al. [16] states that there are few literature reviews offering insight into ways to handle and dispose of disposable nappies. The norm is that diapers should be rinsed off and the soils thrown into the toilet before disposal as municipal waste. However, with no specific guidelines regarding the safe disposal of diapers, hence “single use” diapers are seen polluting the environment [12].

In many SSA countries, there is a lack of monitoring, education and awareness on appropriate methods of disposing used diapers and their potential risk to the environment, as well as health risks that result from such practices [17]. These discrepancies translate to a lack of EHL, which is the ability to identify environmental health risks and apply appropriate measures to prevent any hazard [18]. Hence, the most common and safe method of disposal of solid waste utilized at household level should be done at municipal landfill sites. Subsequently, it is practiced by only a few as it is irrelevant to those in rural communities where municipal waste services are minimal, inconsistent or non-existent [4]. In addition, a survey conducted in 21 villages of Cambodia found that only 13% of care-givers used disposable diapers, even though they are considered clean, convenient and time-saving [19]. Notably, most care-givers reported that their children are taught at a very young age to use latrines, potties and other means to defecate in their yard [19]. These villages had limited access to disposable nappies because of financial income, and cloth diapers were preferred due to low cost. Subsequently, disposable diapers were found to cost three times the price of cloth diapers [14].

In contrast, the use of disposable diapers is high in other SSA countries, for instance, disposable diapers have become popular in Zimbabwe [20]. Most women use them, irrespective of the level of education, social status and age. There are different reasons to be noted in relation to why women in Zimbabwe utilize disposable diapers, namely: they were advantageous, convenient and save time, as they do not have to spend time washing [21]. It is to be noted that the women who participated in the study by Jesca et al. [16] reported using fewer nappies a day because of the ultra-absorbent material. This implied that the baby could spend several hours in one nappy. Although this was the case, their disposal was a major environmental health concern. Many areas have no system in place to cater for their disposal [22]. Furthermore, as reported, these areas lacked the capital to run the waste disposal systems efficiently. Additionally, the local authority cannot afford to provide skip bins in the communities to encourage the separation of waste at the source. Thus, people are encouraged to put disposable diapers in plastic bags and dispose of them in their bins along with municipal solid waste [17].

In Nakuru County, Kenya, 73% of care-givers dispose of soiled diapers with other household waste; 18.9% dispose of it in pit latrines; and 0.7% dispose of it in pit toilets (Figure 1) [23]. Also observed were caregivers’ disposing of diapers in open fields or land (Figure 1). Tanzania is also engulfed by similar disposal challenges, where disposable nappies contribute significantly to the waste stream generated daily by households and consumers [24]. Hence, the research estimated that this accounts for 1.5–2% of municipal solid waste and are the third largest consumer item in landfills, which represents 30% non-biodegradable waste [25]. In Tanzania, there are currently no official government statistics on the importation, handling and use of disposable diapers [24]. However, it is apparent that the use of disposable diapers has grown since the 1990s because the local standard of living and affordability has improved [26]. Consequently, the increased use of diapers in Tanzania’s Zanzibar increases the disposal and treatment challenges for that state and the community [24].

Figure 1.

Methods used for diaper disposal in rural areas.

According to Sepadi [27], 1.1 million metric tons of soiled diapers are generated and disposed of yearly in South Africa, and their usage differs from one care-giver to the next. For instance, a newborn may use 6–10 disposable diapers per day, whereas a toddler uses 3–4 diapers per day. In Mtumbane Township in the Eastern Cape, disposable diapers were found to be the second highest type of waste after food that is generated by the community. The residents at Mtumbane stored their waste in sacks, baskets and plastic bags, whilst others resorted to illegal dumping [28]. In Mthatha, Tsheleza et al. [29] found that households generated 2.84 kg/capita/week of waste and on average, solid waste generation per capita was 0.40 kg for persons living in informal settlements. Furthermore, the study found that diaper waste accounted for 17.9%, which was also the second-most type of waste generated after food waste [29]. Data collected from 19,000 sites across 82 countries between 2011 and 2018 identified disposable diapers as being amongst the top 25 most common items found in the sea, and top 40 items found in terrestrial settings, and also accounts for 21% of items found in waterways [30, 31]. Thus, these practices show a lack of education and EHL within the society.

Various methods are used to dispose of soiled diaper waste in the rural communities of SSA. The different methods of disposal are shown in Figure 1.

Many rural villages in SSA countries are characterized by poor waste management disposal practices, and this is causing detrimental effects on the environment. Open dumping, burying, burning of waste, pit latrines and other methods (Figure 1) such as using buckets to store soiled diapers are common diapers dumping practices in most developing countries [32]. Evidently, the burning of diapers causes air pollution, which further contributes to climate change because of the pollutants released into the air [33]. A common health hazard experienced by rural areas are diapers dumped in open spaces (Figure 1), which are often scattered by roaming dogs and cows. These diapers produce a foul smell and attract rodents and flies which can transmit diseases [34]. Similarly, disposing of diapers inside the pit latrine or burying them inside the pit hole can cause the pit to get full faster, and these could contribute to the non-sustainability of land due to diapers that cannot decompose. The improper management of waste is influenced by a lack of services, which further contributes to indiscriminate waste disposal [21]. Notably, a small percentage of rural areas dispose of waste in landfills. In according to Waste Management Standards, generated waste is supposed to be disposed of in landfill sites. However, some sites operate in open dumping sites where leachate can occur, leading to the contamination of surface and underground water [33].

Many rural communities in South Africa are living in extreme poverty, with a lack of access to basic water, sanitation, hygiene, and waste removal services [35]. Thus, the accumulation of disposable diapers in the environment is an issue. Moreover, a total of 627 disposal sites were identified and found to be near rivers. Additionally, most disposal sites were in villages where dirt roads and the grazing of animals were common [36]. These findings show that residents in rural villages see rivers as a means to wash away waste; which symbolizes lack of knowledge and literacy on environmental health risks. Consequently, indiscriminate dumping of soiled diapers may lead to the contamination of water sources with bacteria and viruses, which could contribute to health risks [36].

3. Health risk impact caused by the disposal of soiled diapers

Careless disposal of soiled diapers increases the amount of human excreta in solid waste and the environment [37]. Furthermore, it exposes people who deal with solid waste, especially municipal employees and waste pickers, to contaminants that could cause illnesses, as some may handle raw fecal matter in the process of disposing of disposable diapers [21]. This act could expose workers to different types of viruses, including enteric viruses, rotaviruses and human calici-viruses. Babies are known to be carriers of enteroviruses. Some of these pathogens have the potential to live in the excreta for several months and are likely to cause harm to people long after they have been discarded [17]. It is a health risk to handle this type of waste. It is moreover a hazard for people to handle it without being aware of its harmful effects. Hence the observation of poor waste handling in rural areas, where waste is handled without taking any precautionary measures indicate lack of EHL.

Diapers discarded in water sources and household environments may result in outbreaks of cholera, diarrheal diseases, dysentery, hepatitis A, polio and typhoid in the communities [38]. In addition, diarrheal diseases are the second leading cause of death in children, with 525,000 deaths recorded annually [39]. Similarly, cholera is an acute diarrheal infection caused by the ingestion of food or water contaminated with vibrio cholera [40], which could be spread due to fecal contamination of the environment caused by the indiscriminate dumping of soiled diapers in open land. According to WHO [40], there were approximately 1.3 to 1.4 million cases of cholera and 21,000 to 143,000 deaths worldwide due to cholera. In 2016, Zambia reported about 1179 cases of cholera, with 31 deaths, in which the most affected were children under 5 years of age [41]. Safe and sufficient water facilities and proper hygiene practices are the key to preventing not only diarrhea diseases but also acute respiratory infections [13]. Thus, it is important for communities to comprehend the appropriate measures of handling and disposing of soiled diapers.

To this end, in rural communities where waste collection is non-existent, care-givers choose to burn nappies on open land [42]. Subsequently, open burning of waste releases harmful gases and particles into the environment, which may cause potential health risks such as lower respiratory infections, lung infections and chronic obstructive pulmonary diseases [34]. Therefore, Environmental Health education and awareness on appropriate measures suitable for the disposal of diapers is important for public health gain.

4. Why care-givers use disposable diapers?

Disposable nappies have become popular in SSA countries as most women use them, irrespective of their level of education, social status and age [42]. It is observed that both working women and stay-at-home women use diapers for various reasons. Care-givers use diapers because of the advantages that they bring [43]. Most working women use diapers because they save time, as they reduce the time of doing laundry [17]. Additionally, others mentioned that they are convenient, easy to use and can be easily disposed of [18]. On the contrary, women in rural areas used diapers because of the water shortages they experience in their communities. Due to water shortages, women in rural communities sometimes spend days without water. Therefore, disposable diapers save them from dealing with foul odors that result from dirty diapers [44]. It was also discovered that some women use diapers because of their popularity and status [27]. Notably, disposable diapers use is seen as a symbol of status. Care-givers using disposable diapers of a particular brand are regarded as better off compared to those using cloth napkins [45]. Notably, it was also evident that disposable diapers were more popular amongst young women than elderly women [20]. Hence, the driving factor of disposable diaper usage is the privileged association that it brings, more than the negative impacts experienced by the environment.

Research conducted in Poland found that only 14.7% of care-givers read the instructions on diaper packages about how to use them; whilst 70% were found not to be interested in the composition of diapers [31]. This could mean that care-givers do not rinse the diaper that has been soiled by feces before disposal, posing a risk to health and the environment. Hence, there is a gap in environmental knowledge amongst the youth and the elderly in SSA countries, which is a contributing factor to waste management problems [5]. To sustain environmental issues in SSA countries, formal education for sustainable development is essential at all levels of education to elicit societal transformation. Therefore, stakeholders with the right knowledge, attitude and skills are required to educate the communities.

5. Environmental and health risk assessment process and environmental health literacy

Environmental Health literacy requires an assessment of environmental and health issues of concern as the methodology to identify if the communities and key stakeholders understand the health risks and issues within their environment and can take actions to prevent environmental degradation and health risks. Hence, the assessment process in Figure 2 aims to identify the baseline level of EHL and measures that can be taken to implement appropriate interventions to protect health and the environment. Such action could boost the level of EHL within the community and, where needed, capacitate key stakeholder as deemed fit. The following process outlined in Figure 2 assesses the environmental health risk assessment as the baseline for EHL, employable for an effective intervention in a typical rural community.

Figure 2.

Environmental health risk assessment process baseline for environmental health literacy.

5.1 Step 1: Identification of environmental and health risk

This process entails identifying activities within the area and their ability to cause environmental problems or degradation that could result in health risks. In this step, one could assess environmental health risks, the related legislation and policies available to control poor environmentally degrading practices. In this step, an observation checklist can be developed to identify all areas where such activities occur. In this instance, the disposal of soiled diapers can contaminate the environment and cause health problems within the area where these activities occur, and this checklist should be able to identify all the necessary community risks aiding the problem. Communities should also be able to identify what they believe is a risk within their environment.

5.2 Step 2: Assess environmental health knowledge

It is important to ascertain whether the communities living in the area where harmful environmental activities occur understand or know the results of environmental contamination. Communities within or adjacent to the site can be assessed through verbal interviews to determine if they know the terms of the environmental and health consequences of their actions. The checklist developed in the previous step could be useful in this process. It is also vital to determine and identify the individuals involved in activities that affect the environment and health in their area, especially indigenous knowledge in the community. Stakeholders mandated to provide services or deal with similar situations ought to be assessed to gauge their level of understanding and their available knowledge to influence the general usage of related information. These exercises will allow the assessment of the status of the EHL. The evaluation of environmental health and key stakeholders, including those involved in activities that causes problems, and the affected communities should be taken in context. The general knowledge of the community concerning the disposal of soiled diapers’ effect on the environment and how it affects the communities, and everyone nearby, should be assessed. This will allow the assessor to determine if the stakeholders know what is supposed to be done to protect the environment and prevent health problems.

5.3 Step 3: Identify environmental and health impacts

Once the knowledge assessment is done, all stakeholders will be involved in identifying the environmental and health impacts. In terms of environmental issues such as the ability for community activities to contaminate the land, water resources and air, pollution will be recorded through inspection and observation. In this instance, it is known that diaper disposal on open land and burning can contaminate the environment, thereby causing land nuisance, air pollution, and waterborne diseases such as cholera and subsequently diarrhea to the consumers or end-users of such contaminated water. It must further be noted that the presence of dioxin can cause cancer after prolonged exposure.

5.4 Step 4: Identify key stakeholders

This process is essential as it identifies those key role-players and stakeholders that could provide resources. Affected stakeholders responsible for providing interventions must be identified in this step. In may be that solutions are within the abilities of other stakeholders within the community. It may be necessary that intervention decisions are taken at this step. Decision-makers could be critical as they develop policies to deal with environmental health problems. This may involve planning, implementing, monitoring and evaluating the identified outcomes of stakeholders. Similarly, communities that are affected by the behavior of those involved in poor environmental health activities should always be recorded.

5.5 Step 5: Draw an action plan

The identification of environmental and health Impacts requires a need for the development of an action plan to deal with environmental and health problems. To come up with a plan to intervene in the problem, a program needs to be set up that will include what (activity), who (affected stakeholders, i.e., Environmentalist, Health Practitioners, other interested stakeholders, individuals involved in the activities and affected communities), why (an action or activity that is causing a problem), where (the area in which such activity is taking place and the magnitude of such a problem), how (how does the activity cause an impact on the environment and health), and when (in terms of date, place and time when the intervention plan can be done).

5.6 Step 6: Implement an action plan

In this step, a target to implement the action plan developed is set. This plan should be communicated with the key participants to ensure that all stakeholders and communities that are affected participate. The message to communities must be clear and precise. Outline the benefits of intervention methods; Show the affected parties how the implementation of the action plans can lead to desirable results; and Identify the enablers that will assist to encourage the affected communities and those involved in the wrong practices of soiled disposal to voluntarily change their behavior by taking appropriate actions.

5.7 Step 7: Co-ordinate and monitor all activities

This process includes identifying all involved in addressing the common problem and assessing its mitigation strategies or activities. In this step, stakeholders should find a common way of addressing the problem to avoid conflicting messages and the duplication of services. It is important to determine how to monitor and manage conflicts amongst different stakeholders. The setting up of a monitoring strategy with goals, targets and expected outcomes is critical at this step, and this should be tied up to the monitoring of planned activities.

5.8 Step 8: Evaluate the outcomes and level of environmental health literacy

Assess if the goals, targets and outcomes are achieved. The outputs versus the outcomes in relation to the period of implementation, as well as the change observed within the environment in which communities live, are assessed. In union, the number of people in communities who are affected in terms of their health outcomes, the best practices and weaknesses are recorded. This is done to ensure that correct interventions and measures can be implemented. This step allows the assessment on the level of EHL within the communities as a baseline.

6. Conclusion

The disposal of diapers requires an understanding and proper knowledge of the risks it causes to health and the environment. Such awareness requires the communities to be aware of what it is required. This is also a complex issue as the manufacturers of these diapers do not have appropriate measures in place to protect health and the environment. Everything is left to the consumer to deal with in terms of the handling and disposal, which causes a major gap in EHL within SSA countries. Conversely, the assessment process outlined could be the first step to imparting knowledge on how to deal with diaper disposal within the communities as a method for awareness and education to improve EHL. However, the challenge experienced in SSA countries demands the need for more monitoring, education, and awareness of appropriate methods for nappy disposal. Community participation should be a cornerstone to encourage the application of appropriate waste management issues and programs required to deal with diaper disposal. In addition, clean-up campaigns should be conducted by the authorities and communities as a way of showing the negative effects of diaper disposal and sharing of appropriate knowledge. In addition, WASH programs should be conducted as they are aimed at reducing illness by improving access to safe water, sanitation and improved hygiene. Lastly, mass media should be used to disseminate information to the public as communication on the appropriate way of preventing risks that could be caused by the poor disposal of soiled diapers.

Acknowledgments

The authors acknowledge Tshwane University of Technology for the opportunity of using library resources for the study.

Conflict of interest

The authors declare no conflict of interest.