Event Description:
Event Type: Flood
Event Onset Date: Between January 29 and February 11, 2019
Location of Event: Townsville, Queensland, Australia
Geographic Coordinates:
Latitude: 19°15′24.98″ South
Longitude: 146°49′26.23″ East
Elevation: 4m
Data Collected: August 2019
Response Type: Community Pharmacy Response
Introduction
In late January 2019, an active monsoon trough and a slow-moving, low-pressure system over tropical northern Queensland caused consecutive days of consistent extremely heavy rainfall. 1 Between January 29 and February 11, 2019, the Townsville region recorded record-breaking rainfall levels (more than 2000mm) 1 which exceeded the region’s average annual rainfall. 2 The Ross River Dam received a rainfall amount 3.8-times its capacity.1 Consequently, the Townsville region experienced major flooding which exceeded previous flood records over the previous 120 years. 2,3 An estimated 3,300 private and commercial properties were damaged. Reference Risk Management4 Natural disasters, such as Queensland’s monsoon trough weather event, impact the community’s ability to access health care, including medications.5 Therefore, the aim of this study was to explore the impacts of this flood event on community pharmacy operations in Townsville, Queensland.
Sources
This qualitative research study utilized semi-structured interviews which were conducted in August 2019. The interview questions (Supplementary Material; available online only) explored pharmacists’ experiences of the flood event utilizing questions relating predominantly to the Response phase of the Prevention-Preparedness-Response-Recovery (PPRR) disaster management model. 6 The interview questions were modified from similar questions employed in two previously published studies of bush fire events. Reference Mak and Singleton7,Reference Singleton, Khng and McCourt8 Prior to data collection, ethical approval was obtained from the Queensland University of Technology (Brisbane, Australia) Human Research Ethics Committee (Approval Number 1900000230).
Sampling Strategy and Participant Recruitment
Ten pharmacies were confirmed as flooded or cut off by floodwaters, with seven owners/managers agreeing to their staff being interviewed. Eligibility criteria for participants were that they had to be a registered pharmacist with the Australian Health Practitioner Agency (AHPRA; Brisbane, Australia) and had to be working in Townsville between January 29, 2019 – February 11, 2019 in community pharmacies which were affected in some way by flooding. Pharmacists who were willing to participate then signed an informed consent document and an interview time was arranged. Participants were also asked if they knew of any other pharmacists who met the eligibility criteria and might be willing to participate in the research. A total of six pharmacists were interviewed.
Data Collection and Analysis
Authors KW and JS conducted the interviews over the phone, and only the interviewee and either KW or JS were present during the interviews. Both KW and JS are registered pharmacists with AHPRA but were not known to any of the interviewees. Being pharmacists, KW and JS could appreciate nuanced responses and probe further, where relevant. Each interview was recorded digitally and averaged 20 minutes. To ensure confidentiality, prior to their interview, each participant was assigned a unique identification code which was used in the audio recording. The audio files were then transcribed using intelligent verbatim by AL. Since participants’ responses often addressed more than one question at a time, the interviews were analyzed in their entirety rather than analyzing each question’s data separately. Whilst a predominantly deductive approach was taken mapping back to the PPRR framework, a formal deductive approach, such as grounded theory (as per Corbin and Strauss), Reference Corbin, Strauss and Oaks9 was not used as the aim was to identify emerging themes.
AL and JS manually coded the data independently in NVivo 14 (Lumivero; Denver, Colorado USA) using an open coding technique. Reference Saldana10 AL and JS then compared codes. JS was able to provide professional insight into some of the participants’ responses for clarity whilst the fact that AL was not a pharmacist reduced the risk of bias. Through discussion, a single set of codes was derived and then condensed into a smaller number of categories (sub-themes) and finally into key themes. Reference Saldana10,Reference Braun and Clarke11 EM and KW provided feedback on the allocation of codes to data, and also on the coding tree, with revisions made through team discussions.
Observations
The thematic analysis yielded six themes – “financial impact on pharmacy owners,” “engagement with Local Disaster Coordination Center (LDCC) important,” “workload pressures,” “preparedness,” “medication supply impacts,” and “communication and collaboration” (Figure 1). Themes and their representative quotations are presented in Table 1 (codes and their representative quotations are presented in Supplementary Material).
Coding Tree for the Thematic Analysis of Interview Data.
Themes and Representative Quotations
Financial Impacts
Understandably, the floods caused financial impacts for pharmacy owners of affected pharmacies that were forced to close. Some closures were precautionary measures which may not have been necessary. One pharmacy’s landlord did not provide support to help the pharmacy to remain open. For those pharmacies that were open, some patients were unable to pay, and many patients who were supplied medication without a prescription never returned to the pharmacy with the prescription. This meant the pharmacies could not claim reimbursement and were impacted financially.
Engagement with LDCC Important
Those participants who reported their pharmacy owners engaged with, and took advice from, the LDCC appeared to be better informed of flood developments.
Workload Pressures
Participants reported increased workload pressures from supplying medications to people whose regular pharmacy was closed, reduced staff numbers, and austere working conditions.
Preparedness
Pharmacies (and the community) were under-prepared for this flooding event. One pharmacy, which was able to stay open, had no power and had to obtain a generator at a time when many other residents and business owners were also trying to source a generator. Ensuing issues with continuity of supply for Opioid Replacement Therapy (ORT) clients also highlighted a potentially overlooked patient group in disaster events. With regards to pharmacies having a documented disaster plan, responses varied from having no plan to a plan that was developed with a focus on cyclones rather than a flooding event.
Medication Supply Impacts
With pharmacies having to reduce hours or close completely, medication supply to patients was impacted, particularly for the large number of patients receiving Dose Administration Aids (DAA) and for patients whose pharmacies retained their prescriptions. Sometimes, medication supply was impeded because the flooded river prevented people accessing a pharmacy. People whose homes were flooded also had medication supply issues. If they were unable to access their regular pharmacy, then obtaining their medications became a challenge, particularly if they didn’t know the names of the drugs they were taking. Participants reported that medication supplies in these circumstances were through Australia’s three-day emergency supply legislation. Some medication were supplied as “owings” where the pharmacy lends the patient a Pharmaceutical Benefits Scheme (PBS) quantity of the medication (usually one month’s supply) with the proviso that the patient returns to the pharmacy with the prescription as soon as they can. Many of these patients presented to evacuation centers with no medications, no prescriptions, and no idea of what they were taking.
The loss of power also impacted medication continuity. Patients lost their refrigerated medications and pharmacies that lost power had to store medications requiring refrigeration off-site. For those pharmacies who still had power or had a generator, My Health Record (Australia’s national digital health record platform) helped pharmacists obtain medication histories for those patients who presented to the pharmacy without prescriptions. Deliveries of medications from the three pharmacy wholesalers were also interrupted, and one of the pharmacies that remained open reported stock shortages. The defense services and emergency services (coordinated through the LDCC) assisted pharmacies in sending medications to locations outside of Townsville. Importantly, pharmacy staff worked hard with stakeholders to ensure there was not a complete breakdown (albeit some delays) in critical medication supplies.
Communication and Collaboration
Facebook (Meta; Menlo Park, California USA) groups were the main communication platform. Some participants spoke of collaborating with other pharmacies to consolidate resources at sites that were open, and some pharmacists whose regular place of employment had closed helped in pharmacies that remained open. Pharmacists also helped at the emergency evacuation centers and provided support to the LDCC.
Analysis
Whilst it was apparent that the Townsville community was unprepared for this flood event, this study highlighted that pharmacies communicated and collaborated with each other to ensure the community was able to access medications and other health needs in a timely fashion. Despite the increased work pressures and the austere working conditions (no lighting or air conditioning in pharmacies running on generators), pharmacy staff were able to avoid a complete breakdown of medication supply.
The key themes that emerged from the interview data (Figure 1) have also emerged from research on the impacts of other disaster events in Australia on community pharmacy operations. Reference Mak and Singleton7,Reference Singleton, Khng and McCourt8,Reference McCourt, Singleton and Tippett12,Reference O’Dwyer, Cliffe and Watson13 During this flooding event, information gathering appeared to be passive rather than proactive; in many cases, participants appeared to be waiting for “someone in authority” to pass on information about the event. This corroborates the findings of Safnuk, et al who theorized that pharmacists revert to a “novice” level of understanding in disaster situations and require explicit instructions. Reference Safnuk, Ackman and Schindel14 Only two participants appeared to understand local disaster management processes and were able to discuss the role of the LDCC and Primary Health Network (PHN). This lack of engagement may have resulted in some pharmacies and General Practitioner clinics closing prematurely due to the owners not understanding what constitutes an “essential service” in disaster messages. These closures have financial impacts for owners. Other financial losses, such as through medication supplies to patients who never returned with a prescription or with money, is an on-going issue for pharmacies during disaster events and has been reported in other disaster research studies. Reference Mak and Singleton7,Reference Singleton, Khng and McCourt8
Preparedness also has financial implications. Power outages are highly probable in any disaster event, and purchasing a generator outside a disaster event when demand is much lower could save money, potentially reduce the risk of losing medications which must be stored in a refrigerator, and allow the pharmacy to keep operating. Preparedness and preparedness behaviors in Australian pharmacists has been found previously to be low-to-moderate and low, respectively. Reference McCourt, Singleton and Tippett15 This is an important point; for community pharmacies to be operational during a disaster, they must be staffed by prepared pharmacists. Reference McCourt, Singleton and Tippett15-Reference Schumacher, Bonnabry and Widmer18 An individual’s preparedness is influenced by numerous variables. These include age (older participants report higher levels of preparedness),19 self-efficacy for preparedness,19-22 perceived severity of the disaster (the greater the perception of the severity of the disaster, the lower the preparedness),15,19 and knowledge and skills. Reference McCourt, Singleton and Tippett15 Context is also important. To have prepared community pharmacies, there needs to be prepared pharmacists, and an individual pharmacist’s preparedness is linked to the preparedness of others in their workplace. Reference McCourt, Singleton and Tippett15
One pharmacist commented that patients with chronic conditions failed to stock up on on-going medications ahead of the flood event. This comment highlights the need for research exploring the concerns of people living with chronic conditions when they receive a disaster event warning. These patients may have reduced physical capacity to organize extra supplies and prescriptions and may have to rely on others. Another patient group affected by disaster events is the ORT program clients because both prescribers and clients can be hard to contact by pharmacists. Staged supply arrangements (where the client comes into the pharmacy daily to collect their opioid dose) may need to be changed so the client receives a number of take-away doses for the duration of the disaster event. However, this and another study found that prescribing clinics often close without contacting pharmacies or clients to make alternative supply arrangements for patients. Reference O’Dwyer, Cliffe and Watson23
There were several limitations to this study. Firstly, the small number of participants risked the data potentially not reflecting a diversity of opinions, making it difficult to determine if data saturation was reached. Secondly, the data were collected in 2019 with the analysis and write up delayed by the COVID-19 pandemic. Lastly, financial data pertaining to the financial loss to pharmacies and hard data on patient days without medication are not collated currently and/or publicly available.
This research highlights a critical need for both improved communication at the public-private interface and greater disaster preparedness among pharmacists to improve the primary care sector’s response. This need could be addressed by including disaster preparedness in pharmacy Continuing Professional Development (CPD) programs. Pharmacy CPD educators could use the International Pharmaceutical Federation (FIP; The Hague, The Netherlands)’s “Global Humanitarian Competency Framework” 24 as a guide. This framework has four domains, two of which align with this study’s findings. The “Pharmaceutical Public Health” domain has a population focus with two competencies – “health assessment” and “health, medications information, and advice.” The “Organization and Management” domain comprises “budget,” “human resources management,” “improvement of service,” “procurement,” “supply chain management,” and “workplace management” competencies. These competencies are also applicable to pharmacist preparedness in other natural weather events nationally and globally.
Supplementary Materials
To view supplementary material for this article, please visit https://doi.org/10.1017/S1049023X25101301
Author Contributions
JS: Conceptualization of project, data collection, data analysis, lead writer on drafts and final version.
KW: Conceptualization of project, data collection, contributed to writing draft and final manuscript.
EM: Conceptualization of project, contributed to writing draft and final manuscript.
AL: Data analysis, contributed to writing draft and final manuscript.
Conflicts of interest/funding
The authors declare there are no conflicts of interest. This research project received internal grant funding of $10,000AUD from the Faculty of Health, Queensland University of Technology. The supporting source was not involved in the study design or data collection or dissemination of findings (there were no restrictions regarding publication).
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