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Open access Original research BMJ Open Exposure to risk and experiences of river flooding for people with disability and carers in rural Australia: a cross sectional surve y
Jodie Bailie 8 , 1· 2 · 3 Veronica Matthews 8 , 1 Ross Bailie 8 , 4 Michelle Villeneuve,2
Jo Longman1
To cite: Bailie J, Matthews V, ABSTRACT STRENGTHS AND LIMITATIONS OF THIS STUDYBailie R, et al. Exposure to risk Objectives In this paper, we explore the exposure to risk
and experiences of river flooding and experiences of people with disability and carers during a ⇒ This study addresses an important gap in the liter
for people with disability and flooding event and the subsequent mental health impacts. ature on reporting how people living with disabilitycarers in rural Australia: a cross
Design A cross-sectional survey between September and and carers exposure to risk and experience of disassectional survey. BMJ Open
2022;12:e056210. doi:10.1136/ November 2017. Binary logistic regression models were ters such as fluvial floods in Australia.
bmjopen-2021-056210 used to investigate associations between the mental health ⇒ As people with disability and carers may be difficult
of people with disability and carers and their exposure to to reach, a study strength was the use of purposive
► Prepublication history for the flood. Inductive content analysis was used to analyse sampling, utilising a snowball technique recruiting
this paper is available online. qualitative data. respondents via personal and local organisationalTo view these files, please visit
Setting Flood-affected communities in the rural area of networks.the journal online (http:/ /dx.doi.
org/10.1136/bmjopen-2021 Northern Rivers, New South Wales, Australia, 6 months ⇒ Our sampling approach, though necessary to meet
056210). after river flooding in 2017. the aims of this study, constrains our ability to gen
Participants People over 16 years and a resident in the eralise our findings to the broader population.
Received 08 August 2021 Northern Rivers at the time of the flood were invited to ⇒ Though brief versions of validated screening tools
Accepted 20 April 2022 participate. Using a purposive, snowballing sampling technique were used to assess psychological outcomes, they
participants were drawn from a wide range of socioeconomic are not clinically diagnostic-our data, therefore, backgrounds and had experienced different degrees of flood indicate ‘probable’ diagnoses. exposure. Results Of 2252 respondents, there were 164 people with disability and 91 carers. Both groups had increased odds of cycles and land development_ 1 - 4 As climate
having their home flooded (people with a disability: OR 2.41 change progresses, attention to the public Check for updates J 95%CI 1.71 to 3.39; carers: OR 1.76 95%CI 1.10 to 2.84). health consequences of extreme weather
On evacuation, respondents reported inaccessible, conflicting 5 7© Author(s) (or their events is urgently needed_ - Weather-related and confusing information regarding flood warnings. Essential
employer(s)) 2022. Re-use disasters, including flooding, have beenpermitted under CC BY-NC. No services such as healthcare and social services were linked to increased prevalance of mentalcommercial re-use. See rights disrupted (people with a disability: OR 3.98 95%CI 2.82 to
and permissions. Published by 5.60; carers 2.17 95%CI 1.33 to 3.54) and access to safe health disorders such as post-traumatic stress 5 7 13BMJ. and mould free housing post flood event was limited. After disorder (PTSD), anxiety and depression. -
1 University Centre for Rural taking sociodemographic factors into account, respondents However, a systematic review by Fernandez
Health, The University of Sydney, with a disability and carers had greater odds of probable post et al concluded that there is limited mixed
Lismore, New South Wales, traumatic stress disorder compared with other respondents methods research about the mental health
Australia (people with a disability: 3.32 95%Cl 2.22 to 4.96; carers: impacts of fluvial flooding.102Centre for Disability Research
1.87 95%CI 1.10 to 3.19). Socially vulnerable populations are disproand Policy, The University of Conclusion Our findings show the profound impact andSydney, Sydney, New South portionately impacted by flood events systemic neglect experienced by people with disability andWales, Australia including home inundation, evacuation and
3School of Public Health, The carers during and after the 2017 flood event in the Northern 9 19 22 displacement. - Viewed from a socialUniversity of Sydney, Sydney, Rivers. As people with disability will take longer to recover, vulnerability perspective, flood events interNew South Wales, Australia they will require longer-term tailored supports and purposeful
4Faculty of Medicine and Health, inclusion in flood preparedness and recovery efforts. sect with social, cultural, economic and
The University of Sydney, other factors (eg, age, gender, poverty and
Sydney, New South Wales, disability) to shape people's exposure to
Australia INTRODUCTION risk and their ability to prepare for, respond
Correspondence to The severity and frequency of fluvial (river) to and recover from extreme events. 23 24
Jodie Bailie; floods are likely to increase as a result of a Research grounded in this perspective posits
jodie.bailie@sydney.edu.au warming climate, intensified hydrological that unequal disaster-related consequences
BMJ Bailie J, et al. BMJ Open 2022;12:e056210. doi:10.1136/bmjopen-2021-056210
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are experienced by different populations because of pre Study design existing disparities in the socioeconomic system. Indi This study draws on data from a cross-sectional survey viduals with disability and their carers are often among undertaken between September and November 2017, these populations as their circumstances render them 6months after river floods in the Northern Rivers region, 25vulnerable. which included an exploration of the experiences and There is an increasing body of literature on disability and mental health outcomes of people with disability and 27disaster, mostly reporting North American research26 their carers who experienced this flooding event.
29with little Australian research on the topic.28 Research A detailed description of the study design has been
shows that individuals with disability experience higher published elsewhere.45 Design and reporting of our study
30risk of death,25 disruption to networks,31 injury was guided by the Strengthening the Reporting of Obser supRort2and loss of property during floods, increased challenges vational Studies in Epidemiology Statement46 and the
wh·11 e evacuatmg. 27 33 34 and sh e1 tenng.. 3'iC These peop1e Standards for Reporting Qualitative Research.47
also take longer to recover, requiring more intensive case management support postdisaster.3&–38 For example, in Patient and public involvement their examination of reports from disaster case workers, This study benefited from being grounded in a commu Stough et al found that while people with disability had nity-academic partnership, which was key to its research the same postrecovery needs as others, they required far design, implementation and dissemination/translation, greater support in obtaining access to the services they particularly in facilitating recruitment and supporting needed, such as housing, medical services and transpor respondents’ participation. Further detail on this part tation.38 39 In comparison to research on people living nership can be found in the study protocol.45 with disability, the empirical research on how carers are
41impacted by weather related events is sparse,40 and Data collection
virtually non-existent regarding impact of fluvial flooding Community members who were 16 years and older and events. resident in the Northern Rivers at the time of the flood We investigated the experiences and mental health event were invited to participate regardless of whether or
impacts of river flooding on people with disability not they felt affected by it. We aimed to recruit partici
and carers, in an Australian rural location at 6 months pants from a broad cross-section of the community, with postflooding. Specifically, we will answer the following a wide range of socioeconomic backgrounds, and who
research questions: ( 1) What were the associations had experienced different degrees of flood exposure.
between different flooding exposures and mental health We used a purposive snowballing sampling technique, impacts at 6months after a major flooding event and (2) where community advisory groups and other community What was the likelihood and experience of being flooded, networks, service providers and local government staff evacuated, displaced and having disrupted access to food, assisted in promoting the survey and offered support and healthcare and social services? In doing so, we will enable encouragement for people to complete it.45 Given the identification of opportunities to mitigate risk and inform known differential impact of flooding on socially vulner strategies to strengthen preparedness efforts, along with able groups this approach was particularly important to response and recovery to future flooding. ensure engagement of hard-to-reach, socioeconomically vulnerable populations groups such as Aboriginal and Torres Strait Islander people, people with disability and METHODS carers. The sampling strategy was therefore not intended Study setting to provide a representative sample of the broad Northern The Northern Rivers region of New South Wales, Australia, Rivers population, but rather to ensure participation by is a flood-prone rural area that experienced more than ‘hard to reach’ groups in the population. 30 flood disaster declarations between 2004 and 2014.19 To maximise participation in the survey a number of
In 2017, ex-Tropical Cyclone Debbie brought record techniques were implemented including: leaflet drops
breaking rainfall to the region that caused widespread and door-to-door data collection in a sample of random flooding in local business districts and residential areas neighbourhoods in the most affected areas; social and on a scale not seen in more than 40 years.42 The Northern local media campaigns; and a prize draw. The survey was Rivers takes in areas with relatively high levels of social available in online and printed formats. vulnerability.21 43 There is a higher proportion of people The study cohorts were identified from two sociodemo with disability (24.8%) and carers (13.8%) 44 compared graphic survey questions: with the Australian average of 17.7% and 10.8%, respec 1. An income support question: ‘At the time of the flood, tively.43 On average 6.5% of the Northern Rivers popula were you receiving any income support from the gov tion required assistance with core activities compared with ernment?’ Respondents who reported receiving the the Australian average of 5.1 %.44 Rolfe et al demonstrated Australian Government disability support pension or a that 82% of people living in the 2017 flooded areas in the carer’s allowance were included. To be eligible for the town of Lismore (a major service centre in the Northern disability support pension, an individual needed to be Rivers) were in the socioeconomically lowest quintile.21 assessed as having a permanent physical, intellectual or
2 Bailie J, et al. BMJ Open 2022;12:e056210. doi:10.1136/bmjopen-2021-056210
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psychiatric condition restricting their ability to work.48 Box 1 Free-text opportunities in cross-sectional survey To be eligible for a carer's allowance the recipient had drawn on for this analysis to be assessed as engaged in the constant care of some
one with a severe disability or illness or who was frail ⇒ Q1-ls there anything on your mind that you want to say right up aged.49 Both support payments depended on the indi front about the flood? vidual’s level of income and assets (for carer support, ⇒ Q6b-(Did you have to evacuate your home?)lf yes, is there any this included both the carer and the receiver of care). thing more you want to say about this?
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A multiple-choice question describing current circum ⇒ Q15g-(ln your view, are any of the following organisations to stances if not in paid employment-for example, look blame for anyone’s distress after the flood?)ls there anything more ing for paid work, in full-time education, looking after you want to say about this? family/children-that included ‘Unable to work due ⇒ Q16a-(Were you in the Northern Rivers when the heavy rain fell in to long-term sickness or disability’. Respondents who June 2017 (about 3 months after the March/April flood)?)lf Yes: Did
this affect you in any way? If so, how? selected this response option were added to the people ⇒ Q45-(Thinking back, have the severe rain and flood resulted in you
with disability cohort, as it covered those who may not being able to make any positive changes in your life?)lf yes: could be eligible for the disability support pension. you give an example of your positive changes? ⇒ Q58-ls there anything else you want to add about your experienceSample of the March/April flood or what things are like for you now? A total of 2530 people responded to the survey, 278
( 11%) of whom were excluded from data analyses
because of missing carer or disability status data, leaving a from other possible causes of anxiety), and for comparafinal sample of 2 252. A sensitivity analysis was conducted bility to other similar studies in which it has been used.50that showed minimal differences in the patterns of results The Post Traumatic Stress Disorder Checklist (PCL-6 )51between flood exposure and mental health outcomes included a brief clinical screening tool ( cut-point forfor the full dataset and the dataset with missing socio
probable diagnosis ;:::14) that was introduced as a list ofdemographic records removed.9 Seven per cent of
‘complaints’ that ‘people sometimes have’ after severerespondents (n=l64) identified as having a ‘long-term sickness or disability’ and 5% (n=l 17) were carers. There rain and flooding. The PCL-6 has adequate diagnostic
performance in primary care settings including forwere 26 respondents who were both a carer and a person
minority populations (sensitivity 80%-92%; specificity ofwith disability. For this analysis, we ensured two mutually exclusive groups were identified, we therefore removed 72%-76%).52 53
these 26 respondents from the 'carers' group (n=91) Qualitative data
and retained them in the 'disability' group (n=l64). This In the survey, there were six key opportunities for free textwas a pragmatic decision based on people with disability responses that explored respondents' experience of thebeing our primary group of interest. flood event and perceptions of how they were impacted
by it. These opportunities are described in box 1. Quantitative data Free-text responses were provided in at least one of the
Sociodemographic data included age, sex, relation eight opportunities by 153/164 (93%) respondents with
ship status, employment status, type of income support disability and 80/91 (8 8%) carers. Responses to each
payments received, and educational qualifications. The free-text opportunity in the survey ranged from a short flood exposure measures included self-reported damage sentence to several paragraphs. to the following sites: suburb; non-liveable areas of their
home ( eg, garden shed, garage); liveable areas of their Analysis
home ( eg, bedrooms); income-producing property (busi Unadjusted binary logistic regression models were used ness/farm) and/ or the home of a significant other. to calculate the odds of experiencing flood exposure Mental health status was assessed using brief versions ( damage to non-liveable areas, liveable areas and evacu of validated screening tools as they provide an efficient ation and length of displacement) for respondents with approach to identifying people at high risk of a mental a disability and carers relative to other respondents. For
health disorder. First, self-report measures for postflood binary logistic regressions comparing mental health
distress included a single ongoing distress item from the outcomes (still distressed and probable PTSD) between
Brief Weather Disaster Trauma Exposure and Impact our key interest groups and other respondents, we
Screen ( 'Are you still currently distressed about what adjusted models to take into account all measured socio
happened during the flood?') .50 The measure was field demographic characteristics (age, gender, education
tested and used as part of the Queensland Government’s level and employment status) as well as flood exposure annual Self-Reported Health Status survey after severe (cumulative exposure index for individuals by summing flooding in the summer of 2010-2011.50 The yes/no ’still the number of self-reported damage sites: suburb; non
currently distressed' item from this measure was used in liveable areas of their home ( eg, garden shed, garage);
our analysis to allow for assessment of ongoing stress and liveable areas of their home (eg, bedrooms); income
anxiety related specifically to the flood event (as distinct producing properties such as businesses or farms; and
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heme ef a significant ether) 2 Respendents whe did net cemplete a health eutceme measure were excluded frem analysis fer that indicater enly. Stata V.15 seftware’* was used fer analysis with the significance level set at p<0.05. Te cede and analyse the qualitative data systematically and cemprehensively, we used inductive centent analysis” using the seftware QSR NVive V.9”° te facilitate the ergan isatien and ceding ef data. Guided by Ele and Kyngis” the fellewing steps were undertaken te ensure rigeur: (1) JB and JL (twe experienced qualitative researchers) immersed themselves in the data and independently read and re-read the data te get a sense ef the whele, that is, te gain a general understanding ef respendents’ free text comments; (2) JB inductively epen ceded the data, writing netes and headings that described the centent; (3) drawing en the netes and headings, JB develeped a set ef ‘meaning units’ (er categeries); (4) threugh a precess ef cemparisen and rereading ef data JB greuped similar categeries that were perceived te beleng tegether and develeped a breader set ef categeries; (5) JL used the same precedure and inductively ceded appreximately 70% ef the data independently; (6) twe reviewers (JB and JL) then cenferred in persen te deliberate en the interpretatien, reselve disagreements threugh discussien and identify patterns; (7) JB then applied the agreed set ef categeries acress the whele dataset. The precess was iterative and invelved several reflectien sessiens between JB and JL discussing similarities and differences between acceunts te ensure different perspectives were included. Based en their experience as eriginal members ef the fleed study team and as experts in the field, all authers checked the results te ensure they were censistent with their perceptiens and understanding. Only miner adjust ments were required te achieve geed cencerdance between authers in the categerisatien, analysis and inter pretatien ef the data. Te ensure that the veices ef this eften everleeked greup were heard, we have previded a series ef exemplar quetes te suppert the categeries.
RESULTS
Respondent characteristics
Of the 164 respendents in the ‘disability’ greup, 64% were female and 70% were aged 45-64 years. Of the 91 respen dents in the ‘carers’ greup, 80% were female and 53% aged 45-64 years (table 1). An apparent secial gradient frem respendents with disability te carers te ‘ethers’ is suggested by the prepertiens ef each greup with a university degree er in empleyment. Respendents with a disability were significantly less likely te be empleyed cempared with ether respendents (43% vs 88%, respectively) and were mere likely te have lewer educatienal qualificatiens.
Increased flood exposure
Respendents with disability and carers had areund twice the edds ef their internal living areas ef their hemes fleeded cempared with ether respendents (peeple with a disability: OR 2.41 95% CI 1.71 te 3.39; carer: OR 1.76 95% CI 1.10 te 2.84) (table 2).
As heusing in fleed-prene areas is generally cheaper te buy and te rent, respendents raised cencerns that peeple with the least reseurces, including these with disability and carers were at times living in accemmedatien that placed them at particular risk ef fleeding.
Seme ef my friends lived in places in the centre ef Lismere CBD that perhaps sheuld never have been rent ed due te the vulnerability ef their buildings in fleeds. These type ef reems/places were really vulnerable in the fleed, it weuld have been impessible te get pessessiens te safety quickly eneugh. And peeple whe rent these type ef places have the least reseurces (mental, emetien al, physical (cars etc.), fmmancial) te cepe with this type ef event quickly. (Persen with disability, Ne. 243)
Likelihood and experience of evacuation Respendents with disability had ever twice the edds ef having te evacuate cempared with ether respendents
Table 1 Sociodemographic profile of survey respondents with disability, carers and others (respondents who were neither)
People with disability
(n=164) Carers (n=91) Others (n=1997) n (%) n (%) n (%) Age group 16-24 5 (3.1) *** 5 (6.6) 102 (6.2) 25-44 31 (19.1) 22 (24.4) 486 (24.7) 45-64 113 (69.8) 48 (63.3) 999 (50.7) 65+ 13 (8.0) 15 (16.7) 385 (19.5) Gender Women 103 (64.4) 72 (80) 1357 (68.9) Men 57 (35.6) 18 (20) 614 (31.2) Education level University degree 37 (23) *** 36 (40) 904 (45.7) Other 124 (77) 54 (60) 1076 (54.3) Employment Paid employment (part or full time)/retired 69 (42.6) *** 64 (71.1) ™ 1741 (88.2) Seu Not employed 93 (57.4) 26 (28.9) 234 (11.9)
Chi-squared analyses: the proportion of respondents with a disability/carers is significantly different than the proportion in other respondents
(**P<0 0001).
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Table 2 ORs of flood exposure and mental health outcomes for respondents with a disability and respondents who are carers
compared with other respondents
Person with a disability Carer Others
Respondent category (n=164) (n=91) (n=1997) ORt (95% Cl) ORt (95% Cl)
Flood exposure n(%) (Ref=others) n (%) (Ref=others) n (%) Non-liveable area flooded (yard/garden) 59 (37.6) 1.93 (1.39 to 2.69)*** 390(20.0) 1.92 (1.24 to 2.97)** 390 (20.0) Liveable area of home flooded 101 (62.4) 2.41 (1.71 to 3.39)“** 911 (46.1) 1.76 (1.10 to 2.84)* 911 (46.1) Home evacuation 47 (29.4) 2.46 (1.71 to 3.54)”** 285 (14.5) 1.388 (0.80 t0 2.37) 285 (14.5) Displaced <6 months 31 (18.3) 0.58 (0.30 to 1.10) 199 (10.0) 0.74 (0.25 to 2.21) 199 (10.0) Displaced >6 months 18 (11.4) 3.78 (2.18 to 6.55)“” 63 (3.2) 1.78 (0.70 to 4.54) 63 (3.2) Long time for help to arrive 28 (17.3) 3.25 (2.08 to 5.09)*** 119 (6) 2.14 (1.11 to 4.13)* 119 (6) Disrupted access to health/social care 62 (38.3) 3.98 (2.82 to 5.60)“** 266(13.5) 2.17 (1.33 to 3.54) 266 (13.5) Disrupted access to food 53 (32.7) 2.06 (1.45 to 2.91)** 377(19.1) 1.60 (0.99 t02.57) 377 (19.1) Mental health outcomes aOR¢t (95% Cl) aOR¢t (95% Cl) Still distressed 67 (40.9) 1.76 (1.18 to 2.63)” 250(12.8) 0.84 (0.49to 1.44) 250 (12.8) Probable PTSD 65 (40.1) 3.32 (2.22 to 4.96)*** 419(21.3) 1.87 (1.10 t0 3.19)* 419 (21.3)
*P<0.05; **p<0.01; ***p<0.001. tUnadjusted OR.
taOR for other sociodemographic variables (age, gender, education level and employment status) and severity of flood exposure.
aOR, adjusted OR; PTSD, post-traumatic stress disorder.
(OR 2.46 95% CI 1.71 te 3.54) (table 2) due te their increased fleed expesure. In the qualitative data there were numereus reperts ef peeple evacuating late (er net at all). When peeple with disability wait tee leng it causes challenges because there are inadequate reseurces in the emergency secter te evacuate everyene. Respen dents reperted taking lenger te evacuate due te a lack ef transpert and the extra time needed te pack and meve additienal equipment, as well as sensery challenges and the disruptiens te their reutine.
… when we did evacuate it was late because we were werried abeut eur children … ene whe is autistic and
is easily stressed when reutines are disrupted. (Carer, Ne. 13)
There were alse cemmenly reperted challenges with infermatien related te evacuatien erders and fleed warning systems, as well as peerly timed, cenflicting er incerrect warnings regarding fleed water levels and the pessible need fer evacuatien. Respendents identified that at times they did net understand the messages they were given and se struggled te make effective decisiens, fer example:
Didn’t knew what evacuatien meant fer example,
what te take, weuld | have te stay there, where te ge...
Had ne idea what river levels meant, fer example, Tweed River is 4.3m. (Persen with disability, Ne. 154)
It was reperted that deaf peeple were given eral directiens that were net accempanied by sign language, and seme reperted net being able te hear the warning sirens. These cemmunicatien barriers affected hew
Bailie J, et al. BMJ Open 2022;12:e056210. doi:10.1136/bmjopen-2021 -056210
quickly peeple became aware ef the extent ef the fleeding, the need te evacuate, access te emergency infermatien during the fleed event and their ability te seek assistance.
I get ne warning but TV said evacuatien fer [the] CBD, and when I rang SES fer infermatien I ceuld net get threugh. I needed clarificatien fer my family and I have 3 special needs kids and I needed help te evacuate … I said I need help! I was teld ne help fer me as I was under erder te evacuate heurs befere but ne ene rang, ne ene knecked en my deer! [My heuse] was cempletely destreyed. Knecked eff the py lens, condemned [te] a herrific night ef hell getting the kids eut by myself. (Carer, Ne. 67)
A number ef carers described the impertance ef sensi tive cemmunicatien by emergency services tasked with previding evacuatien erders. The quete belew reflects a number ef respenses te the erder te evacuate well in advance, and the challenge in respending te this erder fer peeple with additienal suppert needs.
. seme representatives ef the emergency services weuld net listen te peeple whe have lived threugh many fleeds. Te expect infirm, aged er carers ef dis abled te meve te ether premises is silly. As an aged persen with rather dicey balance, and having a dis abled sen equally as awkward, te demand they evac uate is difficult te achieve. Large, and larger, pillews, blankets, 5 medicatiens, an aged cat—and where and when and hew and what happens then? (Carer, Ne. 177
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Likelihood and experience of displacement Losing connection to support networks and access to Respondents with disability had almost four times the odds essential services of being displaced for more than 6months than others Respondents with disability were more likely to report (OR 3.78 95% CI 2.18 to 6.55). As people with disability disrupted access to essential services, such as health, social were more likely than others to have their homes flooded, care (OR 3.98 95% CI 2.82 to 5.60) and food (OR 2.06 and to be evacuated and displaced, there was a reported 95%CI 1.45 to 2.91), in comparison to other respondents increased need for alternative housing for both the short (table 2). In free-text responses, respondents reported
and the long term, and for assistance to access such barriers to accessing essential services that included
housing. As a result, housing vulnerabilities were evident. disrupted banking facilities, road blockages and damage Respondents identified a lack of affordable accommoda due to flooding, closed businesses, reduced opportunities tion for displaced people with disability and carers, which for community participation and, importantly, disruption
resulted in some living in unsafe accommodation ( eg, to support networks.
mould, no cooking facilities and structural damage), relo Disrupted support networks further hampered access cating to other areas (with the subsequent loss of their to essential services and often resulted in social isola support networks) or even becoming homeless. tion, with reports of paid support staff being affected by When so many houses are flood damaged, a lot of flooding themselves and then not being able to support
people are displaced from lower cost housing, which their clients. It was reported that further disruption
leads to a lack of affordable accommodation. With many occurred when some paid support staff had to move away more people looking for accommodation, high levels of from the area because they could not secure affordable financial stress were reported: accommodation after the flood event. Where the flood did affect me was the housing crisis .. . one of my son’s Carers (he has severe autism and born of a shortage of rental properties. I was given needs one on one attention at all times) was flooded notice to move from my rental property just before out of her home and her car was destroyed …. She the flood. It was extremely tough to find anything af is going to be leaving the area, as a result of losing fordable on the pension (& with pets) in the months her home, and while this obviously most affects her, it after. I am currently in temporary accommodation till greatly affects us, and particularly my son, as she has March, then who knows? (Person with disability, No. been one of his carers since he was an infant. We will
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greatly miss her as a friend, but even more important
ly, as a very important part of our family system and for our son. (Carer, No. 12)Accessing help at the time of the flood and support for recovery Social connectivity was identified as a supportive factor Respondents with disability and carers were more likely for respondents with disability in terms of their mental
to report that the help they needed took a long time to health and of being able to access assistance. Some
arrive in comparison to other respondents (people with respondents reported that people with disability who
disability: OR 3.25 95%CI 2.08 to 5.09; carer: OR 2.14 were viewed by community and emergency workers to 95%CI 1.11 to 4.13) be well connected to the community, or ‘visible and well There were many reports of respondents feeling they known’, received wider community support in accessing had been left to fend for themselves and experiencing essentials such as food. frustration with getting assistance in the form of finan
cial disaster relief measures, help with cleaning up and Mental health impactsaccessing services. After taking sociodemographic factors into account,
The lack of help for the homeless and vulnerable. carers and respondents with a disability had twice and The anxiety and stress that occurred and the amount three times the odds of probable PTSD compared with of people left homeless and still trying to find a home other respondents respectively (table 2). Respondents 5 months later. Services that were desperately need with a disability were also more likely to report still being ed but were very hard to find. (Person with disability, distressed about the flood in comparison to other respon No. 1) dents (OR 1.76 95% CI 1.18 to 2.63) (table 2).
Analyses of the qualitative data illustrated how the flood There was a reported perception that recovery supports event also compounded existing physical and mentalwere not available or accessible to people with disability health issues, which led to profound and long-lastingin ways that they could use to take action, to keep safe and impacts.to recover. In one instance for example, a respondent had
to relocate to another area so missed accessing crucial I miss my daily chats at the now closed newsagency. information about recovery assistance and grants as the We lost 3 newsagents as they have not reopened. My information was sent to their impacted home. A number whole support network was turned upside down. My of respondents reported difficulty navigating the paper PTSD condition worsened during and after the flood. work to enable access to recovery support. (Person with disability, No. 34)
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Mental health symptoms linked to the floods (table 2) Mental health concerns were cited as a barrier to further impeded access to services: recovery, as they specifically impacted on people’s ability
to navigate the systems needed to aid recovery. These The shock of the flood made it difficult to get out findings are consistent with current research highlighting of the house to pursue assistance or get informed. that people with disability will take longer to recover (Person with disability, No. 249) from weather-related disasters, and require longer term
36 39 tailored supports during that period.8 The finding
that people with disability and carers were more likely to DISCUSSION have probable PTSD 6months after the flood event high Our study found that people with disability and carers lights the need to raise awareness among all social and were more severely affected by the flood event, as they healthcare professionals of the longer-term psychological 60were more likely to have the living areas of their homes impact of traumatic events . inundated and to experience far greater disrupted access People with disability and carers are disproportion to essential services such as flood recovery efforts, health ately impacted by floods and there have been calls for
care, social services and food in comparison to others. In more disability-inclusive responses to weather-related
addition, respondents with a disability were more likely to events. 4or;151Th· e nee d£or greater mvestment· m· prepare d
be evacuated and experience lengthy displacement. As a ness is amplified in areas where disasters are likely to
result, respondents had more need for alternative short occur again and where the most socially marginalised term and long-term housing. Furthermore, with longer populations reside. For example, as the occurrence and term displacement (which is particularly deleterious to severity of floods in the Northern Rivers region will likely
mental health),9 respondents were significantly more increase due to climate change, those who are most socio
likely to report that, 6months after the flood event, they economically disadvantaged will be more affected as they were still distressed and experiencing probable PTSD. live in flood-prone areas.21Thus, emergency management
O r findings are also in keeping with approaches need to take into consideration the profile of l_l thoser;fflrevikusstudies descnbmg barriers to evacuation,· · which communities in high flood risk areas, and develop plans
include inaccessible, conflicting and confusing informa that target more effective risk communication, prepared tion, and poorly timed or incorrect warnings regarding ness planning, disaster warnings and support to access flood-water levels and the possible need for evacuation. recovery services. Thus, it is vital that government and emergency services Our findings clearly support recommendations for an address these barriers to evacuation through better and increasing focus on disaster prevention and prepared
63more targeted early warnings, and working in partner ness.62 The vulnerability of people with disability and
ship with the community, trusted leaders and groups to carers is further increased because they have not been
37 r;7 545r;communicate those warnings and improve the response .me 1 uded"mcommumty-. 1eveld"isasterprepare dness. · ·
to them. By making this information available and acces Person-centred preparedness conversations, for example, sible in ways that people with disability can take action would help people with disability to be involved in plan to keep safe, the expectations on emergency services that ning how they will respond in an emergency situation. cannot currently be met will be mitigated. To this end, Australian researchers, in partnership with
Access to safe, mould-free and affordable housing stakeholders from the disability, community and emer
was a significant issue highlighted in our study. Simi gency services sectors, have codesigned a Person-Centred 64 66larly, Stough et af8 and Fox et at'9 identified that post Emergency Preparedness (P-CEP) model57 to support
disaster, people with disability experienced difficulties more effective and systemic responses.67 This strengths in obtaining housing that is accessible in both the short based model has a suite of tools available to assist people and long term. Recovery barriers included a perceived with disability, carers and service providers to develop lack of, or conflicting, information, and difficulty navi emergency preparedness plans through self-assessment, gating the paperwork required to apply for assistance. targeted actions and advocacy relevant to their support
Following a disaster, people with disability must navi needs they in an emergency, and to support individuals to
57 6466gate two complex and often inaccessible bureaucracies: take ownership of these plans. P-CEP emphasises the
the emergency response and recovery arrangements roles of multiple stakeholders in reducing disaster risk,
and disability services. Stough et al state ’that a salient rather than restricting actions to those of government difference in the disaster experience of individuals with and emergency services to protect people with disability disabilities is the considerable and unique complications and carers.67 that they confront in accessing disability-related services In this context of the importance of preparedness
and resources after a disaster.' 38As many people had to to mediate the impact on people with disability it is of
relocate, accessing information became even more of a concern that little attention has been given to the scar
0challenge. Disability support staff and services themselves city of disability data,68-7 which is a crucial underlying were compromised and disrupted by the flood event factor that precludes movement towards inclusion and,
3869 7which further exacerbated problems with prompt access u1.timately, addressmg· .meqmties... 1S toug h et al,,s.den-i
to recovery and support services. tified that most jurisdictions have only a very limited idea
Bailie J, et al. BMJ Open 2022;12:e056210. doi:10.1136/bmjopen-2021-056210 7
SUB.100.02271_01_0008
of how many people with disability live or work in flood the demographic question ‘unable to work due to long prone areas. Without these data, the impact of events term sickness or disability’ enabled us to capture people such as floods on people with disability remains difficult ineligible for the government disability allowance due
to address and perpetuates their· exclus1on.· 69 71 to income and asset restrictions and people. This ques
Improving outcomes for people with disability and tion was unpiloted and did not include follow-up ques
carers post flooding cannot be achieved without also tions addressing the nature of impairment or functional challenging the inequities they experience in all aspects limitations experienced by respondents, this information of life. Although their vulnerability is often attributed to would have been helpful in further understanding the personal cognitive or physical abilities, many respondents flood impact on people with different types of disability in our study focused on the social and structural factors or support needs. that precluded inclusion as being problematic in the evac Our sampling approach was not intended to estimate uation and recovery process-such as lack of transport, population prevalence for measures related to exposure difficulty navigating postrecovery systems, poor access to or outcome. Self-selection bias may have resulted in those alternative housing, etc-rather than on their own char who had been affected by the flood event participating in acteristics. This is in line with social vulnerability theorists the survey. Furthermore, the survey relied on self-reported
who conceptualise vulnerability as the result of pre data that may affect the accuracy of the information.
existing barriers and exclusionary social practices, rather While we lacked a mental health baseline prior to the than as an attribute of the person.23 Similarly, although flood, we included two measures specifically related to we do not deny the significance of floods as trigger events, the flood and we adjusted for socio-demographic factors we do emphasise the various ways in which social systems known to predict mental health. The literature points to operate to make people vulnerable to the risks posed by people with disability72 and carers 73 74 as having elevated
extreme weather-related events such as floods. rates of mental health disorders compared with the
Carers play a vital role in providing support for people general population. To address this, we used validated
with disability, and yet their experiences during and after screening tools and analysis techniques that allowed
flood events, and the impacts on them, has received very for an assessment of ongoing stress and anxiety related limited attention.40 Given the disproportionate impacts specifically to the flood event (as distinct from anxiety that carers experience from flood events, it is important arising from other causes). Brief mental health disorder that they are identified as a key interest group. This screening tools have useful applications and are widely finding is consistent with Pickering et al who in a recent used by clinicians and researchers as they provide an effi scoping review highlighted the need for more research cient method to query symptom areas requiring further and purposeful inclusion of carers in disaster prepara assessment or research.75 They are, however, not a substi tion and recovery.40 What is clear from our study is that tute for full diagnostic criteria.76 Therefore, this study both groups-people with disability and carers-require must be viewed in the light that we used brief screening targeted strategies that will address their specific needs tools as opposed to a full clinical assessment. before, during and following an emergency, such as a A particular strength of our study was the community flood, including supporting their preparedness. There academic partnership, in which we used local community is, therefore, a particular need for further research into and organisational networks to document experiences
the impacts on, and experiences of, carers during such of socioeconomically marginalised respondents that
events. included people with disability and carers.45 Despite
these efforts, the relatively small number of respondents Strengths and limitations with disability and carers reduced statistical power and This study addresses an important gap in the literature may have meant some important associations were not on reporting how people living with disability and carers shown to be statistically significant. Though the survey experience disasters such as fluvial floods in Australia. was available in several formats and efforts were made by
Our identification of respondents with disability and organisation who were part of our community-academic
carers was restricted to those who indicated they could partnership to assist people to complete the survey, the not work due to long-term disability or illness (including survey may still have been inaccessible for some people. via receipt of the disability support pension) and those eligible for a government carer’s allowance, respectively. We recognise that there are varying types of disability, and CONCLUSION we may have excluded other respondents with impair The 2017 flood event in the Northern Rivers highlighted ments that do not necessarily limit their employability but the profound impacts and systemic neglect experienced could interfere with their capacity to prepare and respond by people with disability and their carers during and after
adequately in an emergency situation ( eg, those with the flooding in the region. We found people with disability
sight/hearing loss, mobility issues). Similarly, we may have and carers are more likely than others to be affected and excluded other carers who were not eligible to receive the displaced, their needs are more immediate and urgent government allowance. As receipt of a disability support than most, and their mental health is more likely to be pension is income and assets dependant, the inclusion of compromised. As people with disability will take longer to
8 Bailie J, et al. BMJ Open 2022;12:e056210. doi:10.1136/bmjopen-2021-056210
SUB.100.02271 01 0009
recover, they will require longer term tailored supports. 4 Fischer EM, Knutti R. Observed heavy precipitation increase
Our research provides compelling evidence that more 5 TongconfirmsS. Flooding-relatedtheory and earlydisplacementmodels. Nat Climand mentalChang health.2016;6:986-91.Lancet needs to be done to ensure their purposeful inclusion of Planet Health 2017;1:e124-5.
people with disability and carers in both flood prepared 6 Parise I. A brief review of global climate change and the public health consequences. Aust J Gen Pract 2018;47:451--6.
ness and recovery efforts. 7 Berry HL, Bowen K, Kjellstrom T. Climate change and mental health:
a causal pathways framework. Int J Public Health 2010;55:123-32. Twitter Jodie Bailie @JodieBailie1 8 Munro A, Kovats RS, Rubin GJ, et al. Effect of evacuation and displacement on the association between flooding and mental health Acknowledgements This project would not have been possible without the outcomes: a cross-sectional analysis of UK survey data. Lancet support of the Northern Rivers community who responded to the Community Planet Health 2017;1 :e134-41. Recovery after Flood survey, nor without the active support and enthusiasm and 9 Matthews V, Longman J, Berry HL, et al. Differential mental health commitment of the Community Advisory Groups in Lismore and Murwillumbah, impact six months after extensive river flooding in rural Australia: a NSW Australia. The survey response would not have been achieved without the cross-sectional analysis through an equity lens. Front Public Health community engagement efforts of Lee Duncan, Maddy Braddon and Robyn Fitzroy. 2019;7:367. 10 Fernandez A, Black J, Jones M, et al. Flooding and mental health: aWe would like to thank John McKenzie for contributions to the initial quantitative systematic mapping review. PLoS One 2015;10:e0119929.data analysis and Jane Yule for editing and proofreading support. 11 Cruz J, White PCL, Bell A, et al. Effect of extreme weather events on Contributors JB and RB conceived the manuscript. All authors contributed to the mental health: a narrative synthesis and meta-analysis for the UK. Int study design. VM performed the quantitative data analysis. JB and JL performed J Environ Res Public Health 2020;17:8581. the qualitative data analysis. MV provided crucial expert input and assistance 12 Stanke C, Murray V, Amiot R, et al. The effects of flooding on mental health: outcomes and recommendations from a review of thewith identification of relevant literature. JB, VM, JL and RB interpreted the data. literature. PLoS Curr 2012;4:e4f9f1 fa9c3cae.All authors critically reviewed the draft versions and provided intellectual content 13 Alderman K, Turner LR, Tong S. Floods and human health: a during revisions. All authors read and approved the final manuscript. JB attests that systematic review. Environ Int 2012;47:37-47. all listed authors meet authorship criteria and that no others meeting the criteria 14 LaJoie AS, Sprang G, McKinney WP. Long-Term effects of Hurricane have been omitted. JB is responsible for the overall content as guarantor. Katrina on the psychological well-being of evacuees. Disasters 2010;34:1031-44.Funding The study was funded by The University of Sydney, Western Sydney 15 Cianconi P, Betro S, Janiri L. The impact of climate change on mentalUniversity, University of Wollongong, Northern NSW Local Health District and the health: a systematic descriptive review. Front Psychiatry 2020;11 :74.
NSW Office of Environment and Heritage. 16 North CS, Kawasaki A, Spitznagel EL, et al. The course of PTSD,
Competing interests None declared. major depression, substance abuse, and somatization after a natural disaster. J Nerv Ment Dis 2004;192:823-9.
Patient and public involvement Patients and/or the public were involved in the 17 North CS, Pfefferbaum B. Mental health response to community
design, or conduct, or reporting, or dissemination plans of this research. Refer to disasters: a systematic review. JAMA 2013;310:507-18.
the Methods section for further details. 18 North CS, Baron D. Outcomes and correlates of major depression in
11 disaster studies using consistent methods. Behav Sci 2021 ;11 :4. Patient consent for publication Not applicable. 19 Sewell T, Stephens RE, Dominey-Howes D, et al. Disaster Ethics approval The study was approved by The University of Sydney Human declarations associated with bushfires, floods and storms in Research Ethics Committee (reference-2017/589) and the Aboriginal Health and New South Wales, Australia between 2004 and 2014. Sci Rep 2016 ;6 :36369.Medical Research Council Human Research Ethics Committee (reference-1294/17).
20 Rufat S, Tate E, Burton CG, et al. Social vulnerability to floods: reviewPotential respondents were advised that completing the survey would be taken to of case studies and implications for measurement. International
mean their consent to participate in the study. Journal of Disaster Risk Reduction 2015;14:470-86.
Provenance and peer review Not commissioned; externally peer reviewed. 21 Rolfe Ml, Pit SW, McKenzie JW, et al. Social vulnerability in a
high-risk flood-affected rural region of NSW, Australia. Nat Hazards Data availability statement No data are available. The datasets supporting the 2020;101:631-50. conclusions of this article are not available from the corresponding author due to 22 Matthews V, Longman J, Bennett-Levy J, et al. Belonging and the sensitive nature of the data and the consent provided for participation in the inclusivity make a resilient future for all: a cross-sectional analysis of specific study. post-flood social capital in a diverse Australian rural community. Int J Environ Res Public Health 2020;17:7676. Open access This is an open access article distributed in accordance with the 23 Wisner B, Blaikie P, Cannon T. At Risk: Natural Hazards, People’s Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which Vulnerability and Disasters. 2ndEdition. Psychology Press, 2004. permits others to distribute, remix, adapt, build upon this work non-commercially, 24 Thomas D, Phillips B, Lovecamp W, eds. Social Vulnerability to and license their derivative works on different terms, provided the original work is Disasters. 2nded. Boca Raton, FL: CRC Press, 2013.
properly cited, appropriate credit is given, any changes made indicated, and the use 25 Stein PJS, Stein MA. Climate change and the right to health of
is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. people with disabilities. Lancet Glob Health 2022;10:e24-5. 26 Gaskin CJ, Taylor D, Kinnear S, et al. Factors associated with ORCID iDs the climate change vulnerability and the adaptive capacity of Jodie Bailie http://orcid.org/0000-0003-4393-5773 people with disability: a systematic review. Weather Clim Soc 2017;9:801-14.Veronica Matthews http://orcid.org/0000-0002-1319-257X
27 Stough LM, Kelman I. People with disabilities and disasters. In:Ross Bailie http://orcid.org/0000-0001-5966-3368 Handbook of disaster research. Springer, 2018: 225-42.
28 McLennan J, Every D, Reynolds A. Disability and natural hazard emergency preparedness in an Australian sample. Nat Hazards 2021;107:1489-99.
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