Examining Hurricane Helene Flooding Vulnerabilities and Health Disparities in Southern Appalachia

Publication Date: 2026

Abstract

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This convergent, mixed methods study examined the spatial, physical, and psychosocial impacts of flooding from Hurricane Helene in Southern Appalachia. Integrating county-level geospatial analysis (n = 22 counties), a survey of community members (n = 700), and workshops with public health and emergency response professionals (n = 20), the study aimed to: (a) map flood exposure and vulnerability across rural and urban areas in the region; (b) identify physical and mental health impacts and the risk and protective factors associated with outcomes; and (c) assess public health and emergency management officials’ perceptions of essential community needs for addressing flooding and health risks in the region. Geospatial analyses identified areas within the high precipitation zones facing elevated risks due to greater flood inundation, flood damaged landscapes, road closures, population density, and higher social vulnerability. Survey results showed that environmental contaminant exposure (e.g., visible mold, sewage, contaminated water) was the strongest predictor of adverse physical health symptoms, while cumulative flood exposure and post-flood stressors were key drivers of mental health symptoms (e.g., post-traumatic stress disorder, depression). Qualitative findings from public health and emergency management officials highlighted essential needs including logistical coordination gaps, communication and information challenges, inequities in access for vulnerable populations, mental health strain among responders, and the need for strengthening preparedness and long-term recovery infrastructure. Together, these findings underscore the importance of convergent and comprehensive approaches that integrate geospatial and health data, with input from public health and emergency management officials, to address the complex impacts of hurricane-induced flooding and guide future preparedness, response, and recovery strategies across the Southern Appalachian region.

Introduction

On the night of September 26, 2024, Hurricane Helene made landfall along Florida’s Big Bend region as a Category 4 storm, before tracking northward through the southeastern United States. As the system moved inland, its remnants produced catastrophic rainfall and flooding across Southern Appalachian communities in North Carolina, South Carolina, Georgia, Tennessee, and Virgina. Devastating, inland flash- and river flooding occurred across the southern Appalachian Mountains, as mountain elevation effects enhanced precipitation rates to even greater levels than expected, and funneled runoff into surrounding valleys, roads, and populated towns (Office of Water Prediction, n.d.¹). The southern Appalachian region experienced the highest concentration of fatalities—more than 120 confirmed deaths across western North Carolina, eastern Tennessee, and southwestern Virginia—as well as prolonged power outages, communication failures, and severe disruptions to transportation, health care, and access to food and water (Faguy & Drenon, 2024²). With an estimated $78.7 billion in damages, Helene ranks among the costliest storms in U.S. history (Bittle, 2024³).

In response to the scale and complexity of these impacts, we designed a mixed methods study to examine the spatial, physical, social, and health impacts of Hurricane Helene-related flooding in the southern Appalachian region. Drawing on county-level geospatial analysis (n = 22 counties), a community-based survey with residents (n = 700), and workshops with public health and emergency response professionals (n = 20), this study aimed to: (a) assess patterns of flood exposure and social vulnerability across rural and urban settings; (b) identify the physical and mental health impacts of the disaster and the risk and protective factors influencing these outcomes; and (c) capture perspectives of local officials on community needs and opportunities for improving flood-related health disparities in the region.

Literature Review

Flooding events like Hurricane Helene present a multi-faceted threat to human health. Previous studies have highlighted the physical health risks associated with flooding, including the transmission of waterborne diseases, such as leptospirosis and gastrointestinal infections, which can occur in areas with contaminated drinking water. In addition, stagnant floodwaters can become breeding grounds for mosquitoes, increasing the risks for vector-borne diseases like West Nile and Zika viruses, particularly in warm, humid regions (Zhong, et al., 2018⁴). Furthermore, the damp conditions that follow flooding foster the growth of mold in homes and buildings, which can lead to respiratory conditions such as asthma and bronchitis (Zhong, et al., 2018). In addition, research on post-flooding mental health outcomes has found that residents experience elevated levels of depression, anxiety, and post-traumatic stress disorder (PTSD), particularly in areas with the greatest flood exposure (e.g., injury, displacement, loss of property, or loss of loved ones) (Keya et al., 2023⁵).

A critical factor influencing health outcomes from flooding is social vulnerability, which refers to the varying levels of risk and resilience that individuals and communities face due to physical, social, and economic conditions (Cutter et al., 2003⁶; Deziel et al., 2023⁷; Tierney, 2014⁸). Social vulnerability recognizes that not all populations are equally exposed to flood risks or have the resources to mitigate their impacts. However, these disparities do not exist in isolation and are shaped and reinforced by broader structural systems that influence exposure to risk, capacity to respond, and ability to recover over time (e.g., land use planning, transportation access, housing stability, healthcare availability, and investments in flood mitigation). For example, Hurricane Katrina in New Orleans exposed and exacerbated existing systemic inequalities that led to unequal health outcomes during and after hurricane-related flooding. Specifically, low-income and Black residents without access to a vehicle or alternative evacuation routes were unable to leave low-lying, flood-prone areas which increased their direct exposure to life-threatening conditions (Sanchez et al., 2008⁹). Additionally, those lacking financial resources, such as savings or insurance, struggled to recover from the damage caused by Hurricane Katrina, making them more susceptible to long-term health impacts, including chronic stress, respiratory issues from untreated mold, and adverse mental health (Keya et al., 2023; Lichtveld et al., 2020¹⁰; Lowe et al., 2014¹¹; Rhodes et al., 2010¹²). In fact, rates of PTSD, depression, and anxiety were highest among low-income and racial minorities, as they were more likely to experience displacement, loss of loved ones, and economic hardship following Katrina (Sastry & VanLandingham, 2009¹³; Toldson et al., 2010¹⁴). Vulnerability is therefore a dynamic process that evolves over time and across different contexts and geographies (Terti et al., 2014¹⁵).

Despite extensive research on the health impacts of flooding, there is a critical gap in knowledge about the unequal distribution of flood risk and impacts across social groups and contexts, especially within non-coastal communities (Flores et al., 2024¹⁶). Even less is known about hurricane-related flooding in non-coastal, rural and mountainous areas, like Appalachia. Research is needed on the flood exposure, social vulnerability, and health outcomes of populations in these areas because they are increasingly impacted by hurricane-related flooding. The overall purpose of this study was to collect critical insights into the spatial, temporal, and contextual factors of flooding and health outcomes affecting Appalachian communities impacted by Hurricane Helene-induced flooding.

Research Questions

Our study was guided by three research questions:

1. What is the spatial extent of Hurricane Helene’s flooding impacts, and how do spatial patterns of flood exposure align with socio-structural vulnerability in the region?

2. What are the physical and mental health impacts of Hurricane Helene’s flooding, and what risk and protective factors are associated with these outcomes?

3. What do public health and emergency management officials perceive as essential needs for addressing flood and health disparities in the region, and how can geospatial, social, and health science methods converge to support current and future policies and practices to address these needs?

Research Design

Study Site and Context

This study focused on rural and urban populations in the Southern Appalachia region, which stretches across parts of North Carolina, South Carolina, Tennessee, Georgia, and Virginia. Southern Appalachia was disproportionately impacted by Hurricane Helene flooding. We used a variety of methods to examine the population’s vulnerabilities and health outcomes. First, we identified areas with flooding exposure and social vulnerability using geospatial analysis, combining satellite imagery, and socioeconomic data to pinpoint the areas with the greatest impacts. Next, we conducted a quantitative survey of residents in areas with high flood exposure and vulnerabilities to assess their flooding vulnerabilities and physical and mental health outcomes. Finally, we engaged local public health and emergency management officials to share findings and gather their experiences and perceptions on unmet needs through a series of online workshops.

Data Collection Methods

Geospatial

To answer the first research question, we combined five data sources in a geospatial analysis. Each of these datasets are described below.

Land-Cover Change Detection. Bare earth change detection was conducted using the Dynamic World dataset (Brown et al., 2022¹⁷), which classifies high resolution satellite imagery into nine cover types. Pre- and post-event periods were defined as April 1–September 1, 2024 (“Before”) and October 1–November 15, 2024 (“After”). The analysis focused on the bare ground class of land cover—which depicts areas devoid of vegetation and structures—to identify flood damaged areas in the landscape. Isolating changes to the bare ground class is useful for the detection of flooding impacts, as flood waters often scour vegetation and debris, exposing bare soil. Due to modeling confusion between the bare ground and built-up area (i.e., urban) classes, pixels classified as urban in the pre-hurricane classification were constrained as urban in the post-hurricane classification, thereby isolating changes to pixels classified as bare earth in both timepoints. We converted the localized change detections into an inverted distance layer to assign higher impact scores to areas closer to observed change.

Flood Inundation Mapping. Flood extent was characterized using a National Aeronautics and Space Administration (NASA) tool—the synthetic aperture radar-based inundation change detection product—which is produced by NASA’s Alaska Satellite Facility (2025¹⁸). This dataset identified developed land, vegetation, and cropland that had been flooded. Flooded classes were extracted from the dataset, and inverted distance-based layers were generated to create continuous surfaces across the study region. The inverse distance mapping approach first calculates the Euclidean distances from events (in this case flood detection areas) and then inverts these, such that higher values are assigned for locations nearer to events, enabling higher impact values to be associated with areas experiencing flooding.

Road Closure Data. Tabular road closure data with geographic coordinates were obtained directly from the Departments of Transportation in North and South Carolina (North Carolina Department of Transportation [NCDOT], 2024¹⁹; South Carolina Department of Transportation [SCDOT], 2024²⁰). Spatial point layers were generated, and a continuous road closure density surface was produced using tri-weight kernel density estimation. Data from Georgia were not available, but Georgia comprises only a small fraction of the study area.

Human Population Data. Human exposure was represented using population data from the LandScan USA dataset (Weber et al., 2022²¹), which provides gridded population estimates at 90-meter resolution. Population data were reclassified into four classes using a geometric transformation to reduce skewness and ensure balanced contribution during overlay analysis.

Social Vulnerability Data. Social vulnerability was assessed using the Centers for Disease Control and Prevention and the Agency for Toxic Substances and Disease Registry’s (CDC/ATSDR) Social Vulnerability Index (SVI) at the census block group level (Bryan, 2022²²). This index includes variables that cut across four themes: socioeconomic status, household characteristics, racial and ethnic minority status, and housing/transportation. For our analysis, we focused on the following variables: poverty, disability status, adults over age 65, and limited access to services. We joined SVI data to block group polygons and converted these to raster format (i.e., comprised of pixels) to enable overlays with the other project data layers. Afterward, a dasymetric mapping technique was used to enhance the spatial representation of the SVI data. Dasymetric mapping is used to refine coarse polygonal data (such as census polygons) using ancillary geographic information to better represent the true distribution of population within a geographic unit. To accomplish this the National Land Cover Database 2023 Urban Imperviousness dataset (U.S. Geological Survey, 2024²³) was used along with the LandScan USA dataset to mask out areas from the SVI layer that were extremely unlikely to contain human inhabitants. Afterward, a fishnet of 1-kilometer grid cells was overlayed on the SVI grid, and the mean was calculated based on the values of the masked SVI grid to produce the final input layer.

Survey

To answer the second research question, we used an online survey of residents (n = 700) living in Southern Appalachian to gather information on their health impacts from Hurricane Helene’s flooding and the risk and protective factors associated with health outcomes. Survey participants were recruited from county areas with the highest amounts of Helene-related precipitation (e.g., greater than 10 inches) via a third-party platform, Marketing Systems Group, from a pool of U.S. adults who volunteered to be in online research via the company. Recognizing that residents may still be engaged in recovery efforts and experiencing emotional hardships, we designed the survey to be concise, approximately 10-15 minutes in length, and provided participants with a list of available health and community support services, such as crisis helplines and community recovery programs. Survey data were collected January 20- February 6, 2025, approximately three months post-Hurricane Helene.

The survey included the following questions adapted from prior flooding and disaster studies (i.e., First, Yu et al., 2021; Flores et al., 2020²⁴):

Physical Health Problems. We assessed physical health problems based on respondents’ answers to 15 items (see section of Table 1, labeled as Physical health problems) about experiencing physical health issues during or any time after Hurricane Helene. Responses were summed from binary yes/no responses to create a continuous variable representing the total number of reported physical health problems, with higher scores indicating greater overall health burden.

Contaminant Exposure. We assessed contaminant exposure based on respondents’ binary yes/no responses to four items that asked about experiencing exposure to sewage, debris, dirty or contaminated flood water, and visible mold in the first month after Hurricane Helene flooding.

Flood Event Exposure. We assessed flood event exposure based on respondents’ binary yes/no responses to seven items (see section of Table 1 labeled as Flood event exposure) asking if they experienced these events during or soon after Hurricane Helene. Responses were summed to create a continuous variable with higher scores indicating greater overall flood event exposure.

Post-Flood Stressors. We assessed post-flood stressors based on respondents’ binary yes/no responses to 13 items (see the section of Table 1 labeled Post-flood stressors) asking if they experienced these events during or soon after Hurricane Helene. Responses were summed to create a continuous variable with higher scores indicating greater overall post-flood stressors.

Medical and Social Resources. We assessed medical and social resources from related subdomain questions from the Disaster Adaptation and Resilience Scale (DARS) (First, Yu et al., 2021). Participants were prompted to think about the most recent disaster event and to report if they possess a specific protective factor (e.g., medical resources, family, friends, or community support) on a 5-point Likert scale ranging from 0 = not at all true to 5 = true nearly all the time.

Mental Health. We assessed PTSD symptom severity using the PTSD Checklist–Civilian Version (PCL-C; Weathers et al., 1993²⁵), a 17-item scale with scores ranging from 0 to 80. Participants fell into three symptom levels: Minimal (0-17), Mild (18-29), and Moderate to Severe (30+). A score of 30 or higher is considered the cutoff at which a PTSD diagnosis is likely (Weathers et al., 1993). We assessed depression symptom severity using the Patient Health Questionnaire–2 (PHQ-2; Kroenke et al., 2003²⁶), with scores ranging from 0 to 6. Participants fell into three symptom levels: Minimal (0–1), Mild (2), and Moderate to Severe (3+). A score of 3 or higher is considered the cutoff at which major depressive disorder is likely (Kroenke et al., 2003).

Demographic Information. The survey included measures for assessing respondents’ gender, race, ethnicity, employment, age, income, education, and housing structure.

Additional Measures. The survey had three open-ended, qualitative questions on current unmet needs following Hurricane Helene for use in future studies.

Local Workshops

To inform the third research question, we conducted workshops with individuals engaged in Hurricane Helene response and recovery across North Carolina and Tennessee—states that experienced the highest number of flood-related fatalities. Participants included frontline responders—such as emergency managers, public health officials, fire and rescue, and law enforcement—as well as organizational representatives from non-governmental and state agencies. We recruited participants using a combination of professional networks, public directories of Voluntary Organizations Active in Disaster (VOADs), and agency websites. Snowball sampling expanded our participant pool, and potential participants received email invitations two weeks before the workshop series, with follow-up reminders issued closer to the scheduled sessions. Participants were given the option to choose a time that best aligned with their schedules.

We held three virtual workshops via Zoom, each approximately 90 minutes in length and conducted eight months after Hurricane Helene. Each workshop began with introductions and a brief overview of findings from our geospatial and survey data, followed by a semi-structured discussion using an interview guide developed by the research team. We designed the discussion guide to elicit perspectives on health and flood disparities in the region, grounded in their lived experiences during response and recovery. Questions explored topics such as what worked and what did not during the response; the role of data and information sharing; challenges in reaching rural or vulnerable populations; responder well-being; and strategies for strengthening coordination, preparedness, and recovery efforts. We recorded all sessions with participant consent, and automated Zoom transcripts were generated. In addition, researchers took detailed notes throughout.

Data Analysis

Geospatial Analysis

We used a multiple criteria evaluation (MCE) approach (Carver, 1991²⁷) to develop a spatially explicit model depicting the areas most impacted by Hurricane Helene. MCE integrates multiple standardized data layers in a weighted overlay to produce a single impact surface, enabling systematic comparison across diverse input variables. All data layers were resampled to a common resolution (20 meters) and their values converted to a common scale (in this case 0 to 100). As Figure 1 shows, we then used weighted overlays to produce maps depicting the human and physical impacts resulting from Hurricane Helene. In the MCE framework, the weights for the different input variables must add up to 1 (or 100%), and weights for each variable can be adjusted based on expert knowledge, criterion importance, or decision-making objectives. Since assigning weights in MCE involves some degree of subjectivity, and given the scope of the current study, the mapping scenario given here depicts the result where equivalent weights were assigned for all five spatial input layers (i.e., 0.20 for each of the five layers, see Figure 1). Additionally, the results were aggregated to the county level for discussion use in our workshops.

Figure 1. Multi-Source Data Layers Used to Spatially Depict Physical and Social Impacts From Hurricane Helene

Survey Analysis

We conducted all weighted analyses using the Complex Samples module in SPSS (Version 29), which accounts for complex sampling design and uses Taylor Series Linearization for variance estimation to ensure that results accurately reflect the underlying population distribution. To assess the prevalence of adverse health outcomes following Hurricane Helene, we calculated weighted frequencies and percentages for individual symptom items. Next, we conducted multiple linear regression analyses to identify predictors of adverse physical and mental health outcomes. Separate weighted regression models were estimated for physical and mental health outcome scores as continuous dependent variables.

Workshop Analysis

We used an inductive qualitative coding approach to analyze the transcripts and notes from the workshops and six researchers conducted an initial review of transcripts and notes. Three researchers independently generated and reviewed initial codes. We then refined these codes collaboratively and developed an initial coding structure. Four researchers reviewed and clustered codes into emerging themes, which were further refined and finalized through full-team discussion involving all six members.

Ethical Considerations and Researcher Positionality

This project was reviewed and deemed exempt by the University of Missouri and University of Nebraska Medical Center Institutional Review Boards. The research team was composed of eight members with interdisciplinary expertise spanning public health, social work, environmental and atmospheric science. Team members were based across the Southeastern and Midwestern United States, and several held personal or professional ties to communities affected by Hurricane Helene. Although none of the researchers resided in the directly impacted areas at the time of the storm, many had close geographic and emotional connections to the region through family roots, long-standing collaborative projects, or previous lived experience. As a team, we approached this work with a commitment to reflexivity, recognizing that our positionalities shaped by academic training, institutional affiliations, and regional locations could influence how we framed and interpreted knowledge. We acknowledged our status as geographic outsiders and emphasized transparency and centering community perspectives through listening and open dialogue. This approach aimed to foster the co-production of knowledge grounded in local lived realities.

Results

Geospatial Results

Based on weighted overlays, our geospatial results produced maps depicting physical and social impacts resulting from Hurricane Helene-induced flooding. Figure 2 shows areas characterized by high flood exposure, population density, and elevated social vulnerability (e.g., poverty, disability and aging populations, and limited access to services).

Figure 2. Physical and Social Impact Scores of Flooding From Hurricane Helene in Southern Appalachia

Figure 3 shows the physical and social impact scores aggregated at the county level. As the figure depicts, counties such as Yancey, Mitchell, Avery, Watauga, Ashe, Alleghany, Henderson, Pickens, and Greenville were among those with the high composite impact scores. While all the areas mapped in Southern Appalachia experienced extreme precipitation, some counties experienced greater flood inundation, more extensive road closures and damage to critical infrastructure, and had higher pre-existing social vulnerability levels, compounding their risk profiles.

Figure 3. Physical and Social Impact Scores for Hurricane Helene Aggregated at the County Level in Southern Appalachia

Survey Results

Demographic and Descriptive Information

Our sample included 700 participants from South Appalachia communities exposed to Hurricane Helene-related flooding. The majority were 52.3% female, with ages distributed across 18–29 (17.6%), 30–44 (28.6%), 45–59 (30.1%), and 60+ (23.7%). The sample included 60.7% White (non-Hispanic), 32.1% Black or African American/Afro-Caribbean, 6.9% Hispanic/Latino, and 3.0% Asian/Asian American. Most lived in single-family detached homes and income levels were varied, with 26.0% reporting $25,000–49,999 annually and over 21% earning $50,000–74,999. Common post-flood health symptoms included headaches (36.9%), respiratory and skin irritations (16–30%), and gastrointestinal issues. Many participants reported contaminant exposures (e.g., debris 55.1%, floodwater 28.0%, visible mold 21.9%, sewage 15.9%) and post-flood stressors such as lack of electricity and financial or housing challenges. Mental health assessments indicated that 35.2% scored in the moderate to severe range for PTSD symptoms, while 27.5% had moderate to severe depression symptoms. Table 1 shows the full list of descriptive statistics for each survey measure.

Table 1. Descriptive Statistics for Survey

Risk and Protective Factors Predicting Health

We conducted three separate multiple regression models to examine risk and protective factors associated with physical and mental health symptoms following Hurricane Helene. Table 2 shows the results of the regression analysis for physical health outcome. The independent variables included in the model were demographic characteristics (age, gender, race, ethnicity, disability status, and household income), risk factors such as environmental contaminant exposures related to Hurricane Helene flooding (sewage, debris, contaminated floodwater, and visible mold), and protective factors including access to medical professionals and services. The overall regression model is statistically significant, F(10, 689) = 45.30, p < .001, and explains approximately 40% of the variance in physical health symptoms, R² = .404, Adjusted R² = .395. Risk factors for poor physical health included female gender, sewage exposure, debris exposure, dirty or contaminated floodwater exposure, and visible mold exposure. Notably, visible mold exposure had the largest standardized effect with adverse physical health. In terms of protective factors, access to medical professionals and services decreases adverse physical health. Age, race, ethnicity, income, and long-term illness or disability are not significant covariates in the model (p > .05).

Table 2. Variables Associated With Adverse Physical Health Outcomes Following Helene

Next, we examined risk and protective factors associated with mental health outcomes. Table 3 shows the results of the regression analysis for variables associated with PTSD outcomes following Hurricane Helene. The overall model is statistically significant, F(9, 690) = 106.46, p < .001, and explained approximately 58.1% of the variance in PTSD symptoms (R² = .581, Adjusted R² = .576). Among the independent variables, flood event exposure and post-flood stressors are statistically significantly associated with PTSD outcomes. In terms of protective factors, greater levels of social resources are significantly associated with lower PTSD symptoms indicating a protective effect. Demographic variables—including age, gender, race, ethnicity, household income, and disability status—were not statistically significant variables in the model (p > .05).

Table 3. Variables Associated With PTSD Outcomes Following Helene

Lastly, as shown in Table 4, we examined the relationships among risk, protective factors, and depression symptom severity. The overall model is statistically significant, F(9, 690) = 71.10, p < .001, and explained 48.1% of the variance in depression symptoms (R² = .481, Adjusted R² = .474). Of the risk factors, flood event exposure and post-flood stressors were positively associated with depression severity. Age was also a significant variable, with younger respondents reporting more severe depressive symptoms. In terms of protective factors, having more social resources was associated with lower depression symptoms, indicating a protective effect. All other demographic variables—including gender, race, ethnicity, income, and disability status—were not statistically significant (p > .05).

Table 4. Variables Associated With Depression Outcomes Following Helene

Workshop Findings

Demographic and Descriptive Information

Of the three workshops, two included seven participants and one included six, for a total of 20 participants. Participants came from a range of organizational levels and service areas. Half (50%) were affiliated with state-level agencies, while 22% worked at the county level, 17% at the national level, and 11% served in regional or multi-county capacities. Most participants (88%) were based in North Carolina, which experienced the highest number of flood-related deaths during Hurricane Helene. Participants represented a range of professional sectors, including public health (28%), emergency management (22%), social services (17%), and VOADs (33%).

Workshop Themes

To answer the third research question, we conducted a thematic analysis of workshop transcripts. Findings revealed five overarching themes related to response experiences, perceived needs, and recommendations for improving health and flood-related disaster preparedness and recovery. Each main theme is listed below supported by sub-themes and illustrative participant quotes.

Theme 1: Operational Strengths and Gaps in Response Logistics. Participants described both effective logistical strategies and persistent challenges in coordinating volunteers, donations, and resources. Effective response strategies included the use of local volunteer resource centers, informal collaboration among agencies, and real-time site coordination. Strong local relationships enabled rapid coordination, with examples including pre-existing collaborations and flexible non-governmental organizations (NGOs) and VOADs. Some participants reported developing creative volunteer management systems in response to the influx of people and resources, including resource centers and signup portals. One participant noted, “Local volunteer resource centers and strong informal collaboration helped coordinate supplies and services,” while another highlighted the role of digital tools: “Social media, mapping, and centralized websites were used successfully for resource visibility.”

However, there were many logistical challenges. On the one hand, an influx of people wanting to help and donations came into the area in the immediate aftermath of Hurricane Helene. On the other hand, donations were wasted with poor coordination, and impacted residents continued to need help and services long after volunteers returned home. Other issues with volunteers were related to “self-deployers” (e.g., individuals who arrive at a disaster site to assist without an official response organization or integrated into the formal incident command system). As one participant said, “The problem with volunteers was that they showed up without warning. We had hundreds of people here and no housing, no job for them. It became chaos.” However, these self-deployers were still important components of the response and recovery efforts, and a need for better coordination and organization was identified. Others emphasized challenges in managing donations: “We had tons of donated supplies…food, clothes…but no storage. By the time we figured it out, a lot of it had expired.” Finally, other challenges included delayed federal and state aid (e.g., SNAP, energy vouchers, housing vouchers) and inadequate logistics pre-disaster (e.g., emergency equipment stored in flood zones, swift water rescuers needing swift water rescue).

Theme 2: Information Access, Communication, and Data Use. Many workshop participants noted that communication and information for action was a recurring theme, encompassing both strengths and failures. Some communication strategies and data tools were viewed positively. For instance, participants praised social media and community radio for their role in disseminating real-time information in some communities. Many noted that many tools, such as Geographic Information Systems (GIS) layers, and Department of Health and Human Services (HHS) Empower data, were available in real-time and put to use in practical and innovative ways: “GIS mapping tools were valuable for identifying at-risk areas and vulnerable individuals.” However, many of the failures in communication and information systems included the lack of centralized and interoperable systems, the absence of redundancy in these systems, and general technology limitations. There is a need for more robust and accessible GIS data, especially for identifying locations of certain vulnerable populations and providing visibility into disconnected individuals. Participants also described how power outages and outdated contact lists left some communities and responders disconnected. One participant recalled, “When the power went out, we lost everything. No phones, no internet, no radio. We didn’t even have walkie-talkies. It was terrifying.” Others highlighted the need for centralized information systems: “We didn’t know who to contact. The directory was outdated, and everyone kept pointing fingers. A centralized hub could’ve helped.” Updating points of contact frequently, having a centralized source of resources and information hub on these resources, and redundant communications are ongoing challenges and clear priorities for preparing for future events.

Theme 3: Equity and Access for Vulnerable Populations. Participants emphasized the disproportionate impacts of Hurricane Helene on vulnerable populations, both in terms of individual characteristics and geographic location. Specific groups identified in this category include the deaf and hard of hearing, older adults, foster children, and veterans with PTSD. “We had no way to reach the deaf community. They didn’t hear the alerts, and many didn’t know where to go for help,” said one participant. Older adults often needed help but would not ask for it or accept it, if offered, out of pride—often noting that others had greater need than themselves. One participant noted, “There were older folks who needed help but refused it. They didn’t want to be a burden. We need to build trust long before the storm hits.” Trauma-informed and culturally responsive approaches to preparedness and response were needed. The use of trusted intermediaries may have improved disaster response and recovery outcomes among these populations.

Rural and isolated communities also faced unique challenges. Many hard-to-reach communities were reluctant to seek help due to disaster fatigue and skepticism related to past negative experiences. Others noted that these communities felt overlooked and were hard to reach due to impacted roads and communication systems. Supplies were often delayed and outreach was limited. These communities also tended to lack local resource hubs. As one participant noted, “The rural areas were hit hard, and they were the last to get supplies. We need to stop treating them like an afterthought.” Overall, participants agreed that engagement with these communities is critical before disasters occur.

Theme 4: Mental Health, Burnout, and Well-Being Among Responders. The mental health impacts experienced by responders emerged as a distinct and urgent concern. Many participants described burnout, trauma, and a lack of behavioral health support, while others noted that behavioral health needs among responders were often under-prioritized and resources under-utilized. Stigma around seeking mental health support was mentioned which further compounded these challenges, contributing to delayed or unmet mental health needs and contributing to burnout. Many noted that burnout was associated with long hours, insufficient staffing and the dual burden many responders faced dealing with the impacts of the disaster on their own homes and families. One responder shared, "Some of us were working 18-hour days for weeks. People were crying in closets just to get a moment alone. It was too much." Some participants noted some significant supportive practices, including access to chaplains and emotional and spiritual care committees. However, while these resources were present in some locations, other participants emphasized the need for trained mental health professionals during and after disaster response: “We had chaplains, but we also needed more mental health professionals. The trauma didn’t end when the storm did.” Other needs that were discussed included informal peer support and mental health check-ins.

Theme 5: Strengthening Preparedness and Recovery Infrastructure. Many themes emerged related to important areas in developing convergent solutions, such as preparedness and recovery infrastructure. These include better coordination and clarity of roles in response and recovery situations; the need to develop permanent resource hubs in advance of a disaster; earlier, equity-focused distribution of supplies, including pre-positioning supplies and identifying distribution hubs in advance; strengthening 211 services for use in response and recovery; local data integration; and a focus on building pre-event relationships with rural communities to better support their needs. One county-level participant noted that a recent preparedness exercise related to shelter set-up allowed them to rapidly stand up their shelter to provide immediate services to those in need after Helene impacted their community. There is a need for more robust and inclusive preparedness and planning, particularly for catastrophic events. Existing tabletop exercises were seen as insufficient: “We’ve done tabletop exercises, but nothing prepared us for this scale. We need catastrophic-level training, not just small scenarios.” Long-term recovery infrastructure, such as local long-term recovery groups, was seen as critical but also challenged by being under-resourced and lacking formal authority. “Our long-term recovery group was essential, but we didn’t have funding or authority to lead. We had to beg for everything,” one participant explained. It was also noted that the NGOs and VOADs who were on site immediately post-Helene disappeared over time—a sustained presence of these organizations after the acute response phase is needed to ensure success. Others discussed ideas for future long-term recovery situations including transforming community centers into preparedness and response hubs.

Discussion

This study provides new insights into the complex, layered physical, health, and social impacts of Hurricane Helene-induced flooding in Southern Appalachian communities, using a convergent mixed methods approach including geospatial analysis, survey data on health outcomes, and qualitative insights from disaster officials and professionals. Our spatial analyses show that counties with high flood exposure and social vulnerability, such as elevated poverty rates, aging infrastructure, and limited access to services, experienced some of the most severe impacts. These findings are consistent with others (Meng et al., 2025²⁸; Miller & Foubert, 2025²⁹) and reinforce the critical need for place-based disaster planning that incorporates not only hazard models but also social and infrastructural risk indicators. Likewise, our workshop findings also reinforced the importance of addressing disparities, with participants describing disproportionate impacts on rural communities, older adults, people with disabilities, and those with limited financial means. Participants emphasized the need for integrated and comprehensive long-term recovery that addresses the various and multi-layered needs facing communities. These findings underscore the need for localized and coordinated approach to long-term disaster recovery that acknowledges the interconnected nature of individual, social, and community-level needs (Abramson et al., 2015³⁰; First, 2024³¹; Kintziger et al., 2023³²).

In terms of risk factors influencing health, our survey findings revealed that exposure to flooding-related contaminants (e.g., sewage, debris, contaminated floodwater, and visible mold) significantly predicted adverse physical health symptoms. These results are consistent with prior research showing that flooding events can compromise sanitation infrastructure and foster hazardous indoor environmental conditions (e.g., mold) which can have significant impacts on physical health (Flores et al., 2020). In terms of protective factors, survey participants who reported having access to medical professionals and health services experienced fewer adverse physical symptoms, indicating the critical role of accessible health care to protect against adverse health effects of flood-related exposures (Flores et al., 2024).

Additionally, our survey found that flood event exposure (e.g., injury, losses) and post-flood stressors (e.g., utility disruptions, displacement, and financial hardship) are significant predictors of PTSD and depression severity. These findings align with existing literature emphasizing that disaster exposure and cumulative post-disaster stressors further compound mental health outcomes, particularly in socially vulnerable populations (First, Ellis, et al, 2021³³; First & Lee, 2023³⁴; First & Houston, 2022³⁵; Flores et al., 2024). In terms of protective factors, social resources, such as support networks and community-based assistance, are important buffers against psychological distress both in survey responses and workshops. These results echo prior research showing that social support is one of the most consistent and powerful predictors of mental health recovery following disaster events (Bonanno et al., 2010³⁶; Kaniasty 2012³⁷; First, Yu, et al., 2021³⁸).

Conclusions

Implications for Policy or Practice

In terms of implications, findings from this study highlight the importance of integrating health, social, and spatial data to inform equitable flood preparedness, response, and recovery strategies in Southern Appalachia. Our geospatial analysis identified communities with compounded risk, including physical impacts from flooding but also high social vulnerability, population density, and long-term infrastructure disruption. From a policy perspective, these results reinforce the need to incorporate social vulnerability and exposure data into disaster planning and resource allocation frameworks. Federal, state, and local emergency management policies should prioritize pre-disaster investments in under-resourced communities, particularly in rural and socioeconomically disadvantaged areas. These investments should include not only physical infrastructure (e.g., housing, transportation, communications) but also the social infrastructure (e.g., community centers, local nonprofits) that support and sustain localized adaptation and recovery.

Likewise, our workshops further underscore the importance of community-centered strategies to strengthen flooding infrastructure, strengthen communication networks, and address inequities. Together with our survey results, these findings support the need for continued investment in medical and social resources for recovery, as they were essential protective factors against adverse physical and mental health outcomes. Strengthening health and social service infrastructure are core components of flood resilience-building efforts. As hurricane and climate-induced flooding events become more frequent and severe, sustained investment in critical infrastructure (e.g., communication, transportation, utilities, housing, healthcare, and social services) within at-risk communities is essential and a critical component of reducing long-term recovery costs and promoting population health. Our findings highlight the value of convergent approaches (Morss et al., 2021³⁹; Peek et al., 2020⁴⁰) integrating geospatial and health data, with local officials input to better understand the multifaceted impacts of disaster and flooding events and inform equitable and effective preparedness, response, and recovery strategies.

Limitations and Future Research Directions

As with all research, this study had multiple limitations. First, while we were able to utilize our geospatial analyses to target areas to sample for our survey results, our sample size and geographic scope limited the ability to provide direct statistical comparisons between the survey and geospatial variables. Future work could examine statistical relationships between geographic variables and health outcomes through larger sample sizes. Second, this study is cross-sectional in design and therefore the survey data collected precludes any claims of temporal order. Future research could improve on this limitation and employ a longitudinal design that collects data at multiple points of time. Third, while this study initiated the development of convergent, community-driven strategies to improve health and flood outcomes by engaging officials and professionals to define unmet needs, future work is needed to identify core solutions and validate findings through participant feedback and iterative, participatory methods.

References