In consultation with eastern Kentucky local health departments and the National Center for Environmental Health (NCEH) at the Centers for Disease Control and Prevention (CDC), KDPH selected CDC’s Community Assessment of Public Health Emergency Response (CASPER) methodology¹⁵ to conduct the community assessments. Local, state, and CDC staff collaboratively developed an approximately 20-minute, 2-page questionnaire that collected data regarding household demographic characteristics, experiences during the flood, housing status, communications, recovery status after the flood, physical health status, mental health status and needs, and individual-level mental health status (Appendix A).

Two simultaneous CASPERs were conducted across 8 counties during September 6–9, 2022, to adequately assess the populations in the large geographic area affected by flooding. CASPER 1 was conducted in Kentucky River District, which included all occupied households within Letcher, Knott, and Perry counties and the flood-affected area of Owsley (n = 15 848 households). CASPER 2 included all occupied households within the flood-affected areas of Breathitt, Floyd, Pike, and Clay counties (n = 10 841 households) (Appendix B). Local health department directors provided postal codes of the flood-affected areas through geographic information system (GIS) shapefiles to help detect which geographic areas within these counties to select for interviews.

Because the questionnaire included a limited set of individual-level questions, a modified 3-stage CASPER sampling methodology was applied to select a representative sample of households and then persons to interview.¹⁵ In the first stage, 30 clusters (census blocks) were selected for each CASPER with a probability proportional to the number of occupied households within the clusters. In the second stage, interview teams used systematic random sampling to select 7 households from each of the selected clusters for a goal of 210 household-level interviews in each CASPER. Persons interviewed answered these questions for the entire household; therefore, the results are at the household level. In this paper, “household” is used to designate responses that represent all people living in a household. For the third stage, interview teams asked the final 5 questions of the survey to only 1 adult in the household who resided in the home before the flooding. This person was randomly selected (i.e., adult with the next birthday) to complete each individual-level survey questions.¹⁵

The survey was conducted through door-to-door in-person interviews. Interview staff consisted of local and state health department volunteers, University of Kentucky College of Public Health students, University of Michigan Public Health Assistance and Support Team (PHAST), New Vista staff, and University of the Cumberlands students. Interview teams composed of 2 or 3 persons were each assigned 1–3 clusters within a CASPER, depending on location and driving times. Teams were provided detailed maps, driving instructions, and instructed how to randomly select a beginning household within an assigned cluster and then approach every nth household (where n was the total number of occupied households in the cluster divided by 7) to select persons from the 7 households per cluster to interview. Teams made 3 attempts at each selected household before replacement. Replacement selection consisted of counting another 7 houses past the de-selected house to attempt another interview.

Prior to conducting interviews, a 4-hour just-in-time training course regarding the purpose of CASPER, household selection methods, questionnaire content and interview techniques, safety, and logistics was given. Teams conducted interviews during approximately 10:30 am and 6:30 pm Eastern Time on all days except the first day, when teams worked from 3:30 pm to 6:30 pm. Each team used 2 data collection instruments, a paper questionnaire and an electronic tablet with an Epi Info database installed for direct data entry in the field. Each day, interview teams reconciled their completed paper surveys with their tablet data entry to ensure accuracy of data being uploaded into the database. Before data were uploaded digitally to a combined Epi Info database, all electronic surveys were cross-checked with paper forms to account for any missing data or errors in the data entry process.

This paper describes the mental health effects on households and persons living in 8 flood-affected counties in eastern Kentucky after the state’s deadliest flood. Although eastern Kentuckians are familiar with flash flooding, areas that were historically safe from severe flooding experienced unprecedented levels of flooding and damage during this flood in July 2022. This assessment found approximately a third of households in CASPER 1 and approximately 40% of households in CASPER 2 experienced ≥1 mental or behavioral health problems approximately 6 weeks after the flood. These findings are like other U.S. and international studies that reported populations experience anxiety and depression after a flood^7–9,27 and reveal ongoing mental health effects on eastern Kentucky residents after this flood. The individual-level findings are relevant as research shows experiencing ≥1 mental health problem, depression, and stigma associated with mental illness are risk factors for suicide.¹⁸

The findings indicated that despite reporting mental health problems, less than 10% of households in each CASPER reported receiving any behavioral health services since the flood. This lack of mental healthcare receipt could be because of stigma surrounding mental health and seeking care, reduced access to mental healthcare services such as transportation or scheduling challenges, lower availability of providers in rural areas, and the costs associated with mental healthcare.^12,14 Among households that reported receiving counseling, these services were primarily provided by a pastor, therapist, or counselor. Although mental health care services were rarely accessed, households preferred to receive mental health services in-person and locally, followed by telehealth services, and in-person and out of town. Some research describes advantages and barriers to providing telehealth for mental health care treatment in rural areas, with 1 advantage being the ability to alleviate the shortage of providers in rural communities by connecting persons to providers by virtual video conference visits.¹⁹ Overall, these findings reveal a lack of persons receiving mental health care services, yet a need for services and willingness to participate if services were available locally or through the internet.

This assessment found unique demographics in eastern Kentucky that should be considered when planning support after a natural disaster. This investigation showed a substantial older adult population and a high percentage of homeowners in this region.²⁰ Persons aged 65 years and over comprise approximately 17% of the total population in Kentucky, yet results showed approximately 45% of households in each CASPER reported at least 1 person aged ≥65 years, revealing a potential overrepresentation of this age group in eastern Kentucky.²¹ Persons aged >60 years experienced physical health problems such as less mobility, chronic pain, and frailty, which can be associated with mental health problems (and vice versa).²² For example, 7% of the older population (aged ≥60 years) are diagnosed with depression, a disorder that is often underdiagnosed and undertreated in this age group.²² Despite eastern Kentucky having a lower socioeconomic status (SES) than other parts of the state, at least 85% of the population are homeowners, in part because of the lower median property value in the region and lower availability of apartment complexes.^21,24 Lower socioeconomic status among residents of this area might increase their susceptibility to mental health effects after a natural disaster.²⁵ Understanding the unique population demographics, existing mental health problems, and social determinants of health can provide public health leaders and emergency responders with evidence-based information during disaster situations to supply these populations with the most appropriate resources to meet their needs.

These two CASPERs were a successful collaboration among 5 eastern Kentucky local health departments, KDPH, CDC, and university and community partners who were all responsive to assessing the community needs and status of flood-affected areas following the historic and devastating flood in eastern Kentucky. Although prior studies describe mental health effects after flooding,^7–11 this rapid needs assessment adds to a line of work using a CASPER population-based survey methodology and highlighting the mental health effects after a natural disaster (i.e., flood) in several rural communities in eastern Kentucky. Six weeks after the flood, the CASPER data pointed to households experiencing worsening overall health and emotional and mental health concerns, and a strong preference for in-person local mental health and telehealth counseling. As flooding and other natural disasters affect communities, households, and persons year-round, and are predicted to increase because of the possible effects of climate change,²⁶ the findings from these CASPERs could be useful after future natural disasters in Kentucky and for other jurisdictions responding and recovering from natural disasters. Based on the results, mental health services should be considered when developing emergency preparedness and response plans. Through increased promotion, affordability, accessibility, and availability of these services, eastern Kentucky residents might be willing to access these services more often, which could decrease local stigmatization of mental health care.