At the time of the survey, 6 weeks after the flooding event, nearly half of households at shelter sites reported no internet service (46.7%) and 20.0% reported not having access to transportation or cellular service (Table 2). When asked how close their home is to being how it was prior to floods (excluding landscape), 72.4% of households reported their home was not repaired at all. Nearly a quarter of households reported the availability of contractors/skilled labor (23.0%) and finding materials/supplies (24.6%) were barriers to their home being repaired, and 21.3% reported insufficient money.¹ When asked if they would be willing to relocate outside of the floodplain if their household had an offer to sell, 42.6% of households reported they would be willing and 11.5% reported “maybe.” Approximately a quarter (26.7%) of shelter site households reported none of the debris and waste had been removed from their property and almost 40% of households reported some debris and waste and been removed (38.3%). Nearly 15% of shelter site households (12.1%) indicated they did not have a 7-day supply of prescription medications.

Most households at shelter sites reported having no warning of the flood (85.3%); half (50.8%) reported seeing rising water as their first warning sign of the flood; nearly a third heard from friends/family (32.8%); 16.4% received a phone weather alert; and about 10% received warning of the flood through social media, television, and/or internet news (Table 3). When participants were asked if any member of their household had difficulty prior to the flood accessing the radio, television, internet, or cell for communication, 37.7% reported no difficulties. However, almost 30% of households reported having difficulty receiving communication through the internet, nearly a quarter reported difficulty with television (24.6%), and approximately 20% reported having difficulty with cellular service (19.7%) and radio (21.3%).

Households living in shelter sites were asked, since the flood, what, if any health and clean up messages their household heard. Approximately 40% reported hearing messages about mold clean-up and disaster recovery centers, 16.4% about vaccinations, and 27.9% reported not hearing any clean up or health messaging (Table 4). When asked how their household heard messaging about health and/or clean-up, 45.9% reported hearing messaging from friends with only a small percentage of households reporting health and/or clean-up messaging from other sources such as TV, radio, church/place of worship, public health department, internet news, social media, or flyer/poster.

Households living at shelter sites were asked what stage of home clean-up their family’s home was in currently. Half (50.9%) reported their home was destroyed and they can’t live there again. When asked if anyone in their household had attempted to receive assistance related to the floods, 67.4% reported receiving assistance from churches, 57.4% from family/friends, 38.5% from non-profit organizations, 34.4% from Red Cross, and 33.3% from local government.

Regarding assistance from FEMA, 32.8% reported their household attempted to receive assistance from FEMA, and of that group, 62.3% of those reported receiving funds from FEMA. For those who received FEMA assistance, they were asked how difficult it was to get assistance, with 28.1% saying it was “very difficult” and 38.6% saying it was “difficult,” or nearly 70% indicating difficulty. If assistance was received, households were asked if the assistance covered the financial costs needed for the home: 78.2% said “no.” Some of the top barriers to receiving assistance included the documentation/paperwork process being difficult and confusing to navigate (25.0%), issues with FEMA such as attitude of FEMA personnel and documentation (9.3%), and FEMA not paying enough (3.1%).

Households living at shelter sites were asked if it’s been more difficult to get needed professional medical care for any member of their household since the flood, and 15.3% reported more difficulty receiving usual medical care. Households were also asked if it has been difficult to get needed prescriptions; 18.3% said “yes.” When asked if it had been more difficult to get needed medical supplies, 18.6% said “yes.” Since the flood, 41.4% reported their household experienced a worsening of allergies, 35.6% reported experiencing a worsening of high blood pressure, 32.1% worsening overall health, 31.0% a worsening of asthma, and 22.4% a worsening of COPD.

Households at shelter sites were asked, since the flood, how often would you say your household was worried or stressed about having enough money. Approximately a quarter of households reported they were always (22.0%) or sometimes worried or stressed about having enough money to pay bills (25.4%). When asked about meals, 22.0% of households reported they were always and sometimes worried or stressed about having enough money for meals. Regarding rent, 13.6% of households at shelter sites reported they were always and 18.6% of households reported sometimes being worried or stressed about paying rent.

Of households living at shelter sites, 27.7% reported they received services for behavioral or mental health (18.0% from a therapist) and 19.6% received grief counseling (Table 5). When asked about barriers to seeking services for behavioral health concerns, 36.1% reported no difficulty accessing, or no need for counseling services. However, some barriers to receiving counseling services noted were transportation (11.5%) and being unaware of resources (8.2%). When asked how they or their household would like to receive behavioral health assistance, 57.4% reported they would like to receive it locally and 39.3% reported they would like telehealth.

Households living at shelters sites were asked if they or members of their household had experienced any of several different mental health indicators since the flood (Table 6). Households indicated they or some member of their household had experienced nightmares (62.3%), difficulty concentrating (47.5%), loss of appetite (36.1%), agitation (36.7%), witnessed violent behavior or threats (9.8%), or suicidal thoughts/self-harm (6.6%).

Individuals surveyed were asked of themselves only, how often over the past 2 weeks they felt down, depressed, or hopeless? Over half (55.4%) reported either “several days” (28.6%) or “nearly every day” (26.8%), and 7.1% reported “more than half the days.” Participants were asked over the last 2 weeks how often they had little interest or pleasure in doing things; 23% reported “several days” and 21.3% reported “nearly every day.” Participants were also asked over the last 2 weeks how often they felt nervous, anxious, or on edge: 44.1% reported “several days” and 23.7% reported “nearly every day.” These questions originated from the PHQ2. Finally, they were asked over the last 2 weeks, how often had they been unable to stop or control worrying with 35.6% reporting “several days” and 33.9% reporting “nearly every day.” These questions originated from the GAD-2. Approximately a third of participants (36.1%) reported their mental health was “not good,” which includes, stress, depression, and problems with emotions for at least half the days or more out of the past 30 days.

These findings reveal the need to assure there are adequate communication modalities quickly made available in family shelter settings to improve access to health and clean-up messaging. This should include first making available or improving broadband service, as well as targeting radio, television, and written communication for consumption of shelter residents to increase the capacity for relaying important information that will allow households to communicate and receive messages more effectively. Expanding this to community-level activity may also increase preparedness levels prior to another public health emergency, as communities will be better equipped to receive targeted messaging and communication.

Challenges in receiving messaging from sources such as the internet, cellular services, or broadband internet during disasters in rural communities make it imperative to think strategically about effective communication.^14,15 While larger structural changes are needed, such as increasing access to broadband in rural communities, it will also be important to think about technology disparities in ability to access computers and smart phones that differentially impact rural communities.^15,16 Using non-electronic forms of communication such as written materials and messaging from trusted community members may be a critical and more effective means of disseminating important information before, during, and after natural disasters.^17,18

Churches, FEMA, Red Cross, family, friends, and non-profit organizations provided some of the main sources of ongoing assistance to households living at shelter sites after the flood. Some of the main barriers households reported to receiving assistance included difficulty navigating the paperwork process and transportation. Providing more financial, organizational, and logistical resources to connect sources of support to families living at shelter sites may improve their short and long-term recovery conditions.¹⁹ On a larger scale, a key component to disaster preparedness is a need for adequate resources to support preparedness efforts, which includes support for planning, housing resource centers, staffing, trainings, exercising preparedness plans, and improving technical assistance for disaster relief.¹⁹

Households living at shelter sites experienced worse overall health and physical health conditions than before the flood event, such as allergies, asthma, high blood pressure, and COPD. Additionally, many households experienced worsened emotional and mental health conditions like nightmares, difficulty concentrating, agitation, and loss of appetite. Individuals also reported recent feelings of depression, anxiety, and overall problems with mental health. While some households at shelter sites reported seeking behavioral health services and grief counseling, primarily from a licensed therapist, there was also a higher preference for counseling in-person and locally if mental health assistance was ever needed, followed by telehealth.

These findings show a need for access and availability to physical and mental/behavioral health services for household members living at shelter sites. Planning for surge capacity and assuring that mental health resources are available and accessible for families in shelters soon after disaster events is recommended to address the concerns raised by this survey. Targeted social media campaigns, educational resources, and efforts made through trusted sources like churches, non-profit organizations, and schools are avenues to address overall health (including mental health) in disaster situations¹⁹ for families with no recourse other than shelter living for extended periods.

Improving access to communication and messaging, housing assistance and logistical resources, and physical and mental health resources are all avenues to ensure communities are prepared to respond and recover from disasters. Partnership and efforts from the Kentucky Department for Public Health and community partners from Pathways, Mountain Comprehensive Care Center, and University of the Cumberlands were integral in conducting the work described in this paper. These results may be used to help improve future communication messaging, promote the public’s health, and strengthen preparedness capacity of eastern Kentucky as well as other rural communities. This work may inform insights into allocating resources for future flooding events and evaluating and implementing best practices for communication, resources, and physical, and mental health services in disaster shelter settings.