TYPE Methods
PUBLISHED 24 November 2022
DOI 10.3389/fpubh.2022.942795
OPEN ACCESS
EDITED BY
Holley A. Wilkin,
Georgia State Unive rsit y, United States
REVIEWED BY
Ciara Heavin,
University College Cork, Ireland
Tracie Risling,
University of Calgary, Canada
*CORRESPONDENCE
Stephen A. Rains
SPECIALTY SECTION
This article was submitted to
Public Health Education and
Promotion,
a section of the journal
Frontiers in Public Health
RECEIVED 13 May 2022
ACCEPTED 31 October 2022
PUBLISHED 24 November 2022
CITATION
Colombo PM, Freylersythe S,
Sprinkle MM, Ernst KC, Yubeta M,
Barbati JL, Merchant N, Iyengar S,
Crane TE, Oxnam M and Rains SA
(2022) Design and implementation of a
health messaging protocol employed
for use within a COVID-19 health
dissemination platform.
Front. Public Health 10:942795.
doi: 10.3389/fpubh.2022.942795
COPYRIGHT
© 2022 Colombo, Freylersythe,
Sprinkle, Ernst, Yubeta, Barbati,
Merchant, Iyengar, Crane, Oxnam and
Rains. This is an open-access article
distributed under the terms of the
Creative Commons Attribution License
(CC BY)
. The use, distribution or
reproduction in other forums is
permitted, provided the original
author(s) and the copyright owner(s)
are credited and that the original
publication in this journal is cited, in
accordance with accepted academic
practice. No use, distribution or
reproduction is permitted which does
not comply with these terms.
Design and implementation of a
health messaging protocol
employed for use within a
COVID-19 health dissemination
platform
Paulina M. Colombo
1
, Sarah Freylersythe
2,3
,
Mary Margaret Sprinkle
4
, Kacey C. Ernst
1
, Marcela Yubeta
1
,
Juliana L. Barbati
5
, Nirav Merchant
6
, Sriram Iyengar
3,4
,
Tracy E. Crane
2,3
, Maliaca Oxnam
6
and Stephen A. Rains
5
*
1
Department of Epidemiology and Biostatistics, College of Public Health, University of Arizona,
Tucson, AZ, United States,
2
The University of Arizona Cancer Center, Tucson, AZ, United States,
3
Department of Internal Medicine, University of Arizona College of Medicine, Phoenix, AZ,
United States,
4
BIO5 Institute, The University of Arizona, Tucson, AZ, United States,
5
Department of
Communication, The University of Arizona, Tucson, AZ, United States,
6
Data Science Institute, The
University of Arizona, Tucson, AZ, United States,
7
Sylvester Comprehensive Cancer Center, Miller
School of Medicine, University of Miami, Miami, FL, United States
Introduction: AZCOVIDTXT, a bilingual, two-way information sharing platform
was created in April of 2020 in response to rising COVID-19 cases in Arizona.
The aim of this paper is to delineate the protocol and processes used to
develop and disseminate health messaging to serve as guidance for other
groups, universities, or public health programs in the implementation or
enhancement of health communication services.
Methods: Health messaging formats included website articles, published
on the system’s website (
azcovidtxt.org), infographics posted on social
media, and SMS. Social media and SMS infographics were intended to
highlight and augment the topics covered in the weekly website articles,
to create a seamless multimo dal source of reliable COVID-19 information
for AZCOVIDTXT enrollees and the broader public. All health messaging
information, text message and social media content was planned and reviewed
collaboratively by the AZCOVIDTXT team topic experts for accuracy, ecacy,
and content consistency.
Results: As of July 2021, AZCOVIDTXT provided weekly COVID-19-related
health comm unication to 3,747 participating households located across 225
Arizona zip codes. AZCOVIDTXT has developed and sent 446 unique, bilingual
SMS for a total of 271,977 contact points. The team has produced and
published 179 website articles, which averaged a combined 7,000-page views
per month, and 173 social media posts were made available to 268 followers
across three platforms.
Discussion: Several programmatic aspects were deemed essential to the
success of AZCOVIDTXT. These included (1) addressing community specific
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Colombo et al. 10.3389/fpubh.2022.942795
needs, (2) creating timely and relevant content, (3) developing an adaptable
system, and (4) prioritizing system automation where possible, (5) having an
interdisciplinary team approach to identifying and crafting key messages.
KEYWORDS
health messaging, health education (MeSH), short message services (SMS), COVID-19,
SARS-CoV-2, pandemic response
Introduction
Since t he st art of the COVID-19 pandemic, an abundance
of misinformation (
1–3), rapidly changing science, and
a lack of access to reliable COVID-19 information has
hindered United States mitigation efforts (
4). Ambiguous and
contradictory health recommendations also lead to significant
losses of the public’s trust in governmental organizations and
science (
5). Rese archers at the University of Arizona identified
a critical need to create a mutually beneficial platform to
(1) provide local Arizona residents’ with access to critical,
continually evolving COVID-19 information and (2) assist
scientists in collecting COVID-19 dat a. A multidisciplinary
group of data science, public health, behavioral science, health
education, and communication experts developed a service to
accomplish these goals.
AZCOVIDTXT, a bilingual, two-way information sharing
platform was created in April of 2020 in response to rising
COVID-19 cases in Arizona, coupled with the spread of
inaccurate information about the virus, which remain ongoing
challenges today. The overarching goals for AZCOVIDTXT
were outlined in a previously published article (
6). We aim
to delineate the protocol and processes used to develop and
disseminate health messaging for AZCOVIDTXT as guidance
for other groups, universities, or public health programs in
the implementation or enhancement of health communication
services. Our objective of rapidly deploying AZCOVIDTXT to
meet the immediate and evolving needs created by the pandemic
led us to not prioritize theory testing or formal evaluation
protocols as might be the case in a traditional intervention.
As such, we believe that our project offers a novel case study
that can aid in preparing for and responding to unanticipated
future health crises. This paper provides lessons learned from
the methods used to implement and operate AZCOVIDTXT
that drew upon the expertise of interdisciplinary team members.
From April 2020 to July 2021, the AZCOVIDTXT team sent over
271,977 text messages, disseminated 179 articles, and created 173
social media posts.
Abbreviations: AZCOVIDTXT, Arizona COVID Text; SMS, Short me ssage
service.
Materials and methods
AZCOVIDTXT system overview
AZCOVIDTXT is a free service that Arizonans could
voluntarily join at any time by sending a text message (SMS) t o
enroll. The system consists of two components which work in
tandem to assist public health and Arizona residents in better
understanding COVID-19. A surveillance component collects
initial household demographic information, using the Research
Electronic Data Capture (REDCap), from subscribers along with
a brief, weekly survey where they can disclose household health,
vaccination status, and challenges related to financial, social, or
other issues encountered in the past week (
7, 8). These surveys
enable the second system component, a health messaging
program, to be tailored to specific groups of respondents, such
as those who report a sick household member. Subscribers
can opt in to receive additional health communications in the
initial demographic survey. This messaging component of the
system provides regular, credible, Arizona-specific pandemic
resources and information through weekly SMS, social media
posts, and website articles in both English and Spanish. Multiple
channels (e.g., website forum, email communic ations, SMS
responses to outgoing messages, and a periodic community
survey) for user feedback were developed to inform content
creation and prioritize community interests. AZCOVIDTXT
remains ongoing, but this article focuses on processes utilized
from its establishment to July 2021. We next detail our process
of content development and data management.
Health messaging overview
Health messaging for AZCOVIDTXT was designed to meet
the evolving information needs of Arizonans since the beginning
of the COVID-19 pandemic. Health messaging modalities
included SMS, website articles, published on the system’s
website (
azcovidtxt.org), and infographics posted on social
media. Research has demonstrated an increased effectiveness
of health communication campaigns and improved adoption
of health-related information when multiple media approaches
are utilized (
9). The unique affordances of each modality were
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Colombo et al. 10.3389/fpubh.2022.942795
leveraged to deliver complementary information about COVID-
19 to a wide audience.
Text messages (SMS)
Three to five SMS per week were determined to be ide al to
avoid undue burden on enrollees (
10). One weekly SMS, sent
to all users, served a reminder to complete the brief weekly
survey. This SMS contained a specific-participant link that was
associated with the individual user’s prior longitudinal data.
Additional informative SMS were released with the goal of
disseminating educational material to users. To receive this
message type, subscribers opted-in based on their preferences
during the AZCOVIDTXT enrollment process. Content for
informational SMS was intended to mirror and augment
website article material, and address challenges and topics of
particular interest to Arizonans. One informative SMS sent to
all subscribers was intended to spark interest and encourage
subscribers to visit the weekly updated website articles. Messages
that directed subscribers to view the website articles included a
URL as part of the character count limit. A second informative
SMS s ent to all subscribers provided an opportunity to send
more general information, such as current events and changes
in official guidance, local Arizona supportive services, and social
support reminders. All SMS were translated into Spanish by
staff at the University of Arizona Cancer Center’s Behavioral
Measurements and Shared Resource (BMISR) and were released
to subscribers who indicated a Spanish preference for receiving
their informative SMS.
Data provided by the surveillance component of
AZCOVIDTXT were reviewed to allow responsive messaging
back to the users. This design was in accordance with rese arch
demonstrating higher efficacy for text messaging-based health
promotion interventions when applying personalized messaging
(
11). Thus, these general SMS were often tailored, especially
during the early months of the pandemic, to address the
challenges that enrollees were reporting on their weekly
surveillance surveys (e.g., accessing cleaning and hygiene
supplies, medical and mental health care, and basic human
services such as housing, food, and water). A third informative
SMS was sent only to a specific group of subscribers: those
who reported that someone in their household that week was
sick. This gr oup of messages included information specifically
tailored to minimizing spread within households, how and
when to isolate and quarantine, and when and how to seek
urgent care.
AZCOVIDTXT offers real-time response. In the event
of a critical or emergent issue, additional, one-time SMS
could be sent. Examples of critical or emergent issues of
public health and safety, included wildfire evacuations during
lockdown, executive orders such as the Stay-at-Home order,
and to address widespread and life-threatening misinformation.
Urgent messages were only sent on six instances during
2020 (
Table 1).
SMS were sent via the AZCOVIDTXT communications
platform: a Django-powered application developed by
programmers and data scientists at the University of Arizona’s
Data Science Instit ute. The AZCOVIDTXT platform interfaced
with Twilio, a cloud-based communic ation service, in order to
send and receive SMS with subscribers (
12). The AZCOVIDTXT
communications platform enabled advanced scheduling of SMS
for a spe cific date and time and to unique subscriber groups,
such as Spanish SMS sent to Spanish-speaking enrollees. Further
filtering was possible (e.g., by zip code or specific flags such as
subscribers who reported a sick household member on a weekly
survey), allowing for messages to be tailored as needed, (e.g.,
sending messages regarding wildfire evacuations to only the
zip codes affected). The AZCOVIDTXT SMS communication
platform also logged and tracked all incoming and outgoing
SMS for reporting purposes. SMS released through this platform
had a 160-character limit.
Website articles
An average of t hree articles regarding pressing COVID-
19 related information were developed and published on the
system’s website each week. The articles were complementary
to the service’s other communication features and served to
provide comprehensive COVID-19 health information. The
intent was to clarify current science and policies and provide
tips and information for resilience during the pandemic.
Specific topics included in the articles discussed an array
of pandemic-related information including evolving COVID-
19 science, state-issued executive orders, available Arizona
resources, and interviews with field experts (e.g., university
researchers, healthcare professionals, etc.). Articles typically
ranged between 300 and 600 words and were written in a manner
that could be easily interpreted by the lay public.
Decisions about the content included in each article
were informed through multiple channels including (1)
surveillance data input from users, (2) community feedback
forms administered periodically, (3) feedback forum,
email, and incoming SMS responses, and (4) as guided by
AZCOVIDTXT team leads who had extensive backgrounds
in health communication, public health, nursing, and health
education prioritizing and ranking important emerging
topics. The articles were mainly researched and written by
AZCOVIDTXT st aff who have expertise in public health and
health education. Periodically, external health professionals
and experts were consulted for additional content matter.
After the material was drafted, any health-related content was
carefully vetted by public health and nursing professionals as
well as a health communication expert who refined language
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TABLE 1 Urgent SMS sent.
English SMS sent Date
Drinking or injecting disinfectants will make you sick and can kill you. Use only as directed. Contact Poison Control immediately if needed:
800-222-1222
4/24/20 11:00 AM
From AZCOVIDTXT: The AZ Governor has extended the stay at home order for COVID-19 until May 15 in Arizona 4/29/20 4: 30 PM
If y ou are evacuating, be sure to take masks and disinfecting supplies with you. Masks can reduce smoke particulate exposure AND risk of
transmitting COVID-19
6/11/20 4: 00 PM
Tucson Area Alert: Imminent fire danger in the Catalina Foothills area. Sign up for alerts from Pima County here: https://
emergencyalerts.pima.gov/
6/11/20 4: 00 PM
Maricopa County Alert: Imminent fire danger in the Tonto Nat’l Forest area. Stay up to date with state fire agencies:
http://fb.com/
bushfireinfo
6/19/20 2: 00 PM
If y ou are evacuating, be sure to take masks and disinfecting supplies with you. Masks can reduce smoke particulate exposure AND risk of
transmitting COVID-19
6/19/20 2: 00 PM
and formatting to eliminate any messaging inefficiencies. The
content was then translated into Spanish, again by BMISR staff.
Individual articles were organized and titled us ing specific
taglines (e.g., All Things Vaccines, Testing Tips, etc.) into 15
macro-categories. Overarching topic groups allowed readers to
quickly identify the general content of an article prior to reading.
These 15 article categories were collapsed into six dropdown
menu items, which were made available in the resources tab on
the main page of the website.
The AZCOVIDTXT website was a supplemental feature
to the regular text messages received by subscribers of the
platform. In addition to housing the weekly articles, the
website provided general information about the program and
team, and contained an automated, interactive map and
corresponding table that displayed de-identified AZCOVIDTXT
household subscriber data at the county and zip code level (e.g.,
confirmed case counts (gathered from Arizona Department
of Health Services), the number of households reporting to
AZCOVIDTXT and, of these, how many reported experiencing
food scarcity). COVID-19 content could be easily located under
the resources tab. Updated articles and social media material
were condensed into 6 topic categories: High-Risk Groups (e.g.
Kids, Essential Workers, Vulnerable Populations); COVID-19
Science; Prevention and Planning; State-Wide Mandates; Mental
Health; and Vaccine Information. Additional relevant resources
including volunteer and further research opportunities are also
found under the website’s resource tab.
Social media i nfographics
To support and more broadly disseminate reliable COVID-
19 information, infographics were developed weekly and posted
on three major social media platforms: Twitter, Instagram, and
Facebook. Information from the weekly website articles were
adapted into an infographic with a focus to share the core ideas
in a visual format. These visualizations were used as a tool to help
process and retain complex or emerging COVID-19 updates
quickly and clearly. Infographic messaging was intended to be
brief, easy to read and understand, and eye catching. As of July
2021, AZCOVIDTXT had a combined follower count of over
350 across all three social media platforms.
Each week, ∼2–3 infographics were developed. A brief
description of the infographic was included as text with the
post, and a wide variety of COVID-19, University of Arizona,
and accredited public health entities (e.g. CDC, WHO, etc.)
were tagged. Most infographics were a single picture, optimized
for both desktop and mobile viewing. On Instagram, additional
infographic sequences were developed to take advantage of the
swipe-through carousel feature. All infographics were branded
with the AZCOVIDTXT logo. Infographic s were made available
in English and Spanish.
The infographics were designed using Canva Pro, a web-
based graphic design tool, and presented to the leadership team
for review. After feedback was incorporated and all revisions
made, the infographics were posted to all three social media
platforms using the web-based platform SalesForce.
As a method of further outreach to the community, images
were made available in a download able format for public access
and so they could be repurposed for use by other organizations.
This was beneficial for less-resourced, external groups who
did not have the bandwidth or staffing to develop Arizona-
centric graphics on their own. The team reached out to a
range of community groups to promote these graphics as free
and trustworthy resources including medical facilities, school
districts, fitness centers, and rest aurants.
Content development and data
management
The AZCOVIDT XT team met weekly in order to review and
approve the following week’s content (i.e., website articles, text
messages, and social media infographics) and plan for future
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FIGURE 1
Content development and dissemination process outline.
content. Developed content was reviewed by the team, revisions
were made, and then the content was translated to Spanish. After
identifying topics for the next week, the topics were r esearched,
and the next round of content was drafted.
Figure 1 delineates
the content development and dissemination process.
Community feedback evaluation
Providing tailored, Arizona-centric COVID-19 information
was a fundamental goal of AZCOVIDTXT. Thus, acquiring
community feedback was essential to incorporating and
addressing the COVID-19-related concerns of local,
participating Arizona residents. One optional program
evaluation, provided in both Spanish and English, was
administered in September 2020 and remained open to
collect responses for 1 month. We chose to solicit responses
approximately 5 months after beginning in April because
we had accumulated a relatively sizeable number of
subscribers and recognized that there would likely be a
continued need for our service as the pandemic evolved.
The survey was designed to evaluate our performance
through anonymously collecting input regarding user
preferences for content as well as to provide an opportunity
for subscribers to voluntarily disclose confusion or worry
about particular COVID-19 topics. Multiple question formats
including multi-select and write-in options to allow for
comprehensive feedback. A brief report containing both
qualitative and quantitative survey data was then made
available to subscribers through the platform’s website. The
results have also been regularly used to inform decisions
regarding AZCOVIDTXT content output in the form of text
messages, social media posts, and weekly articles posted on the
platform’s website.
Results
In this section, we report on the user data that our
service collected from April 2020 until July 2021. We also
provide findings from the community feedback we conducted
in September 2020.
Subscriber base
Subscriber demographics are provided in
Table 2. In
brief, as of July 2021, AZCOVIDTXT provided weekly
COVID-19-related health communication to 3,747
participating households located across 225 Arizona zip
codes. Designated individuals who reported household
health information were predominantly female (73.4%), and
white (87.1%). 15.3% of household respondents identified
as either Hispanic or Latinx. The average age of household
respondents was 51.3 years (range = 15–99 years old,
standard deviation = 15.9). The majority of enrollees
opted in to re ceive the informational text messages (n =
1,940, 51.8%).
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TABLE 2 Demographic characteristics of AZCOVIDTXT users (April
2020–July 2021), n = 3,337.
n %
Gender
Male 864 25.9
Female 2,443 73.4
Non-binary 10 0.3
Other 2 0.1
Age
15–29 385 11.6
30–44 766 23.0
45–59 962 28.9
60–74 1,040 31.2
75–99 176 5.3
Are you Hispanic or Latino/a?
No 2,769 84.7
Yes 501 15.3
Race
American Indian or Alaska Native 49 1.5
Asian 94 2.9
Black or African American 41 1.3
Native Hawaiian or Other Pacific Islander 11 0.3
White 2,801 87.1
More than one race 116 3.6
Column headers may not sum to table total due to missing data.
Content and engagement
AZCOVIDTXT has developed 446 unique SMS in two
languages, English and Spanish, and sent a total of 271,977
SMS to subscribers. The team has produced and published
179 website articles in both English and Spanish. From April
2020 to July 2021, the weekly website articles averaged 7021
views per month (SD: 4410.5; 95% CI: 4670.7, 9371.1), and
the AZCOVIDTXT website received 112,334-page views as a
whole. Additionally, 173 social media posts were developed
and made available to 268 combined followers across three
platforms.
Figure 2 provides content creation and engagement
metrics of the platform’s different modes of communication.
There was a gradual decrease in website page views as the
pandemic persisted, which may be due to pandemic fatigue.
Community feedback
The community feedback evaluation yielded responses from
over 450 subscribers. To inform content creation, users were
asked to provide COVID-19 topic areas that were of most
interest to them. The most common responses focused on the
long-term health impacts of COVID-19 and vaccine s afety and
effectiveness. Respondents also overwhelmingly noted concern
regarding an overall lack of precautionary measures taken
in their communities and a mistrust of politicized COVID-
19 information.
Discussion
Successes
The AZCOVIDTXT team successfully developed and
implemented a protocol to disseminate COVID-19 content
to more than 3,700 households located across 225 zip codes
over the first 16 months of the pandemic. AZCOVIDTXT’s
large subscriber base emphasized the need for an information
platform to provide timely and credible information about
COVID-19 specific to the citizens of our state. Moreover, the
sustained enrollment in the SMS system component suggested
subscriber satisfaction with the program.
The multidisciplinary team provided access to expert
reviewers across many fields of study. Further, the large majority
of funding for this work supported personnel time for website
and texting service implementation, content development, and
review by public health experts. Thus, the project provided
an opportunity to involve students from journalism, public
health, and public relations to assist with operational areas of
the project.
Challenges and limitations
As AZCOVIDTXT developed highly dynamic and
responsive material, the development process required
weekly planning meetings, close collaboration, and the
input of many subject matter experts in order to meet the
rolling weekly publication deadline and provide relevant,
timely information to AZCOVIDTXT subscribers. Thus,
developing health messaging material continuously for
a weekly publication deadline was a challenge for the
team. This task was made even more difficult by the
rapidly evolving COVID-19 science as well as national
and Arizona-specific guidance.
Another challenge encountered was developing effective
health promotion messages with a 160-character limit for both
English and Spanish SMS. The general idea for the message
would be refined down to a single idea or action, then reduced to
as few words as possible while remaining grammatically correct
and understandable.
There are limitations to the messaging component of this
project. The structure of the system only allowed for SMS to be
sent to the phone number of the single participating household
member. However, the social media and website posts could be
accessed regularly by any Arizonan, regardless of whether they
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FIGURE 2
Content creation and engagement metrics.
had subscribed to AZCOVIDTXT. In addition, as of July 2021,
the subscriber base was largely white and non-Hispanic and
thus was not represent ative of the Arizona population. Potential
ideas for promoting the service to a more diverse audience
include adding communication modalities (e.g., utilizing radio
or printed materials), targeting messaging more granularly to
vulnerable populations, and utilizing translational services to
offer health information in additional languages (
13). We are
engaging in efforts to expand this demographic reach in order
to better serve Arizona communities. Finally, this project was
rapidly developed in real time at the outset of an unprecedented
global health thre at. As a result, it was not driven by the
goal of theory testing or with evaluation in mind as might
be the case in formal health interventions. As researchers
work to prepare for t he next pandemic, however, it would be
worthwhile to start from one or more established theoretical
frameworks such as those involving technology adoption or
design science.
Practice implications
The project’s successes and challenges helped to identify
several of AZCOVIDTXT’s programmatic elements that were
essential to the system’s effectiveness and efficiency. These
implications were informed through participant feedback and
AZCOVIDTXT staff input.
Addressing community-specific needs
Tailoring content to identified needs of the community will
likely improve user retention and increase engagement. This
is consistent with previous research on health messaging and
aligns with feedback provided by our subscribers (
14).
Timeliness of content
Due to the nature of continually evolving COVID-19
research, it is essential t hat content be developed and released in
a timely manner to ensure its’ relevance to readers. Users noted
being more actively engaged with messaging when content was
“relevant and actionable.”
Program adaptability
Similarly, it is important that the program operations and
logistics (e.g., website and survey structure) remain flexible
to accommodate changes as updates are made to COVID-
19 guidance or as the community needs evolve. This was
informed through team experiences and multiple survey
iterations to account for the intake of continually changing
community challenges.
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Automation of processes
Automating project aspects such as SMS dissemination
and tailoring, or the release of regular community feedback
opportunities will reduce the burden on project staff.
Bidirectional information exchange
Engaging the audience in dire cting the content of the public
health messaging successfully identified theme areas. Adding
contextualization for messaging that is relevant to users is a
proposed strategy for disseminating tailored content (
14).
Multiple modalities to reach a wider audience
Having redundancies of different lengths (SMS vs. article),
graphical vs. word (infographic vs. article) allowed messaging to
reach multiple preferences and audience members.
This project built the foundation for continued work for
Arizona health messaging, such as expanding to information
about other emerging health issues (e.g., West Nile virus,
extreme heat, air quality, fires and extreme weather events).
Future directions of AZCOVIDTXT include better outreach and
engagement aimed at vulnerable populations (e.g., racial and
ethnic minority groups, rural communities, etc.), automating
content identification through machine learning, and providing
more regular opportunities for user feedback.
Data availability statement
The original contributions presented in the study are
included in the article/
Supplementary material, further inquiries
can be directed to the corresponding author.
Author contributions
SR, KE, SI, TC, MO, NM, and MS served as project
leadership. PC, SF, JB, and MY developed and disseminated
health messaging content. SR and KE reviewed all health
messaging content. All parties contributed to protocol
development. PC, SF, and SR wrote the manuscript. All authors
contributed edits to the final manuscript.
Acknowledgments
The development and implementation of this messaging
protocol would not have been possible without the help
of many people and agencies. Within the University of
Arizona, we would like to thank Nick Eddy and Hagan
Franks for their computer science expertise. We would
also like to thank Angela Yung, for her data management
contributions and Julissa Alvarez, Zul Santiago, Marbella
Aguilar, Daniela Gracia Rios for their assistance in
content translation.
Conflict of interest
The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those
of the authors and do not necessarily represent those
of their affiliated organizations, or those of the publisher,
the editors and the reviewers. Any product that may be
evaluated in this article, or claim that may be made by
its manufacturer, is not guaranteed or endorsed by t he
publisher.
Supplementary material
The Supplementary Material for this article can be found
online at:
https://www.frontiersin.org/articles/10.3389/fpubh.
2022.942795/full#supplementary-material
SUPPLEMENTAL FIGURE 1
AZCOVIDTXT Website.
SUPPLEMENTAL FIGURE 2
Interactive map used to tailor messaging.
SUPPLEMENTAL FIGURE 3
Social Media Infographic Examples (in English and Spanish).
References
1. Bin Naeem S, Kamel Boulos MN. COVID-19 misinformation
online and health literacy: a brief overview. Int J Environ
Res Public Health. (2021) 18:8091. doi: 10.3390/ijerph1
8158091
2. Gabarron E, Oyeyemi SO, Wynn R. COVID-19-related misinformation on
social media: a systematic review. Bull World Health Organ. (2021) 99:455–
63a. doi: 10.2471/BLT.20.276782
3. Janmohamed K, Walter N, Nyhan K, Khoshnood K, Tucker JD,
Sangngam N, et al. Interventions to mitigate COVID-19 misinformation:
a systematic review and meta-analysis. J Health Commun. (2021) 26:846–
57. doi: 10.1080/10810730.2021.2021460
4. Roozenbeek J, Schneider CR, Dryhurst S, Kerr J, Freeman ALJ, Recchia G, et al.
Susceptibility to misinformation about COVID-19 around the world. R Soc Open
Sci. (2020) 7:201199. doi: 10.1098/rsos.201199
Frontiers in Public Health 08 frontiersin.org
Colombo et al. 10.3389/fpubh.2022.942795
5. Ferreira Caceres MM, Sosa JP, Lawrence JA, Sestacovschi C, Tidd-Johnson A,
Rasool MHU, et al. The impact of misinformation on the COVID-19 pandemic.
AIMS Public Health. (2022) 9:262–77. doi: 10.3934/publichealth.2022018
6. Rains SA, Crane TE, Iyengar S, Merchant N, Oxnam M, Sprinkle
MM, et al. Community-level health promotion during a pandemic: key
considerations for health communication. Health Commun. (2020) 35:1747–
9. doi: 10.1080/10410236.2020.1837443
7. Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal L, et al. The
REDCap consortium: building an international community of software platform
partners. J Biomed Inform. (2019) 95:103208. doi: 10.1016/j.jbi.2019.103208
8. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research
electronic data capture (REDCap)—a metadata-driven methodology and workflow
process for providing translational research informatics support. J Biomed Inform.
(2009) 42:377–81. doi: 10.1016/j.jbi.2008.08.010
9. Robinson MN, Tansil KA, Elder RW, Soler RE, Labre MP, Mercer SL,
et al. Mass media health communication campaigns combined with health-related
product distribution: a community guide systematic review. Am J Prev Med. (2014)
47:360–71. doi: 10.1016/j.amepre.2014.05.034
10. Hall AK, Cole-Lewis H, Bernhardt JM. Mobile text messaging for h ealth:
a systematic review of reviews. Annu Rev Public Health. (2015) 36:393–
415. doi: 10.1146/annurev-publhealth-031914-122855
11. Head KJ, Noar SM, Iannarino NT, Grant Harrington N. Efficacy of text
messaging-based interventions for health promotion: a meta-analysis. Soc Sci Med.
(2013) 97:41–8. doi: 10.1016/j.socscimed.2013.08.003
12. Twilio. Programmable Messaging API. (2021). Available online at:
https://
www.twilio.com/messaging-api
(accessed April 1, 2022).
13. Kalocsányiová E, Essex R, Fortune V. Inequalities in Covid-
19 messaging: a systematic scoping review. Health Commun. (2022)
1–10. doi: 10.1080/10410236.2022.2088022
14. Hawkins RP, Kreuter M, Resnicow K, Fishbein M, Dijkstra A. Understanding
tailoring in communicating about health. Health Educ Res Jun. (2008) 23:454–
66. doi: 10.1093/her/cyn004
Frontiers in Public Health 09 frontiersin.org
