Houston, Texas is the fourth largest city in the US with an estimated population of 2.3 million. Houston is among the most culturally and ethnically diverse cities with minorities comprising 68% of the population. The Houston Health Department (HHD) is a full-service, nationally accredited local public health department serving the Houston jurisdiction. HHD leads the area's COVID-19 response inclusive of community-based testing centers, laboratory, contact tracing, human services, and public information and communication. In response to the pandemic, HHD launched Better. Together., a multilingual public health education campaign empowering Houstonians with the knowledge and skills to protect their families from COVID-19. The campaign involved two parts; a)  communications and b) outreach and community engagement. In an ethnically diverse city where over 145 different languages are spoken at home, culturally relevant and accessible messaging are at the crux of effectiveness for this overarching campaign.

The goal of the Better Together COVID-19 public health education campaign is to spread the 4 key COVID-19 preventative messages in Houston: Mask up – Wash hands – Social distance – Get tested.

Communications Objectives: Create a Coordinated, Data-Driven Response to the Public Health Crisis; Reduce the Number of People Who Become Impacted by COVID-19; Increase Access to Care and Improve Health Outcomes for High-Risk Individuals; Reduce COVID-19 Related Health Disparities for Diverse Populations

Engagement and Outreach Objectives: Implement a variety of activities to reach an estimated 2.3 million by December 2020; implement a variety of activities that prioritizes the top 15 priority zip codes monthly; and develop relationships and implement activities, weekly, in apartments, faith, business, health, education, and civic sectors in four quadrants of Houston Texas by December 2020.

Planning and preparation for the campaign began in the Summer of 2020. External communications partners were contracted to conduct focus groups, analyze tones and sentiments, craft responsive messaging, and design and test the accompanying artworks. To launch the campaign, Houston Mayor Sylvester Turner proclaimed the month of August Better. Together. month, encouraging Houstonians to work together to reduce the city’s COVID-19 positivity rate to at least 5%. Civic leaders, elected officials, business owners, faith leaders, and health care providers are just some of the partners we engaged in this process.

Engagement and outreach efforts rolled in two tiers defined by the intensity of intervention. Tier I involved targeted apartment canvassing. External canvassers used a contact-less approach to leave door hangers in apartment complexes in priority zip codes. Tier II involved a strike team that intervenes directly in communities through activities such as relationship development, food drives, mask distributions, small scale mobilizations to deliver physical resources to families, church engagements, business engagements, and more.

Within one month of the campaign’s launch, Houston’s city-wide positivity rate dropped over 13 percentage points. Between August to December the campaign engaged 10 different industry sectors, reached over 170,000 apartment doors and 3.7 million via Tier 2 outreach, held over 2600 outreach activities, made 104,228 social media impressions, and provided printed campaign material to over 1,200 organizations; many becoming campaign ambassadors.

Addressing the impacts of COVID-19 in Houston required a unique approach to our usual communications practices. As one of the most culturally and ethnically diverse cities in the U.S. Houston experiences complex socio-economic challenges and disparities that are exacerbated when taxed by natural disasters such as hurricanes and was especially necessary during this COVID-19 pandemic. Clear and trusted communication was seen as the answer. Thus, the goal of the Better Together COVID-19 public health education campaign is to spread the 4 key COVID-19 preventative messages in Houston. These 4 messages, Mask up – Wash hands – Social distance – Get tested, needed to reach multitudes of people where they live, work, and play, and they needed to reach them in the languages they could understand.

The Communication Division is comprised of a team of fewer than 10 people, who are responsible for all public and internal communications for staff and the public alike, producing weekly and monthly e-newsletters, community e-blasts, social media posts, blogs, and videos, and a myriad of other interactions and story-telling engagements that ensure the accurate dissemination of public health information as well as proper documentation of the department’s work. The promulgation of the Better. Together. project led to a significant number of community leaders becoming partners and the cooperation of the public who helped to replicate the program’s message within their circles of influence.

The HHD’s Office of Chronic Disease, Health Education and Wellness (OCDHEW) is a premier health education and health promotion division whose subject matter expertise is health promotion, health education, and health communication. OCDHEW has a history of successfully planning, designing, implementing, and evaluating public health education campaigns locally, nationally, and globally. Recalling the frameworks of successfully implemented campaigns and adapting to the emergence of COVID-19 in Houston was feasible and contributed to how quickly the Better Together campaign was able to launch at the grassroots level.

• Organizational Structure: The Communication Division is led by the Department’s Public Information Officer (PIO) who has final approval of all collateral. A Communications Chief oversees daily communication operations and supervises the additional staff of 2 Senior Communications Specialist, 1 Social Media Specialist, and 1 Graphic Artist. The Outreach and Engagement project teams were organized using the FEMA Incident Command Structure and deployed in teams of 6 to the four quadrants of the city.
• Staff: The communication division and the outreach and engagement teams were diverse along the ethnic, race, gender, age, and socio-economic axis. Staff reflected and came from the communities they served. Staff areas of specialty included news broadcasting, public relations, community organizing, community outreach, health education, graphic design, videography, and photography.
• Technology: Various cloud-based technology was employed to adapt to the virtual nature of community engagement in a pandemic. Microsoft Teams, Zooms, Constant Contact, Smartsheets, Hootsuite were a few of the technical aspects used in the implementation of the campaign.
• Resources: Campaign resources largely used designated funds from the C.A.R.E.S. Act and supported COVID-19 staff, community resources, and collaterals exclusively.

The campaign was unveiled in August 2020 with the first of four campaign messages – Better. Together. The focus of Better Together – Todos Juntos Mejor emphasized to the public that this disease was not an illness of a certain segment of the population, but one that we have all been impacted by, either by us or our loved ones directly contracting the disease or by the consequences of the onslaught of business shutdowns and other consequences of living in a pandemic society. Hence, we were all in this together, and if in it together, we can come out of it together, if we all worked towards a common goal. The other focus of the Better. Together. campaign strategy was to teach the four science- endorsed measures for helping to slow the spread of the disease: hand washing, social distancing, wearing a mask, and getting tested.

In November 2020, the second campaign message – Don't Stop. Don't Forget., was unveiled. Again, following the data which showed that people were beginning to have Covid-19 "fatigue" and were growing weary of the stress of the pandemic, we implemented the next communications as a reminder to everyone to remain vigilant. We doubled the size and scope of our billboards, widened the scope of our social media campaigns, expanded the reach of the door to door canvassers, and with the help of the trusted voices of our community partners, we were able to saturate Houston with our messages via every available communication tool available: television, radio, social marketing, webinars, online courses and virtual town hall meetings to name a few. The volume and simultaneous casting of all of these efforts uniquely qualify as unprecedented communications response in Houston. 

The third campaign message, set to unveil in March 2021 will come around the time of the pandemic responses 1-year mark. It will focus on vaccinations and remaining dedicated to the four basic practices to ensure that we continue to slow the spread of COVID-19.

The last campaign message will focus on the shared sacrifices we all made to ensure we arrive at our desired outcome, which we optimistically believe will be our shared successes. 

The community outreach approach was a vital data-driven aspect of the Better Together campaign. COVID-19 positivity rate maps, GIS-coded maps loaded with positive test result case numbers by zip codes, enabled us to target areas where coronavirus health education/resources were badly needed. When the data showed areas that had either increased or decreased, the outreach strategy pivoted to align with the data. This also helped us to leverage the best use of our limited staff resources to the areas where they could be most effective.

The practices used to develop and plan the Better. Together. campaign are evidence-based strategies based on several guides, including The Social-Ecological Model: A Framework for Prevention; 2) The NACCHO MAPP Toolkit. and 3) The National Incident Management System's Incident Command Structure. Together, these provided guidance on proven organizational methods which allowed us to quickly deploy staff and strengthen communications.

Given the pandemic’s wide and devastating effects on Houstonians, we knew that we would need the help of all of the trusted voices in the community to help us saturate the community with coronavirus awareness. The Better. Together. campaign was the ideal platform to bring the leaders across every operating industry into the active arena of this campaign’s efforts. Whether it was small or large businesses, restaurants, faith-based, civic, healthcare, education, non-profit, or government, everyone has a place and a role in Better. Together.

The goals intended for partners were outlined in our materials and presentations. Outreach Teams provided businesses and community leaders Calls to Action as invitations to join the Better. Together. campaign. These short, one-page documents were tailored for each business or industry sector and described the key goals and deliverables for all partners. While they differed slightly in their individualized letters, the underlying goal of all calls to action was to amplify the reach of the 4 key messages to slow the spread of Covid-19.

To bring partners on board, we started with known relationships and existing partners to the City of Houston’s Health Department, such as other City of Houston departments, elected officials, other Houston healthcare organizations, faith leaders, civic organization leaders such as homeowners association and management district presidents, school leaders like principals and superintendents, and small business and restaurant owners. We established a base by providing collateral, offering online courses and training, and providing webinars and town hall meetings. We provided toolkits and ambassador boxes with extra personal protective equipment, signage, t-shirts, and other collateral for partners who fully committed to helping us with our tasks. Because health equity is a core value of our mission statement, it is underlined in all of our activities. We prioritized partners in areas of the community that were experiencing surges of active cases. We provided them with extra support[PG-H5]  in the form of training, and ambassador kits that included print collateral like multi-lingual signs, tent cards, t-shirts, masks, and other materials for employees, customers, and constituents.

The policy landscape was constantly changing, and we were very sensitive to our partners’ desires to have the right information the first time. To leverage our shared interests, we looked for ways to engage partners where they felt they gained a “win” from the partnership.

For example, Fitmix Communities is a nonprofit organization dedicated to improving the well-being of Houstonians. Their goal is to decrease the occurrence of health problems associated with obesity, loneliness, and stress, through fun, empowering, and creative ways. This organization, led by women, represents a diverse group of members. Through our partnership based on our shared goals, we accepted an invitation to join FitMix Communities on their weekly Facebook Livestream to talk about Better. Together. and share our message to all of their viewers. We received FitMix’s commitment to continue to help us spread our messages and update their community with the latest COVID related news as they receive them. This partnership opened the door for other collaborations as other guests who attended were also sharing our information with their respective organizations, as well as individually reaching out to us to be a part of our efforts. This is just one example of how collaborating with a non-traditional partner during the pandemic created opportunities for information sharing which increased the public’s knowledge.

We also partnered with the Houston Independent School District, the largest school district in the state of Texas, and the first partnership of this kind for HHD. District officials in the Human Resources Division agreed to host webinars for teachers and staff featuring the Better. Together. Outreach Team, and they shared our messages on their district website, where over 200,000 students and their parents visit for information. We made a similar partnership with Memorial Hermann Hospital, another large employer in the Houston area and one of the area’s largest hospital systems. This partnership provided an avenue for us to usher their discharged COVID-19 patients into HHD’s Human Services Division so that they could receive COVID-19 post-care information and learn about needed resources.

The Better. Together. public health education campaign aligned its Quality Improvement efforts with the recent Houston Health Department's (HHD) Strategic Plan for 2018-2022 and Quality Improvement (QI) Plan 2018 – 2021.  The HHD QI Plan for 2018-2021 describes how HHD will fully integrate QI into the operations/processes of the department while increasing the skills/knowledge of department staff at all levels. To align with the department and execute this goal, all Better. Together. staff was trained and knowledgeable in the application of QI methodology by regular, accessible training, and daily practice.

The HHD QI plan is in alignment with the HHD Strategic Plan for 2018-2022, Priority 8 – building a Culture of Excellence. Staff training for QI included equipping staff with training and tools to implement improvements and facilitating quality improvement projects. The Plan-Do-Study-Act (PDSA) served as the primary methodology for conducting HHD quality improvement activities and projects. In addition, staff had access to QI templates for Cause/Solution and Effect diagrams, team rosters, agendas, minutes, and sign-in sheets. These templates standardized and aligned how the Better. Together. team documented its activities and further established a culture of continuous QI across HHD's vast COVID-19 response.

The campaign made continued QI improvements to monitoring and reporting by routinely monitoring the effectiveness of implementation. To effectively adapt and respond to meet the dynamic needs of Houstonians living in High priority zip codes, the Better. Together. campaign utilized data-driven decision making to guide its communication, engagement, and outreach efforts. By carefully measuring and monitoring process and outcome data, The Better. Together. team identified areas for improvement and adjusted its engagement strategies and services accordingly. Data resources utilized to guide efforts included weekly COVID-19 positivity rate maps, active case maps, death count maps, and wastewater fecal data to target areas where coronavirus health education and resources were badly needed. As COVID-19 positivity trends improved or worsened for certain zip codes, our strategy pivoted to align with the updated data. This method ensured that we were targeting communities that needed our resources the most. For example, initially available COVID-19 insight data suggested that large employer sites and schools were sectors that were in most need of campaign intervention. However, as more data become available and time progressed, the strategy switched to focus more on reaching apartments and civic organizations.

Feedback mechanisms were utilized as part of QI activities and involved both analyzing the input from staff and participants. The Better. Together. team leads provided weekly situational reports on campaign progress and made recommendations to address elements that were not working as planned. The team also distributed satisfaction surveys to gather feedback from community partners on how the Better. Together. campaign could better address their needs.

Several improvements were made during the implementation to address identified challenges and obstacles. With the COVID-19 data trends and the needs of the community constantly changing, communication and timely response were key. It was critical to ensure that the uniformity and consistency of our message remained intact internally and externally. Examples are described below.

1. Communication and training for a team of over 35 staff were difficult initially when in-person meetings were no longer a best practice and staff experience with virtual platforms varied. We addressed this barrier by utilizing the Microsoft Teams platform wherein all team members could meet, collaborate, exchange ideas, verify data and information, and ensure alignment with the tasks for the week. Creating one place to contain the data and providing easy access to information was key to ensuring that everyone was on the same page and speaking the same things. This virtual communication method allowed for the swift correction of misinformation and the ability to make adjustments to assignments and tasks as staffing and other resources shifted. The MS team’s platform was also great for providing staff training, QI documents, and other instruction.

2. The MS platform, along with other reporting protocols, aided with efforts to collaborate internally with other aspects of the department's COVID-19 response. For example, internal partnering and scheduling to incorporate the Better. Together. campaign to support COVID-19 testing efforts by increasing awareness of local testing site locations and the importance of getting tested.

3. In the area of supplies and logistics, communications were particularly crucial as well to ensure an adequate supply of printed and virtual content. As we planned, acted, analyzed and adjusted, we noted how quickly we were able to refill our inventory based on a steady flow of information, both from staff and partners. This enabled us to reorder and receive supplies much faster than usual.

4. Another challenge faced was the delay in vendors' responses, since they were receiving similar requests from so many others. We met this challenge by ordering extra supplies at the start of the campaign to accommodate the anticipated delays and by establishing protocols to coordinate communication to prevent duplication, aid in reallocating resources, and avoid depletion of key resources.

Lessons learned from the Better. Together. campaign include: setting realistic goals and timelines for each tier of the campaign, establishing collaborations across multiple sectors to increase reach and leverage resources, gathering community and partner feedback as much as possible to help foster an initiative that can be sustained by the community members and partners long-term, and identify and celebrate early wins to establish credibility and motivate community partners and internal staff to continue to push and maintain the COVID-19 prevention behaviors supported in the messaging. 

While aspects of the Better. Together. campaign will have to be scaled down as funding is reduced, many aspects are becoming increasingly sustainable by maximizing the use of virtual platforms and collaborations to increase reach. The OCDHEW staff are cross-trained for a wide variety of COVID-19 response areas, including the Better. Together. campaign. This allowed for increased staff capacity to conduct COVID-19 education training for newly established partners.

The public was better served because of the measures taken to implement resource allocation, staff alignment, and program messaging strategies based on robust communication and engagement plans created to address the pandemic.