Pharmacies and their communities
Pharmacies are intricately connected to their communities and play a significant role in daily life by dispensing prescription drugs and selling over-the-counter medicine. In Japan, there is increasing recognition of the importance of having a family pharmacy/pharmacist along with a family doctor.
Experiences of large-scale disasters and emerging infectious diseases have reaffirmed the importance of healthcare professionals in times of disaster, and pharmacists are attracting attention as a member of this group. In Japan, pharmacists are basically not allowed to dispense medicines without a prescription from a doctor, except when engaged in disaster relief activities, and this exception has been applied in past disasters. In addition, vaccinations are administered by doctors and nurses, but when the new coronavirus infection spread, pharmacists, who had not previously been recognized as candidates to administer vaccines, appeared on the scene as a measure to secure labor. Although direct vaccination by pharmacists was eventually abandoned, pharmacists played a variety of roles related to vaccination. Their main roles included preparing for, and assisting in the implementation of vaccinations, storing, and managing vaccines, as well as monitoring and providing information on the health status of vaccine recipients.
In Japan, after becoming a pharmacist, many efforts are made to respond to various situations, and improve professional skills by continuing education, research in specialized areas, cooperation with medical teams, and participation in pharmacist associations and societies. Furthermore, pharmacies where approximately 60% of pharmacists in Japan work, have a particularly important responsibility to supply necessary medications to disaster victims to save lives in the event of a disaster in the community. In addition, pharmacies must be able to respond to patients in a flexible manner (e.g., by incorporating telemedicine) in response to unexpected changes in social conditions such as during outbreaks of infectious disease such as COVID-19. Reference Ozeki and Ojima1 In times of disaster (including outbreaks of emerging infectious diseases), access to medicine is an important issue for victims, especially those with illnesses because it is a matter of life, and death as well as health security. Pharmacies are well prepared for disasters if they can promptly supply medicine to victims who need them in times of disaster.
In recent years, Japan has experienced many earthquakes, weather events, floods, and other disasters that have caused major damage and made it difficult for people to obtain medicine. Reference Liu and Yamazaki2,Reference Cho, Li and Wang3 The tsunami following the Great East Japan Earthquake of 2011 destroyed many pharmacies, cutting off the supply of medicine. Reference Hashimoto and Earthquake4 This triggered the idea of using campers as mobile pharmacies. Reference Nagata, Iwata and Sone5 These “disaster-preparedness pharmaceutical supply vehicles,” which are equipped with facilities for dispensing medicine, were deployed in 2014 after the Kumamoto earthquake, demonstrating their potential as pharmaceutical logistics bases in disaster areas. Reference Inaba and Amagata6 Mobile pharmacies might also be used to provide regional support during outbreaks of emerging infectious diseases, especially in areas where there are drug supply problems due to increased demand for medicine as well as reduced manufacturing and logistics capacity. Reference Bookwalter7,Reference Hirakawa and Takizawa8 Presently, the number of prefectural pharmaceutical associations (PPAs) that own a mobile pharmacy is on the rise.
Disaster-preparedness training for pharmacies at the community level is especially important. In the event of a disaster, medical infrastructure may be damaged, and pharmacists can play a vital role in the community by sharing medical information and supplying medicine. To facilitate the smooth communication of medical information and provision of medical care, it is important to prepare for disasters in cooperation with local pharmacies and pharmacy associations.
This study focuses on pharmacies, which are thought to play a key role in providing necessary medications to disaster victims and examines the characteristics of pharmacies that are well prepared for disasters in terms of being able to provide medicine to patients so that they can continue taking their prescribed medications in the event of a disaster. In addition, we investigated the activities of the PPAs to which the pharmacies belong.
Methods
Two surveys were conducted from November 2021 to January 2022. In the first survey, a self-administered questionnaire on matters related to disaster preparedness was mailed to 50 randomly selected pharmacies in each of Japan’s 47 prefectures. The survey included the following items: respondent and pharmacy attributes, whether or not furniture is securely fixed, and whether or not water is stockpiled; as well as whether or not there are rules of conduct for pharmacists in the event of a disaster, the utilization of online systems, the status of discussions with neighboring or nearby medical institutions regarding cooperation in the event of a disaster; consideration of a reserve of leftover medications in case of a disaster, the status of cooperation with neighboring or group pharmacies, whether or not support for disaster-affected areas is provided, and disaster preparedness.
In the second survey, a self-administered questionnaire on matters related to disaster preparedness was mailed to all 47 PPAs in Japan. The survey asked whether disaster-preparedness training was conducted and, if so, the number of disaster-preparedness training sessions, as well as whether the PPA owned a mobile pharmacy.
Logistic regression analysis was performed to examine the association of the pharmacies’ preparedness for disasters as an objective variable with the following explanatory variables: the items on pharmacy background included status of online utilization, status of cooperation with neighboring or group pharmacies, status of discussions with neighboring or nearby medical institutions regarding cooperation in the event of a disaster, and consideration of a reserve of leftover medications in case of a disaster, as well as the existence of support for disaster-affected areas, and awareness of natural disasters, while the items on the PPA included whether the pharmacies had received disaster preparedness training and whether they owned mobile pharmacies.
Pharmacies with good disaster preparedness were defined as those that satisfied the following criteria: having securely fixed furniture, stockpiled water, stockpiled disaster supplies, and rules of conduct in the event of a disaster. Pharmacies using online systems were defined as those that reported the intention of using online systems, posted their business status information online, and provided online medication counselling. Regarding disaster preparedness, the responses, “very aware” and “aware” pharmacies were defined as “high awareness,” while “cannot say either way,” “unaware,” and “not aware at all” were defined as “low awareness.” Model 1 was analyzed using only the single explanatory variable, Model 2 using the single explanatory variable plus the respondents’ sex and age, and Model 3 using the single explanatory variable plus the respondents’ sex, age, chain store status, and number of pharmacies per 100 km2 of inhabitable land area.
In addition, logistic regression analysis was performed using the activities of the PPA to which the pharmacies belonged (whether they received disaster-preparedness training and whether they owned a mobile pharmacy) as explanatory variables and pharmacies’ disaster awareness as the objective variable. Model 1 was analyzed with each single explanatory variable only, Model 2 with each single explanatory variable plus the respondents’ sex and age, and Model 3 with each single explanatory variable plus the respondents’ sex, age, chain store status, and number of pharmacies per 100 km2 of inhabitable land area.
Ethical Code
This study was approved by the Ethics Committee for Clinical Research of the Hamamatsu University School of Medicine (Study No. 21-139). The purpose of the study was explained to each pharmacy and PPA, and responses were obtained only from those pharmacies and PPAs that provided consent.
Results
Responses were received from 931 of the 2 350 pharmacies (response rate: 39.6%) and 39 of the 47 PPAs (response rate: 83.0%). Table 1 shows the demographics of the pharmacy survey respondents; 54.6% were male and 45.1% were female. There was equal distribution across respondents in their 30s, 40s, 50s, and 60s, with each accounting for about 20%. The position of most of the respondents was managerial pharmacist. About 30% of the respondents belonged to a chain pharmacy with 11 or more stores, and about 70% to individual pharmacies or those with 10 or fewer affiliated pharmacies.
Attributes of survey respondents
Table 2 shows the status of pharmacy preparedness and pharmacy characteristics. The preparedness status of the pharmacies tabulated in this study is as follows: 35.2% of the pharmacies did not have securely fixed furniture such as medicine cabinets, refrigerators, and dispensing machines which could lead to serious accidents potentially resulting in injury, or death in the event of a disaster such as a large earthquake. In addition, some pharmacies stockpiled bottled water, a commodity to sell to patients that can be converted to disaster supplies. However, 31.8% of the pharmacies did not stockpile water, which is important both for drinking and for taking medicine, and 8.2% had not stockpiled any disaster supplies. About a third of the pharmacies (34.6%) had regulations regarding the actions of pharmacists in the event of a disaster, while 45.8% did not, and 17.5% were unclear. Thus, only 18.4% of the analyzed pharmacies satisfied all the criteria for being well prepared for disasters.
Pharmacy preparedness status and characteristics
Regarding the status of discussions with neighboring or nearby medical institutions regarding collaboration in the event of a disaster, most pharmacies (71.5%) reported that they did not have any such discussions. Less than 50% of the pharmacies considered creating a reserve of leftover medication in case of disasters when adjusting residual medications. Regarding the status of cooperation with neighboring or group pharmacies, most of the pharmacies were engaged in some form of cooperation, while less than 20% of pharmacies responded that they were not, or that cooperation was unnecessary. In terms of whether they had experience providing support to disaster-affected areas, only about 10% of the pharmacies reported having done so. A minority of pharmacies (44.8%) were willing to implement online drug counselling, and just over 50% answered that they would not be able to post their business status online in the event of a disaster. Many pharmacies were willing to use a simple online system that could be used during disasters to inform community pharmacies if they were open for business, whereas a few were reluctant to do so, with 25% undecided. Thus, only 21.6% of the pharmacies satisfied the following criteria: willing to use an online system, posting business status information online, and providing online drug counselling.
Regarding awareness of natural disaster preparedness, more than 50% of the pharmacies were “very aware” or “aware,” while 35% were “cannot say either way,” and about 12% were “unaware” or “completely unaware.”
As for the implementation status of disaster prevention training organized by PPAs, 56.4% of the respondents answered that they “do not conduct such training,” 30.8% answered that they “do conduct such training (including online),” and 12.8% answered that they “used to conduct such training before the COVID-19 pandemic.” Among the PPAs that conduct disaster-preparedness training, 52.9% of the respondents reported that they conduct disaster-preparedness training “once a year,” 23.5% conduct it 3 or more times a year,” and 5.9% conduct it “twice a year.” Regarding the availability of mobile pharmacies in the prefecture, 30.8% responded “Yes” while 69.2% responded “No.”
Table 3 shows the background of the pharmacies and the results of the association between the activities of the PPAs to which the pharmacies belong and pharmacies that are well prepared for disasters. In Models 1, 2, and 3, better disaster preparedness was significantly associated with high online utilization (odds ratio [95% confidence interval]: Model 1, 2.48 [1.71 - 3.58]; Model 2, 2.43 [1.67 - 3.53]; Model 3, 2.39 [1.64 - 3.48]), collaboration with neighbouring or group pharmacies (2.50 [1.47 - 4.56]; 2.50 [1.42 - 4.39]; 2.39 [1.35 - 4.21]), discussion about cooperation in case of a disaster with adjacent or nearby medical institutions (3.25 [2.29 - 4.61]); 3.46 [2.42 - 4.96]; 2.25 [1.51 - 3.35]), consideration of a reserve of leftover medications in case of a disaster (2.08 [1.48 - 2.95]; 2.10 [1.48 - 2.97]; 2.23 [1.57 - 3.17]), providing support for disaster-affected areas (1.76 [1.08 - 2.81]; 1.89 [1.16 - 3.07]; 1.91 [1.17 - 3.13]), high disaster awareness (2.32 [1.63 - 3.34]; 2.50 [1.72 - 3.63]; 2.14 [1.45 - 3.16]). In terms of prefectural activities, in Model 3, pharmacies belonging to PPAs that conducted 3 or more disaster-preparedness trainings a year were significantly better prepared for disasters (1.76 [1.001 - 3.11]). Ownership of a mobile pharmacy was not associated with better disaster preparedness.
Pharmacy background and activities associated with better disaster preparedness
Pharmacies with high disaster preparedness were defined as those meeting all of the following criteria: have securely fixed furniture, have a disaster protocol, have stockpiled water, and have stockpiled disaster supplies.
*Online utilization was defined as those meeting all of the following criteria: plan to implement of online drug counseling, ability to post business status online in the event of disaster, and willingness to use an online system that can be used during disasters to notify whether pharmacies are open or not.
**For “Plan to implement online drug counselling,” “already implemented” and “likely to implement in the future” were defined as “Yes,” while “unlikely to implement in the future” and “no plan to implement” were defined as “No.”
***For “Availability to post business status online in the event of a disaster,” “can post” was defined as “Yes,” while “cannot post” and “no need for such a system” were defined as “No.”
****For “Willingness to use a simple online system that can be used during disasters to notify whether pharmacies are open or not,” “already use such a system,” “would like to use such a system” and “somewhat willing to use such a system” were defined as “Yes,” while “cannot say either way,” “not particularly willing to use such asystem”, and “unwilling to use such a system” were defined as “No.”
*****Low disaster awareness: “cannot say either way,” “unaware,” and “completely unaware.”
******High disaster awareness: “very aware” and “aware.”
Model 1 included only each single explanatory variable, Model 2 included each single explanatory variable plus the respondents’ sex and age, and Model 3 included each single explanatory variable plus the respondents’ sex, age, chain store status, and number of pharmacies per 100 km2 of land area available.
Table 4 shows the results of the association between the initiatives of the prefecture to which the pharmacies belong, and the pharmacies’ awareness of disaster preparedness. Models 1, 2, and 3 all showed significantly higher disaster awareness among pharmacies in prefectures with at least 3 disaster-preparedness training sessions a year (1.83 [1.16 - 2.91); 1.98 [1.24 - 3.17]; 2.24 [1.38 - 3.64]), and those with mobile pharmacies (1.46 [1.08 - 1.98]; 1.41 [1.03 - 1.92]; 1.61 [1.16 - 2.24]).
Association between the activities of the prefectural pharmaceutical association to which pharmacies belong and pharmacies’ high disaster awareness
Model 1 included only each single explanatory variable, Model 2 included each single explanatory variable plus the respondents’ sex and age, and Model 3 included each single explanatory variable plus the respondents’ sex, age, chain store status, and number of pharmacies per 100 km2 of land area available.
Discussion
This is the first study to examine the activities of PPAs to which pharmacies belong and to identify pharmacies that are well prepared for disasters.
The results suggest that pharmacies belonging to PPAs that conduct disaster-preparedness training sessions at least 3 times a year are better prepared for disasters compared with those that provide such training only once or twice a year, suggesting that the number of training sessions should be increased if possible. Furthermore, pharmacies belonging to PPAs that conduct 3 or more disaster-preparedness training sessions were considered to have more opportunities to participate in training, and they were also more aware of disaster preparedness. In addition, as a community-specific activity involving pharmacists, some prefectures provide disaster-preparedness training programs that enable pharmacists to learn about disaster scenarios, and response measures based on earthquake-damage assumptions, using educational materials developed by the prefecture. 9
Ownership of a mobile pharmacy was not associated with better disaster preparedness, although pharmacies belonging to PPAs that owned mobile pharmacies had higher disaster awareness. This finding suggests that pharmacies in prefectures with mobile pharmacy ownership have more opportunities to use and see mobile pharmacies compared with those without mobile pharmacy ownership, which may increase disaster awareness.
Regarding the preparedness of individual pharmacies, the authors conducted a similar study in 2016 in Hamamatsu, Shizuoka Prefecture. Reference Ozeki and Ojima10 In the present study, the scope was expanded to include pharmacies nationwide, and additional questions were added, including those related to telemedicine, which enabled contactless interaction between pharmacists and customers during the COVID-19 pandemic and may also be applicable to disaster preparedness.
Regarding telemedicine, it was suggested that pharmacies that are willing to use online systems are better prepared for disasters and can be regarded as community pharmacies that can be connected online as an option if their own pharmacies are unable to respond in the event of a disaster. This was also supported by the fact that pharmacies that collaborated with neighboring or group pharmacies were better prepared for disasters. Many group and chain pharmacies were already connected via the Internet, and the increase in the number of such pharmacies willing to utilize online systems was thought to be linked to the progress of medical digital transformation, which advanced rapidly during the COVID-19 pandemic. Reference Takahashi11 On the other hand, some pharmacies were reluctant to use online systems. Reasons for this include concerns about personal information, concerns about the reliability of information, security issues, workload and time constraints, and lack of digital literacy.
Pharmacies that discussed disaster preparedness with adjacent and nearby medical institutions were also significantly more prepared for disasters, and some pharmacies and medical institutions had simple disaster prescription arrangements in place for disasters.
Pharmacies that considered a reserve of leftover medications in case of a disaster also showed prominent levels of disaster preparedness. In particular, it is thought that drugs for patients with intractable diseases, which are rarely handled by pharmacies, may need to be kept in reserve for a longer period compared with drugs used for chronic diseases, which require a 3 or 4-day reserve to last through the acute phase of a disaster. Reference Tanoue and Saito12 It is also important to provide guidance to patients regarding the use of reserve medicine.
Pharmacies with experience in supporting disaster-affected areas witnessed the extent of the damage, suggesting that they are aware of the possibility of their own pharmacies being affected by a disaster, and may be preparing for a disaster. In addition, pharmacies with high disaster awareness are reported to be better prepared for disasters. Reference Ozeki and Ojima10
A variety of specific initiatives and logistics are important for pharmacies to support community residents in the event of a disaster. These include emergency drug stockpiling in preparation for disasters, development of procedures for providing medicines during disasters, health counselling for community residents at evacuation centres, and sharing information on drug history/home health care, as well as providing information/ communication to community residents. Pharmacies can effectively support community residents and contribute to the provision of medical care during disasters.
In addition, pharmacists should conduct drills for disaster preparedness based on scenarios. The content of such training could include strengthening collaboration through the participation of doctors, nurses, and government officials, as well as other multidisciplinary personnel; exercises in providing medicines at evacuation centres, training in inventory management, logistics, use of digital tools, and formulation of recovery plans, as well as review and feedback. A comprehensive training program combining these elements would improve the skills of pharmacists in the event of a disaster and provide prompt assistance to community residents.
The important findings on disaster preparedness in Japan obtained in this study, such as enhanced disaster drills and collaboration, use of mobile pharmacies, introduction of telemedicine, and collaboration/ information sharing with medical institutions and other pharmacies, as well as stockpiling of medicines and providing information during emergencies, can be applied in other countries as well. It is suggested that these approaches be considered to further enhance local disaster preparedness.
Limitations
This study had several limitations. First, the response rate from pharmacies was low at 39.6%, although this was considered adequate for the sample size. The response rate from PPAs was high (39 out of 47 prefectures), but it was not possible to obtain responses from all associations. In addition, some respondents did not answer all the questions.
Conclusion
Pharmacies that can promptly provide medicine to disaster victims who need them in the event of a disaster are well prepared for disasters. The provision of disaster-preparedness training at least 3 times a year by PPAs was associated with good disaster preparedness among member pharmacies, suggesting that the number of disaster-preparedness training sessions by PPAs should be increased if possible. In addition, pharmacies with high online utilization, high collaboration with neighboring or group pharmacies, discussions with neighboring, or nearby medical institutions regarding collaboration in the event of a disaster, allocation of additional drugs for disasters, provision of support for disaster-affected areas, and high disaster awareness were significantly better prepared for disasters.
Acknowledgments
We would like to express our sincere gratitude to the pharmacies and prefectural pharmacists’ associations that participated in this study.
Author contributions
KO and TO designed the study: KO surveyed and reviewed the literature and analyzed the data; KO and TO both wrote the manuscript; Both authors reviewed and approved the final manuscript.
Funding statement
This research was supported by JSPS KAKENHI Grant Number JP 20K18879.
Competing interests
The authors have no conflicts of interest to declare.
