The Main study was a cross-sectional survey. The survey was made available online, on mobile phone and in paper form between September and November 2017.
Recruitment methodology
The aim of recruitment was to reach people living in the Northern Rivers region at the time of the 2017 flood who experienced damage to any of five physical locations or structures: suburb; non-liveable areas of their home (e.g., garden shed, garage); liveable areas of their home (e.g., bedrooms); income-producing property (business/farm, if applicable); and the home of a significant other, as well as those who were not exposed (no surrounding infrastructure damage, evacuation or displacement). As some of the key interest groups are difficult to reach (e.g., people living with disadvantage), purposive sampling utilising a snowball technique recruiting respondents via personal and local organisational networks and encouraging respondents to raise awareness of the survey with friends, family and colleagues was conducted. As the study did not aim to assess population prevalence of flood exposure or mental health outcomes but rather to quantify relationships between flood impact and mental health risk the sample was not randomly selected, but was purposively recruited [
49]; the focus was to ensure adequate numbers of respondents from key interest groups to enable analysis of exposure and outcome for these groups.
Community-academic partnership was key to the study design and implementation, particularly in facilitating recruitment to the Main study and in providing support for respondents completing the questionnaire. The partnership with community took many forms including recruiting two new staff members from the community into the research team with a focused community engagement role; one with an impressive track record in local TV/radio and print media journalism and the other, one of three women who were the driving force behind the establishment of an inspiring self-organising group (
Helping Hands) connecting hundreds of volunteers with locals requiring support following the flood. The leader of, and the five members of the recruitment team for the Sub-study (see
Sub-study section below and Fig.
3) were also highly networked, experienced, and well known members of the community.
Two Community Advisory Groups (CAGs) were also established one in Lismore and one in Murwillumbah. The CAGs included representation from around 60 local health and community organisations, business groups and state and local government authorities, met frequently and provided critical advice on the research questions, study design, recruitment strategies, questionnaire content (including piloting), analysis priorities and dissemination strategies.
The community-academic partnership was initiated by academic researchers. Members of the partnership were not funded to participate in the partnership, their commitment to contribute (either in one-to-one meetings by phone or face to face, or by being a member of one of the CAGs and attending CAG meetings) stemmed from a commitment to the community, grounded in the shared experience of the flood. The partnership was large in comparison to other studies [
10] and was made up of NGOs, community organisations, local government, service providers, members of the public, the business community and others, many of whom were members of the CAGs. The CAGs had agreed Terms of Reference which helped to clarify purpose and roles. The nature of the community-academic partnership was characterised by a goal (to successfully complete the research and disseminate the findings so that they could be used to inform improved support for the community before, during and after flooding), relevant to the community, and involved community members as well as academics. As such the community-academic partnership was congruent with the conceptual definition of community-academic partnerships by Drahota et al. [
10] Description of the timeline for the partnership is provided in Fig.
3.
Initial invitation to participate in the survey (most commonly by email) was via social and organisational networks of community organisations, the CAGs, the local health service, local government authorities and business/farming groups. For example, the local health service (one of the largest employers in the region) who were part of the CAGs sent an email to their all-staff list inviting participation and including a link to the questionnaire online and instructions about how to access a paper version of the questionnaire if preferred. This approach was supplemented by an extensive local media (print and broadcast) advertising campaign, fliers and posters (which included a QR code - a 2-dimensional bar code that enabled potential respondents to access the survey website easily using their mobile phones). The posters and leaflets along with paper surveys (with franked return envelopes) were placed in central community locations such as council offices, coffee shops, in every library and post office, and in shops belonging to charitable organisations such as Lifeline, Interrelate, St Vincent de Paul and the Salvation Army. Social media was also used intensively and strategically to raise awareness and invite potential respondents, including Twitter and a Facebook page incorporating short videos of key community members talking about the survey. The survey was launched at face-to-face media and community events marking 6 months since the flood. The team’s community engagement staff had high visibility in the community throughout the duration of the survey period by staffing a stall at farmers’ markets and attending a plethora of other community events. Appropriately skilled members of relevant organisations (e.g. Lifeline, a crisis support service) received information about the ethical aspects of conducting the survey and provided one-to-one support for survey completion. Door-to-door recruitment took place in Lismore and Murwillumbah.
When participation in the Main study was reviewed with the community via the CAGs at the halfway point a number of specific strategies were discussed, agreed and employed to maximise participation from men (promoting the survey via men-specific organisations such as the Men’s Shed, posting videos on the project’s Facebook page of men talking about completing the questionnaire), older people (taking paper copies of the questionnaire and advertising material to residential aged care facilities) and people aged 16–25 years (promoting through networks of youth workers and Facebook). A leaflet delivered by post to residents in Lismore and Murwillumbah was also added at this point.
A lottery style draw of gift vouchers for $100 to spend in local businesses was offered to respondents who opted to put their details into the draw.
Questionnaire content
The final 58-item questionnaire covered: socio-demographic characteristics; the six flood exposures established a priori (suburb, non-liveable areas of their home, liveable areas of their home, business/farm and/or the home of a significant other flooded, plus not exposed to any of these evacuated or displaced); respondents’ experiences during the flood including evacuation and displacement; mental health items and items measuring individual and community resilience and social capital. Table
1 contains information on the main measures and their origins and how they relate to the Flood Impact Framework. In addition to these items, the questionnaire contained eight free-text opportunities inviting respondents to report their perspectives on their flood experience.
Table 1
Main questionnaire items, their origins and how they relate to the Flood Impact Framework (Fig.
1)
Socio-demographics variables: • Age • Gender • Indigenous status • Relationship status • Education level • Employment status • In receipt of income support • Farmer • Business owner | N/A | Personal characteristics, including those identifying key interest groups |
Flood exposure (liveable area of home flooded; business flooded; non-liveable area of home flooded e.g. garage; suburb flooded; home of close friend or relative flooded; none of the above). Degree of flooding: water above your head height through entire home/property; water between knee and head height (more than 50 cm) through entire home/property; water below knee-height (about 1-50 cm) through entire home/property; water in some but not all areas of home/property | Derived from the Brief Weather Disaster Trauma Exposure and Impact Screen [ 9] and the English National Cohort Study on Flooding & Health [ 22]. | Impact of flooding |
Evacuation: • Did you have to evacuate your home/business? • How much warning did you get? | Derived from the English National Cohort Study on Flooding & Health [ 22]. | Impact of flooding Pre-flood mitigation systems: Warning systems |
Displacement: • Because of the flood did you have to live elsewhere? | Derived from the Brief Weather Disaster Trauma Exposure and Impact Screen [ 9] English National Cohort Study on Flooding & Health [ 22]. | Impact of flooding |
Support at the time of the flood: • Did support requested from Govt/Community organisations/insurance/emergency services/volunteers meet your needs? | Bespoke measure developed for the Flood Impact Framework | Agency response: disaster relief Perceptions of responses Community & health service response: mental health & wellbeing needs |
Blame: • Are Govt/Community organisations/insurance/emergency services/volunteers to blame for distress? | Bespoke measure developed for the Flood Impact Framework | Perceptions of responses: sense of blame |
Previous flood experience: • Have you ever been in heavy rain or floods in which your home, business, workplace or school was damaged? | Bespoke measure developed for the Flood Impact Framework | Previous flood exposure, cumulative flood exposure |
Post-traumatic growth: • Have the severe rain and flood resulted in you being able to make any positive changes in your life? | Bespoke measure developed for the Flood Impact Framework | Personal factors |
Individual and community resilience: • Personal social capital – community participation | Australian Community Participation Questionnaire [ 50].
Seven point agree/disagree scale
| Community factors Personal factors |
• Community functioning | A measure of ‘social’ (or ‘generalised’) trust from Berry et al. 2003 [ 51], a question from the CRACE study [ 52] and a bespoke measure for the Flood Impact Framework | Community factors |
• Personal social cohesion - connection, sense of belonging & support | Two sub-scales from the Interpersonal Support Evaluation List (Cohen et al. 1985 [ 53]) Berry 2008 [ 54]
Seven point agree/disagree scale
| Community factors Personal factors |
• Social trust | Adapted by Berry, 2008 [ 55] from the Organisational Trust Inventory (OTI) (Cummings & Bromiley,1996 [ 56]) and the World Values Survey (Inglehart et al., 2000 [ 57])
Seven point agree/disagree scale.
| Personal factors |
• Generalised reciprocity | Adapted by Berry, 2008 [ 55] from the World Values Survey (Inglehart et al., 2000 [ 57])
Seven point agree/ disagree scale
| Personal factors |
• Trait optimism | Adapted from the Life Orientation Test – Revised (LOT-R) (Scheirer et al. 1994) [ 58]
Seven point agree/disagree scale
| Personal factors |
Mental health and wellbeing outcome measures: • Flood-specific - Still distressed about the flood | Brief Weather Disaster Trauma Exposure and Impact “Are you still currently distressed about what happened during the flood?” Yes/No | Mental health & wellbeing of community members and subsequent needs |
• Flood-specific - Post-Traumatic Stress Disorder (about the flood) | Post-Traumatic Stress Disorder Checklist (PCL-6) [ 59]. A list of complaints that people sometimes express after extreme rain and flooding. Cut-point for probable diagnosis was ≥ 14 [ 59] | Mental health & wellbeing of community members and subsequent needs |
• Not flood-specific - Depression | Patient Health Questionnaire (PHQ-2) [ 60]. Cut-point for probable diagnosis was ≥ 3 [ 60] | Mental health & wellbeing of community members and subsequent needs |
• Not flood-specific - Anxiety | Generalised Anxiety Disorder scale (GAD-2) [ 61]. Cut point for probable diagnosis was ≥ 3 [ 61] | Mental health & wellbeing of community members and subsequent needs |
• Not flood-specific - Suicidal ideation | A single suicidal ideation item from the Screening Tool for Assessing Risk of Suicide [ 62]
Yes/No
| Mental health & wellbeing of community members and subsequent needs |
As the questionnaire was rather long, respondents were offered the choice between completing a shorter (15 min) or longer (25 min) version. The shorter version (the first part) contained socio-demographic variables, flood experience items, mental health measures and a post-traumatic growth measure. The longer version included all of the above as well as personal and community resilience measures.
Consistent with previous research, a high level of community distress following the flood was anticipated [
2,
38,
63]. Caring for respondents and minimising the risk of harm to their mental health was, therefore, a core component of the questionnaire design. For example, the number of difficult items was minimised, more difficult items (e.g., items about suicide) were located after or before less difficult items, free-text opportunities were included, any distress caused by completing the questionnaire was acknowledged and apologised for in the introductory material, and contact information for counselling and support services featured prominently throughout.
At the end of the survey (short and full versions) respondents were asked if they would be willing to be contacted in future to participate in further research about the flood. The online survey was generated using Qualtrics software (version Sept-Nov 2017, Qualtrics Provo Utah).
Planned data analyses
The dataset for the Main study has been cleaned and an initial descriptive analysis including means and standard deviations, frequencies and proportions for all social and mental health and wellbeing variables undertaken (Matthews V, Longman JM, Berry HL, Passey ME, Bennett-Levy J, Morgan G, et al.: Mental health six months after extensive flooding from cyclone Debbie in rural Australia: a cross-sectional analysis through an equity lens, submitted). These statistics will be calculated separately for the sample as a whole, for the six exposure groups and the key interest groups. Mental health and wellbeing outcomes across each of the exposure and key interest groups will be examined. Respondents reporting none of the exposures will form a control group for comparison to groups which reported one or more exposures. Analysis of proposed protective factors for mental health and wellbeing (such as community resilience) between the different flood-exposure groups will be undertaken. A broad range of inferential statistical procedures will be employed to describe relationships between exposure and outcome variables and associations with other factors according to the proposed Flood Impact Framework. These may include calculation of correlation coefficients, analyses of variance, hierarchical and logistic regression analyses, cluster analyses and multi-level and structural modelling. The necessary data have been collected to adjust for a wide variety of factors known to predict psychiatric morbidity. Analyses will assist in evaluating the plausibility of the proposed Flood Impact Framework and in improving both the Framework and future study design.
Free text data will be analysed deductively using a content analysis approach following Elo et al. [
64]