Associate Professor
Aim – To explore GP perceptions of the impact of the 2010/2011 Canterbury earthquakes on primary care clinic patients. Methods – Qualitative study using semi-structured interviews with eight GPs from the Christchurch area exploring GPs’ perceptions of the impact on patients. Results – Patients experienced significant strain and anxiety following the earthquakes. The impact of this differed due to personal circumstances. Secondary stressors such as insurance and housing issues contributed to experiences of distress. Conclusions – The GPs identified significant impacts on patients as a result of the earthquakes with significant levels of strain and anxiety being due to the on-going recovery process. It appears that a significant proportion of the affected population felt comfortable talking with the GPs about the earthquakes, secondary stressors and their effects upon them.
Experts agree that disasters can have a negative impact on people’s mental well-being
Research has also identified that secondary stressors such as lack of financial assistance, insurance issues and continued lack of infrastructure can have an impact on mental well being following a disaster
Primary care physicians in the community are well placed to deal with the health issues, which commonly present in the post disaster phase
On 22 February 2011, Christchurch New Zealand experienced a large earthquake, resulting in the deaths of one hundred and eighty-five people and extensive damage to the built environment. The earthquake was part of a sequence which began in September 2010 and continued with magnitude 5+ earthquakes until December 2011. Aftershocks still occur and are experienced throughout the region.
This research explored GP perceptions of the earthquakes’ impact – both directly and indirectly through secondary stressors - on patient presentations and reactions and provides valuable information to assist in future disaster education, preparation and planning resources for GPs and the local community. Further information on GPs’ experiences in this major New Zealand disaster response contributes to the on-going recovery effort and preparation/planning for future events can be found in a related paper
A qualitative research methodology was used to explore the GPs experiences and perceptions following the earthquakes. The data were collected between November 2012 and February 2013. Two years had passed since the start of the earthquake sequence, which enabled the research to include longer term impacts and challenges. The research design used semi-structured open-ended interviews to elicit extended answers to questions about the challenges GPs have faced following the earthquakes. The rationale for interviewing GPs was to capture an overview of the health related concerns, which patients presented at primary care clinics. This represents a useful source of additional information when trying to describe the experiences of people going through a disaster and its aftermath, especially those presenting for help in primary care services.
Interviews took place with eight GPs from across the Canterbury area and included practices from different socio-economic areas (poorer to more affluent suburbs). GPs were recruited using a snowball technique in which key informants with knowledge of GP services in the area nominated GPs who were then invited to participate. The interviews were scheduled at a place and time convenient for each GP and audio-taped with permission from each participant. Five female GPs and three male GPs were interviewed covering a range of employment types from locum and salaried GPs to practice director/owner.
Although data proved difficult to obtain, local Primary Health Organisations (PHOs) indicated that 320 GPs worked in the area: Pegasus PHO, 275 GPs (128 female, 144 male, 3 gender unrecorded); Canterbury PHO, 45 GPs. The New Zealand Medical Workforce 2012 data available from the New Zealand Medical Council indicted that 459 GPs were registered in the area, though not all of those may have been practising at the time. This means our study sample somewhere between 1.7% and 2.5% of the regional GP workforce, depending on the denominator.
The transcribed interviews were analysed and coded using a grounded theory approach
The study was peer reviewed and judged to carry low risk of potential harm to participants. This review was recorded on the Massey University Ethics Committee low risk database after having met their set criteria, and participants were informed accordingly.
The interviews reveal that the earthquakes had a significant impact on GP workload, types of consultations and on patient’s experiences. Four themes were identified in our analysis and are discussed below:
All the GPs talked about the increase in workload they experienced following the earthquake. For some this was due to earthquake-induced population movements. Some areas saw an exodus of people, whereas others saw a significant influx:
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However for others the increased workload was due to the number and type of issues presented:
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GPs reported that patients presented with a range of issues including anxiety, stress, panic reactions, lack of sleep and physical symptoms. Many patients visited their GP “
The GPs recognised that some of the strain and anxiety that patients were experiencing at the time of the interviews was due to the recovery process and focused on housing and/or insurance issues, which:
Earthquake damage to residences meant that some of those in rental accommodation had been required to move, possibly to new areas at a time where rental accommodation was in short supply:
Others were living in damaged properties or with relatives waiting for insurance company decisions about repairs:
Five of the eight GPs talked about how they saw different groups of patients at different times, suggesting that the psychological impact of the earthquake was not evenly distributed both in terms of when patients sought help or who presented for help:
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Four of the eight GPs felt that people who had previously experienced mental health issues or who had attended the GP practice following the September 2010 earthquake appeared to cope well:
Six of the eight GPs commented on the number of children they had seen especially in relation to sleeping disturbance and anxiety:
While initially the sleeping disturbance was probably due to the significant number and strength of the aftershocks, the GP comments from their own personal experiences suggested that this may be an ongoing issue:
One GP commented specifically about stressed nine to twelve year old boys:
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Three of the GPs talked about the impact on their elderly patients, with particular concern for those patients who lived alone:
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Other patient groups such as migrant and refugee populations with complex health and psychological needs were significantly affected following the earthquake as the group of people requiring housing support increased:
The GPs acknowledged the support that was put in place to help patients in the form of access to counselling services and government funded extended consultations with the GP (ordinarily in the NZ health care system the majority of patients make a co-payment for GP appointments):
These additional services helped the GPs to deal with the increased workload, and the widespread communication programme concerning the availability of mental health assistance combined with ease of co-located access to counselling meant that patients did not feel stigmatised accessing the service:
The GPs talked about the community spirit that was evident following the earthquakes both in terms of people helping to get GP practices up and running and in terms of the wider community:
There was a sense from some of the interviews that has time has gone by this community support has dissipated and people are now at different stages of the recovery process:
The GP interviews indicate that patients experienced stress and anxiety as a result of the earthquakes, though the impact of this differed depending on individual patients’ circumstances. Many patients just wanted to talk through their experience and get reassurance that their feelings were normal. Interestingly some GPs identified ‘waves’ of different patient groups consulting at different times with higher levels of psychological distress coming some weeks after the earthquake. This could reflect people moving through the early phases of the disaster which have been termed ‘heroic’ and ‘honeymoon’ phases
The GPs also identified particular demographic groups that had been affected by the earthquake such as children and the elderly. Previous research
The GPs described some of the impacts on their elderly patients. Research has reported that disasters can result in increased vulnerability of older people particularly greater mortality, decline of physical health, functional and cognitive decline, increased emotional distress and loss of social supports
While our findings relating to children and elderly patients are broadly in line with previous research, GP commentary relating to patients with previous experience of mental ill health differed from previous research. Freedy & Simpson (2007)
The concept of emotional work or emotional labour may also be useful here (Hochschild, 1979, 1983)
It is encouraging that people appear able to present to their primary health care provider for help after disaster, albeit in waves. Souza, Yasuda and Cristophani (2009)
Recent research about post-disaster recovery suggests that the post-disaster stressors, such as delayed decisions about property and insurance, are some of the most significant risk factors for mental ill health
The Canterbury Earthquake Recovery Authority Wellbeing Survey
Our research has shown that GPs continue to play a vital support role within the community during the post disaster recovery of Christchurch and are an important source of information. This role has also been confirmed in findings from the All Right? Becoming All Right? (2013) survey
GPs identified significant strain and anxiety in patients presenting at primary care clinics, which accounted for a large proportion of their increased workload after the Canterbury earthquakes. This increased distress seemed to stem from multiple causes, including fear of recurring earthquakes and ongoing issues due to the impact of secondary stressors. GPs reported children, older adults and migrants / refugees as groups that seemed to be disproportionately affected when attending at primary care. Half of the GPs interviewed commented that those with previous mental health issues or who had presented following the September 2010 earthquake appeared to cope better with subsequent earthquakes. Although community spirit seemed to increase in the immediate aftermath of the earthquakes, this appeared to dissipate as different parts of the community moved through the recovery at different speeds. GPs reported that the extra resources made available (counseling services and extended consultation time) helped them to cope with their increased workload, and were appreciated and well-used by patients.
The authors would like to gratefully acknowledge the participants who gave their time and shared their experiences for this research.