Developing a survey instrument to assess flood health beliefs among residents of river flood zones in the Heartland




river flooding, Health Belief Model, environmental health, emergency management, instrument development, risk perception


Introduction: Flooding represents a significant health risk to residents of states bordering the Missouri and Mississippi Rivers. In Nebraska and Iowa, nearly 280,000 individuals live in floodplains that put them at higher risk for experiencing a flood. In Nebraska, 8.60 percent of residents live within floodplains, while in Iowa, 3.83 percent of residents live in floodplains.1 Flooding poses immediate risks including injury and loss of life, but it additionally threatens longer-term impacts due to increased exposure to environmental health risks and damage to physical and social infrastructure.2,3 Health education interventions depend on risk communication based on accurate knowledge of the health beliefs of at-risk individuals. This paper outlines the development of a survey instrument designed to solicit flooding health beliefs of individuals living in river flood zones.

Methods: This study developed the survey instrument through a series of revisions designed to increase the construct validity of the data collected. These steps included item sourcing and modification, expert review, and cognitive interviewing. Content for the initial survey draft was sourced from existing flood risk survey instruments and other standardized demographic surveys.4-8 This study then validated the instrument through sequential expert review and cognitive interviewing, collecting and conducting qualitative analysis of data collected through each phase.

Results: Themes from the expert review include (1) improvement of the user experience through revision of response categories and removal of unnecessary structural elements, (2) improvement of construct representativity through attentiveness to existing flood preparedness policies in the Heartland, and (3) streamlining of data analysis through revision and clarification of item prompts and responses. Themes from the cognitive interviewing include (1) the addition of items soliciting respondents’ awareness of their flood risk as well as open-ended items soliciting respondents’ existing personal flood plan components, (2) revision of existing demographic items to solicit respondents’ estimated—rather than exact—household income, and (3) clarification of our definition of a flooding event.

Discussion: This study adapted existing survey items into an instrument designed to gather data on respondents’ flood health beliefs and relevant demographic characteristics, producing a developed instrument that can be used to measure a population’s flood health beliefs with reasonable evidence of validity. This instrument may be further tested by gathering baseline data and conducting psychometric testing to determine which items wield significant influence over respondents’ decision to develop a personal or household flood plan.9 Additionally, this study provides a model for risk communication professionals seeking to adapt existing survey items to develop instruments designed to gather data on locally relevant health outcomes.10

Author Biographies

Kevin Boes, MPH Candidate

Creighton University School of Medicine, Omaha, Nebraska

Dhitinut Ratnapradipa, PhD

Creighton University School of Medicine, Omaha, Nebraska

Timothy C. Guetterman, PhD

University of Michigan School of Medicine, Ann Arbor, Michigan

References 2017. Available at Accessed March 1, 2021.

Chakraborty J, Collins TW, Grineski SE: Exploring the environmental justice implications of Hurricane Harvey flooding in greater Houston, Texas. Am J Public Health. 2019; 109(2): 244-250. DOI: 10.2105/AJPH.2018.304846.

Frumkin H: Healthy buildings. In Frumkin H (ed.): Environmental Health—From Global to Local. 2nd ed. San Francisco: Jossey-Bass, 2010: 689-728. DOI: 10.4159/9780674246102.

Musacchio A, Andrade L, O’Neill E, et al.: Planning for the health impacts of climate change: Flooding, private groundwater contamination and waterborne infection—A cross-sectional study of risk perception, experience and behaviors in the republic of Ireland. Environ Res. 2021; 194: 1-15.

O’Neill E, Brereton F, Shahumyan H, et al.: The impact of perceived flood exposure on flood-risk perception: The role of distance. Risk Anal. 2016; 36(11): 2158-2186.

United States Census 2020: 2020. Available at Accessed October 19, 2021.

Ware Jr JE, Snow KK, Kosinski M, et al.: SF-36 Health Survey Manual and Interpretation Guide. Boston: RAND Health Program, 1993. Available at Accessed April 5, 2023.

Centers for Disease Control and Prevention (CDC): Behavioral Risk Factor Surveillance System Survey Questionnaire. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2019.

Thorndike RL: Applied Psychometrics. Boston, MA: Houghton Mifflin, 1982.

Glanz K, Rimer BK, Viswanath K (eds.): Health Behavior and Health Education: Theory, Research, and Practice. Hoboken: Jossey-Bass, 2008.

Ratnapradipa D, Cardinal C, Ratnapradipa K, et al.: Implications of Hurricane Harvey on environmental health in Harris County, Texas. J Environ Health. 2018; 81(2): 24-32.

Ludy J, Kondolf GM: Flood risk perception in lands “protected” by 100-year levees. Nat Hazards. 2012; 61(2): 829-842. DOI: 10.1007/s11069-011-0072-6.

Lemée C, Fleury-Bahi G, Krien N, et al.: Factorial structure of the coastal flooding risk perception and validation of a French coastal flooding risk evaluation scale (CFRES) for non-experts. Ocean Coast Manag. 2018; 155(January): 68-75. DOI: 10.1016/j.ocecoaman.2018.01.030.

Siegrist M, Gutscher H: Flooding risks: A comparison of lay people’s perceptions and expert’s assessments in Switzerland. Risk Anal. 2006; 26(4): 971-979. DOI: 10.1111/j.1539-6924.2006.00792.x.

Sheffield PE, Landrigan PJ: Global climate change and children’s health: Threats and strategies for prevention. Environ Health Perspect. 2011; 119(3): 291-298. DOI: 10.1289/ehp.1002233.

Landrigan PJ, Schechter CB, Lipton JM, et al.: Environmental pollutants and disease in American children: Estimates of morbidity, mortality, and costs for lead poisoning, asthma, cancer, and developmental disabilities. Environ Health Perspect. 2002; 110(7): 721-728.

Marmot M, Wilkinson RG: Social Determinants of Health. Oxford: Oxford University Press, 1999.

O’Sullivan GA, Yonkler JA, Morgan W, et al.: A Field Guide to Designing a Health Communication Strategy. Baltimore: Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs, 2003.

Messick S: Validity of psychological assessment: Validation of inferences from persons’ responses and performances as scientific inquiry into score meaning. Am Psychol. 1995; 50(9):

-749. Available at Accessed February 8, 2022.

NOAA NOS: What is storm surge? Available at Accessed September

, 2020.

Lo AY, Chan F: Preparing for flooding in England and Wales: The role of risk perception and the social context in driving individual action. Nat Hazards. 2017; 88(1): 367-387. DOI: 10.1007/s11069-017-2870-y.

Beatty PC, Willis GB: Research synthesis: The practice of cognitive interviewing. Public Opin Q. 2007; 71(2): 287-311. DOI: 10.1093/poq/nfm006.

Kuckartz U: Qualitative Text Analysis: A Guide to Methods, Practice and Using Software. New York, NY: Sage Publications, Inc., 2014.

NOAA: Severe weather 101—Floods. Available at Accessed February 16, 2022.

Peled Y: Language barriers and epistemic injustice in healthcare settings. Bioethics. 2018; 32(6): 360-367. DOI: 10.1111/bioe.12435.

CDC/ATSDR SVI Fact Sheet: Available at Accessed March 25, 2022.

Larson PS, Gronlund C, Thompson L, et al.: Recurrent home flooding in detroitMI 2012–2020: Results of a household survey. Int J Environ Res Public Health. 2021; 18(14): 7659. DOI: 10.3390/ijerph18147659.