In response to the COVID-19 pandemic, the City of San Antonio’s Emergency Operations Center created COVID-19 Community Health & Prevention (CHP) & Communications Teams with a goal to reduce the impact of COVID-19 on communities of color by providing timely and accurate COVID-19 prevention and testing information. The CHP Team uses an Equity Demographic Indicator Map created by the City’s Office of Equity. The CHP and Communications Teams focus on census tracts with the highest overall equity score. The Equity Atlas includes scores that range from 2 to 10 and are a combined score of race and income, indicating that the higher the number, the higher the concentration of both people of color and low income households in that census tract. A plan was developed in late March to establish a COVID-19 community outreach and communications initiative that would run from April 1, 2020 to December 31, 2020 to promote prevention and testing in San Antonio census tracts with high equity scores. This objective was revised in October 2020 to extend the initiative to March 31, 2021. The CHP & Communications Teams are led by Metro Health. The CHP Team staffing complement changed over the summer months as department response roles changed. During the summer, the CHP Team was redirected to assist with case investigations as COVID-19 cases surged. After additional staff were brought in to assist with case investigations and contact tracing, the CHP Team was redirected to community outreach in mid-August. While practicing COVID-19 precautions, the CHP Team engages residents where they are (shopping centers, car washes, laundromats, medical clinics, food pantries) and shares COVID-19 prevention and testing information in English and Spanish. The CHP Team also visits businesses, restaurants, apartment complexes, corner stores, faith based and non-profit organizations. The community outreach and education efforts are supported by communications via outdoor billboards, radio spots, video ads on gas station pumps, door hangers, bus shelter ads, and social media messaging in the target Census Tracts. The Metro Health Communications Team also initiated a campaign titled “What Will it Take?” referencing what will it take for the San Antonio community to return to social gatherings and activities with family and friends. The campaign includes well-known local music artists. In regards to outcomes, Metro Health’s October COVID-19 Epidemiology Report indicated a decrease of between 2.8% t o 21.7% in case rates from September to October in the targeted Census tracts where the CHP Team and communication efforts were implemented. Thus far, the success of the activities is based on the established trust in communities of color utilizing Metro Health’s Community Health Worker model that has been in place several years engaging residents on chronic disease prevention with a focus on reducing health disparities. In addition, San Antonio local artists giving their time and talent to help with community messaging is also a great local success.

The CDC has identified populations of color at higher risk of COVID-19 cases, hospitalizations,
and deaths. To reduce the impacts of COVID-19 on communities of color, the City of San
Antonio, Metropolitan Health District (Metro Health) implemented innovative approaches to
include utilizing Community Health Workers, the use of an Equity Demographic Indicator Map,
ArcGIS mapping App for field staff, input from the Department’s Health Equity Manager, and
local peer influencers and music artists to help with enhancing prevention messaging. The City’s
Office of Equity Demographic Indicator Map is an interactive tool that highlights the
demographics, disparities and some infrastructure distribution within the City of San Antonio. This
is a tool that city staff, community members, partners, and other decision makers can use to help
ensure that they are making data-informed decisions that address disparities across a variety of
indicators and improve access to opportunity for all San Antonio residents. The Metro Health
Equity Officer was also key in providing guidance in locations for COVID-19 testing and
community messaging. The Metro Health key activities are centered on Community Health
Workers and communication messaging to build public trust to help change behavior such as
wearing a face mask, practicing social distancing and getting tested. The initial make-up of the
community outreach efforts included Metro Health Community Health Workers, Parks and
Recreation, San Antonio Fire and Police Department staff. This innovative approach allowed for
a multi-city department approach to reach specific neighborhoods during the early community spread of COVID-19 in San Antonio. The use of Community Health Workers is not new and in fact supported by The U.S. Department of Health and Human Services, Office of Minority Health to connect minority communities and residents to healthcare and public health
services. One example of a peer reviewed journal article is titled Community Health Workers as an Extension of Care Coordination in Primary Care. The article illustrates how Community Health Workers help communities address social determinants of health and promote health equity. In addition, the City of San Antonio’s IT Services Department assisted in the creation of an ArcGIS mapping App for field staff to document their contact locations by census tract with high equity
scores. The IT department also worked with the Communications Team to create the City’s COVID-19 Response-Recovery Website providing residents with information on local COVID-19 data and resources for businesses and residents. In September 2020, the City of San Antonio was the recipient of the City Government Experience - COVID-19 Response Award by the Center for Digital Government for the City’s Response-Recovery Website. This competition honors U.S. governments who are leveraging innovative IT to enhance services and citizen experience during the pandemic. During a surge of COVID-19 cases in San Antonio that started in June 2020, the CHP and Communications Teams worked with other City Departments on an innovative face mask donation-distribution initiative for individuals and families in need. The face mask
initiative collected over 46,000 face masks and distributed ninety percent of masks to seniors, families and non-profits by the end of August 2020. Many seniors received their face masks during their lunch meal curbside pick-up at City Senior Centers and families were able to receive their masks through community non-profit agencies. To enhance the communication within the City’s most affected communities, the CHP and Communications Teams meet residents where they are to include their personal connection to music. The communications team employed the help from well-known local music artists such as
conjunto accordionist Santiago Jimenez, San Antonio’s Poet Laureate Andrea “Vocab” Sanderson, and Tejano Music Award star Shelly Lares. These music artists composed and recorded songs, and produced music videos encouraging the San Antonio community to stay the course with COVID-19 prevention so families can come together soon. The City’s Office of
Equity Demographic Indicator Maps along with the ArcGIS Mapping App and monthly epidemiology reports have been innovative approaches to help the CHP Team determine outreach and education in specific geographic areas, track outreach activities and determine impact of overall education and communication efforts. Utilization of these platforms allows the CHP Team to quickly shift to the most recently affected areas. To date, these approaches have shown some promising impact according to Metro Health’s October COVID-19 Epidemiology Report . The report indicated a decrease of 2.8% to 21.7% in case rates from September to October in the same communities where the CHP and communication efforts were implemented.

In keeping with the community outreach and communications practice, the CHP Team ‘s ‘Boots-on-the-Ground’ efforts were developed to target and reduce the mortality and infection rates of those vulnerable populations who are also most adversely affected by the ‘Digital Divide’. In this case the "digital divide" refers to the growing gap between the underprivileged members of society, especially the poor, rural, elderly, and handicapped portion of the population who do not have access to computers or the internet. It is the purpose of the community outreach and communications initiative to build culturally appropriate messaging which allows the Metro Health teams to reach the multi-generational households who are impacted by the ‘Digital Divide’. Metro Health has utilized various communication methods to include community stakeholders to-date. One such communication method has been the support of Metro Health’s COVID Response Coalition (CRC) which has multiple work groups recognized for their response work on COVID-19. Early on in the pandemic response, the City of San Antonio moved to meet the needs of the community by creating the CRC. The CRC is designed to provide critical guidance and oversight to all aspects of the public health response through the following five working group categories: Indicator Monitoring, Testing and Lab, Contact Tracing, Enforcement & Education, and Policy & Health Alerts. Each work group is made up of health experts from a variety of local organizations and sectors based on the nature of the work. Each work group is Co-Chaired by a Metro Health team member and a community partner. Work groups provide critical guidance on the aforementioned work group categories. For example, the following are those stakeholders partnered within the CRC Policy Work group: SA Food Bank, The Health Collaborative, Healthy Futures – Texas Women’s Healthcare Coalition, San Antonio Hispanic Chamber of Commerce, San Antonio African American Community Fund along with many other organizations within the community. One key partnership in the Enforcement and Education Workgroup is with the University of Texas Health – San Antonio Medical School. This partnership designed the Neighborhood Peer Groups also known as Community Health Clubs. This activity is well known in international health organizations and is developed based on organized neighborhood units coordinated by community health workers. These local peer groups are developed around the concern for informing organized neighborhoods of local health prevention and lifestyles which have been recognized to improve overall health of a community. The greatest benefit of having key agency partnerships was community feedback especially on the impact of COVID-19 on families. Metro Health teams learned that those at this level did not have access to the latest prevention messaging via electronic means. This knowledge allowed Metro Health teams to reach the most impacted populations via community health workers with added insight of their target communities.

Metro Health and its partners were required to adapt their community outreach and communication efforts continually as the data and information coming out of the Centers for Disease Control and Prevention (CDC) along with local information changed daily and at times hourly. Not only was updated data reallocating resources across varying Census Tracts, Metro Health was required to move swiftly in recognizing changing age-group targets and the methodology in reaching them. To adjust and improve the messaging approach, the CHP Team conducted a resident survey in August 2020 to help the City learn what information and messages residents in marginalized neighborhoods have seen/heard as well as what they want to receive regarding information on COVID-19. Just over 700 resident surveys were completed. In addition to COVID-19 prevention and testing information, 31% of respondents indicated that they needed information on housing and utility assistance, and 30% requested information on food assistance. Using this information, the CHP Team collaborated with the City’s Department of Human Services to distribute a COIVID-19 Resource Flyer along with updated COVID-19 prevention information in census tracts that experienced a high number of COVID-19 cases and deaths during San Antonio’s surge in the summer. In addition, there was a recognition that residents ages 18 to 40 needed to be targeted as cases were increasing in this age group. Thereby a new way of thinking was required t o inform them. It was at this point that the CRC Enforcement and Education work group began discussing the use of social influencers. It was at the height of the summer surge of COVID-19 cases that the work group decided to develop messaging that could be sourced to local social peer influencers. With the assistance of Metro Health's Communications Team, the work group developed the concept of the 3P's: 1. PREVENT the spread from continuing, it starts with YOU! - Headline- Wear your mask, wash your hands, keep your distance like your life depends on it, because it does! – Tagline 2. PROTECT yourself + your friends and family - Headline - Only go out when absolutely necessary, you can literally get it anywhere. 3. PROVIDE information to help stop the spread – Headline - Get tested if you have symptoms and answer your phone to help the city manage contact tracing. – Tagline. Thus, a new messaging campaign was born using social influencers as a way to reach out within the marginalized community’s younger population. Since 4th of July 2020 this methodology of connecting to 18-t o-40-year-old’s has been utilized.