Introduction
Flood hazards are becoming more frequent and severe, resulting in significant loss and damage and negative mental and physical health impacts.1 Across the Midwest Great Plains region (i.e., Nebraska, Kansas, Iowa, Missouri, South Dakota) alone, 33 flood disasters have occurred, with losses exceeding $1 billion, since 1980. Fifteen of these events occurred in the last decade.Reference Smith2 These events have shown that inland floods result in adverse health impacts, including accidental injury, drowning, exposure to waterborne and infectious diseases, hypothermia, mental health impacts, and death.
Underinvestment in flood preparedness, particularly in rural communities, has led to great losses and decreased community resilience. Following the 2019 Nebraska floods, limited engagement and apathy in preparedness activities, the widespread nature of flooding, infrastructure damage leading to isolation, language barriers, and inadequate communication from relief initiatives contributed to subpar response.Reference Calloway, Nugent and Stern3
Event Narrative
Winter Storm Ulmer swept through the Great Plains region from 8 to 16 March 2019, resulting in record-breaking damage across the region. Subsequent high temperatures led to a significant melt, with the still frozen ground impeding runoff and rainfall infiltration. An Emergency Declaration was issued in Nebraska on March 12 due to risk of inland flooding resulting from ice jams within the Platte, Loup, and Elkhorn Rivers. Flooding occurred swiftly through the Great Plains with high concentrations of damage within Nebraska. Three hundred-fifty miles of levees were damaged, agricultural land was inundated, and power outages occurred at well fields—impacting water production. Twenty-six Nebraska towns were under full or partial evacuation orders, while Fremont, Nebraska, was left completely surrounded by water. Due to excessive damage, Nebraska issued additional disaster declarations, with communities still facing recovery challenges more than 5 years after the event.Reference Lee, Tang and Nam4
Aims
Understanding flood response, emergency preparedness, and recovery efforts in the rural United States is key to rural resiliency and vital in the improvement of rural emergency preparedness and response. Therefore, the objective of this study was to assess emergency preparedness and satisfaction with flood response, recovery, and relief efforts 5 years following the 2019 flooding in Nebraska.
Methods
Thirteen affected communities were surveyed. Using stratified simple random sampling proportional to the rural community size, this study used Nebraska Geographic Information System (GIS) parcel data to select the sample population from the 13 communities; 850 households were invited to participate in the survey via postcard mailouts.
Two inclusion criteria were required for household participation in the survey: 1) respondent must be 19 years or older and 2) current occupants must have resided at the same property when the flooding occurred in 2019. Forty-three questions were included in the survey, offered in both English and Spanish. The survey included questions about household demographics, household preparedness, and household impact, as well as lived experiences of wellbeing and response efforts (see Supplementary Material).
Ethics Statement
Informed consent was obtained through an introductory paragraph on the postcards with the link and QR code to the REDCap survey. All questions were confidential and optional. This study, methods, and related materials were reviewed by the University of Nebraska Medical Center’s Institutional Review Board (#0395-24-EX) and were determined to be exempt under Category 2 of the US Department of Health and Human Services regulations for the protection of human subjects in research at 45CFR 46.
Survey Analysis
Survey analysis was conducted using SAS Enterprise Guide 8.4 (Cary, NC). Descriptive statistics, including prevalence estimates and 95% confidence intervals (CI), were calculated using the SURVEYFREQ procedure.
Results
A total of 34 households (4% response rate) responded to the survey. All households reported English as their primary language. Most households consisted of only participants over the age of 18 years (57.50%), and 65.63% of households surveyed reported being impacted by the flooding. Most households described the damage to their homes as none/minimal, reporting that they had no mandatory inspection of their homes. Many of those that did have damage to their home reported it took them 6 months or less to recover from the flood. Out of those that did report flood impacts, roughly 20% reported evacuating, with all sheltering with friends or family.
Preparedness
Households reported receiving flood warnings via word-of-mouth, including phone, text, or email from emergency personnel, family, friends, or neighbors. Around 24% of participants lost access to power and/or information services during the event. Households reported they knew how to receive information such as emergency alerts or warnings in a disaster (55.88%). Households reported text messages or phone alerts (79.41%) and internet or online news (64.71%) to be their preferred sources of emergency communication. Other preferred sources included television and emergency medical services radio. Most respondents reported their confidence in acting during a disaster as “moderate.” A higher proportion of participants impacted by the floods were more likely to say yes to utilizing flood preparedness lessons, classes, or educational materials compared to their counterparts. Household-reported level of emergency preparedness increased 35.71% following the flood.
Response and Recovery
When asked about post-flood assistance, 14.71% of participants reported receiving cleaning supplies and/or water. Other assistance received included food, help with repairs, and grants. Most participants rated post-flood assistance as “good” and “very good.” Some households reported needing assistance but not receiving any, and others reported needing help with clean-up, insurance, and a place to evacuate. Participants who reported flood impacts had more negative opinions about their experience with the Federal Emergency Management Agency (FEMA) compared to those not impacted, although most participants rated FEMA timeliness as “fair” and “good.” Participants who reported that they were impacted by the flood event had more positive opinions of non-governmental (e.g., families, churches, communities) response compared to their non-impacted counterparts. More impacted households knew of resources in their area that assist during flood events than their non-impacted counterparts (Figure 1).
Figure 1. Likert scale ranking of recovery initiatives. The graph shows the percentage of responses of very poor, poor, fair, good, very good, and excellent, for specific questions relating to respondents’ experiences with recovery initiatives following the 2019 Nebraska floods.
Physical and Mental Health
More households reported new or worsening mental health conditions following the flooding than physical health conditions. Participants whose households were impacted during the flooding of 2019 were more likely to have experienced new or worsening physical and mental health symptoms. However, when asked about households’ ability to carry out or participate in usual social activities, many reported their ability to be “good” or “very good” (Figure 2).
Figure 2. Likert scale ranking of physical and mental health following flood event. The graph shows the percentage of responses of very poor, poor, fair, good, very good, and excellent, for specific questions relating to physical and mental health following the 2019 Nebraska floods.
Future Flood Events and Flood Management
Impacted households reported being more likely to worry about future flood events, with most worrying “occasionally” to “all the time” while households not impacted reported worrying “rarely.” The majority (52.94%) of participants expressed worry about infrastructure failure when asked about future flood hazards, and 85.71% of respondents rated infrastructure repairs following the 2019 flood disaster as “good” or “worse” than before the flood. When asked what improvements participants would like to see regarding flood management in their area, most respondents discussed improved infrastructure like roads, levees, and dams, as well as improved funding for flood mitigation. Improved water drainage, repaired and regularly inspected dams and levees, and better roads were the most common infrastructure improvements households reported wanting to see. Most households (33.33%) reported that they felt the flood risk facing Nebraska was “not changing” or “slightly increasing” (33.33%). When asked about flood risk facing their specific community, households reported flood risks to their communities, specifically, were “not changing” (41.38%) or “slightly increasing” (27.59%).
Limitations
This study had a low response rate, limiting the ability to compare personal effects of the 2019 floods or other respondent characteristics. Given the 5-year period between the event and this study, recall bias could affect participant responses. This concern was mitigated by the criteria that all participants, regardless of self-reported effects, must have lived in the same residence during the floods at time of survey.
Discussion
Households impacted by the 2019 Nebraska flood emphasized a range of unmet needs extending beyond the immediate response phase. Findings underscore the urgent need for a more comprehensive and sustained response that not only addresses immediate shelter and safety, but also the long-term health and psycho-social needs of affected communities.
Communications
Respondents noted that inadequate communications about local, state, and federal resources contributed to confusion and distrust during the event. Poor trust in essential early warning systems can pose significant challenges to mitigating the impact of further disaster. Furthering warning system communication transparency, timeliness, clarity, completeness, and reliability was found to be critical in ensuring public trust of emergency communications, which in turn dramatically reduces the human health impact of disasters.Reference Holroyd, Oloko and Salmon5 Further, effective early warning systems rely on timely message dissemination and reception. Strong community engagement, risk perception, and understanding of emergency warning are crucial in ensuring participants take appropriate protective action to prevent hazards from becoming disasters.Reference Fakhruddin, Clark and Robinson6
In addition to early warnings, robust communication systems and community knowledge sharing have the ability to play an effective role in the post-crisis phase of a flood disaster. Sharing, utilizing, and assessing knowledge among community members, organizations, and emergency personnel facilitates improving the management of future crises. Integrating scientific knowledge with existing local knowledge of experiences and learned lessons can greatly support decision-making before, during, and after a crisis while increasing community resiliency.Reference Yousefi Mohammadi, Abbasi and Farhadian7 These considerations should be applied to all hazards. Addressing shortcomings in communications is vital for protecting rural communities from disasters and their human impacts. One of the ways to promote trust and build communication channels is through community-engaged resiliency planning to ensure that recovery efforts are inclusive and locally driven.
Mental Health
Our findings indicate a need for integrated mental health support both in the short- and long-term recovery phases. In our study, mental health impacts were exacerbated by the prolonged recovery period, and many respondents perceived being underserved once short-term relief efforts concluded. This is reflective of findings from other flood disasters,Reference Stanke, Murray and Amlôt8 as well as from rapid needs assessments after the 2024 Arbor Day tornado that impacted eastern Nebraska.Reference Scales and Kintziger9 These gaps highlight the need for a more robust mid- to long-term response to address the negative social and health outcomes resulting from catastrophic floods.
Infrastructure
The concerns around infrastructure failure in our study are reflective of the wider literature. Qiang (2024) found that there is great variability in critical infrastructure vulnerability across the U.S. While the predominance of studies highlighting critical infrastructure vulnerability is focused in urban and suburban areas where there is significant infrastructural density,Reference Qiang10 rural-urban designations do not necessarily capture the population-level impacts of these vulnerabilities. Inaccessibility and permanent damage from infrastructural failures resulting from disasters have severe ramifications for rural public health emergency response, including continuity of care for both acute and chronic health conditions. Given the potential inaccessibility of rural communities following flooding disasters, as well as the limited household-level preparedness reported in our study, reflection should be made to continue to address acute and chronic health conditions during disaster.
Improving Community Preparedness
Ongoing investment in rural community preparedness initiatives is essential for enhancing post-disaster outcomes. The majority (76.93%) of respondents would consider attending a flood preparedness course, and 79.16% believe they might benefit from such training. These findings underscore both the demand for and the perceived value of publicly accessible, disaster-specific preparedness education. Given that many participants report lacking fundamental preparedness measures (e.g., go-kits, evacuation plans, and communication strategies), it is critical for rural communities to prioritize public education on these topics. Strengthening local capacity to prepare for disasters can significantly reduce casualties during rural disasters.
Conclusions
While this work had a small sample size, the findings give important insights into the experiences, needs, and impacts related to the 2019 flood on communities in rural eastern Nebraska. This study offers preliminary insights that should inform future research and evidence-informed policy. Learning from and expanding on this study is critical as rural America faces unique social and physical risks while catastrophic flooding events continue to become increasingly recurrent. Future work should be scaled up to include more respondents to strengthen evidence of the unique impacts of flooding on rural communities.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/dmp.2026.10305.
Author contribution
Elizabeth Cole: conceptualization, methodology, investigation, formal analysis, data curation, writing—original draft, writing—review and editing, and visualization. Layhla Currier: conceptualization and writing—review and editing. Kristina W Kintziger: conceptualization, methodology, investigation, resources, writing—review and editing, supervision, and funding acquisition. Sarah Elizabeth Scales: conceptualization, methodology, investigation, writing—review and editing, supervision, and project administration.
Funding statement
Elizabeth Cole received funding for this work through the Summer Undergraduate Research Program at the University of Nebraska Medical Center.
Competing interests
None of the authors has potential conflicts of interest to declare, financial or otherwise.
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