Holiday Tweets: A Qualitative Analysis of How Major Health Organizations Addressed Culture During the COVID-19 Pandemic

Abstract

This study examines COVID-19-related messages disseminated by major health and government organizations on Twitter during the overlapping holidays of Easter and Ramadan in 2022. Recognizing the importance of tailored health communication, the research focuses on the textual and visual content of tweets to understand how messages attend to diverse cultural, religious, and ethnic groups. Qualitative analysis of 382 Tweets revealed 3 Major Themes related to COVID-19 and Easter and 4 Major Themes associated with Ramadan. Easter-related tweets emphasized celebrating safely and the importance of vaccinations using science-based messaging, slang, and playful imagery. Ramadan-related tweets prioritized safety during religious practices, incorporating traditional symbols and religious references; countering vaccine-related myths; and social responsibility. The findings highlight culturally relevant health communication and tailoring messages to specific cultural contexts. The study contributes insights for public health organizations aiming to improve communication strategies during pandemics, fostering engagement, and addressing the unique needs of diverse populations.

What do we already know about this topic?

• Inattention to culture and contextual factors in messaging and online communications about COVID and pandemics in general may negatively impact vaccine perceptions and other protective behaviors.

How does your research contribute to the field?

• The findings highlight culturally relevant health communication and tailoring messages to specific cultural contexts.

What are your research’s implications toward theory, practice, or policy?

• The study contributes insights for public health organizations aiming to improve communication strategies during pandemics, fostering engagement, and addressing the unique needs of diverse populations.

Introduction

Scholars have increasingly discussed the need for public health agencies to better tailor health related messages and delivery by attending to the specific socio-cultural contexts of audiences^{1 -4} such as in the case of communicating about pandemics. A lack of culturally sensitive information has been found to be one of the barriers to vaccination. More specifically, there is a need for targeted and tailored programs aimed at reducing hesitancy and increasing acceptance and complacency toward COVID-19 vaccines and other proactive health behaviors.^5,6 Culturally competent messaging enables informed consent, allays genuine concerns, and breaks down barriers to uptake. ⁷

Most of the interventions designed to increase trust in medical systems and health interventions have focused on multiple outreach and communication strategies with high-risk groups, ⁸ though not necessarily via social media. Twitter is one of the most popular social media platforms in terms of use and it has been found to strongly influence health behavior. ⁹

Health agencies post a significant number of tweets related to COVID which tend to get retweeted relatively often. ¹⁰

Given the importance of culturally relevant messaging and the use of social media by major health organizations, it is important to examine the ways in which health and government officials frame online messages for diverse cultural, religious, and ethnic groups. Little is known about how social media platforms are utilized by public health organizations in pandemic situations such as COVID-19, the specific content of this information, ¹¹ and the degree to which it is tailored to specific populations.

Religious and culturally related holidays are critical occasions to promote effective messages as they are associated with greater travel, family get-togethers, and increased attendance at religious services. These occasions can accelerate the spread of COVID-19 ¹² and other infectious diseases. Examining the extent to which online health related messages (both text and images) meet the cultural, social, and religious needs of individuals and communities during holiday times is critical to ensuring effectiveness.

Methods

We conducted an exploratory study using qualitative analysis of COVID-19 tweets (i.e., both text and image) from major health and government organizations related to two major holidays during 2022; that is Ramadan, and Easter. Ethics approval was waived by the office of research and development as this study does not meet the definition of human subjects research. Qualitative inquiry allows for a contextualized understanding of the ways in which both text and images are used in culturally relevant ways. For the first time since 1991, Easter and Ramadan overlapped in 2022 allowing for the collection of data during the same time period. Easter and Ramadan are times when people come together to pray, attend religious services, feast, and celebrate with family and friends.

A preliminary exploration of COVID-19 related tweets from government and health officials found that they were overwhelmingly in English. Moreover, multiple studies have examined COVID-19 related tweets in english.^{13 -19} In order to understand our results in the context of previous research, we focused on English language tweets for this study.

Using Twitter API, ⁱ all tweets mentioning the keywords Easter and Ramadan and COVID-19, Coronavirus, and pandemic were scraped from March 1 to May 2, 2022. Several key events occurred during this time period including expanded access to COVID-19 vaccines and the Centers for Disease Control and Prevention ²⁰ outlining goals to increase vaccine levels worldwide, reduce the spread of COVID-19, and expand scientific knowledge of the SARS CoV-2 virus. Only verified Twitter users were included in the analysis as a safeguard against accounts promoting misinformation. Twitter defined “verified/blue tick” accounts, or those receiving a blue badge, as authentic, notable, and active.

The scope of the search was extended worldwide using all tweets mentioning the holidays (Easter and Ramadan) with the following query:

“(COVID19 OR COVID-19 OR CORONAVIRUS OR #COVID19 OR #CORONAVIRUS #pandemic) (Easter OR #Easter OR #Easter2022 OR Ramadan OR RamadanMubarak OR #Ramadan OR #RamadanMubarak OR #Ramadan2022) is:verified -is:retweet –‘News.’” This query resulted in 2110 tweets from 912 unique users. The raw data scraped from Twitter was then cleaned by deleting irrelevant metadata and filtering out non-English language tweets. Further, tweets were not included if they contained tangentially related COVID information, for example, government officials gathering to discuss COVID, or if they included messages related to multiple holidays as it would be difficult to derive themes from such tweets with respect to a particular holiday. The latter represented only a small number of tweets. Additionally, to maintain data authenticity, we further filtered out tweets to only include those from government and health official Twitter accounts, resulting in 154 unique health and government accounts including National Health Service (NHS) led organizations, World Health Organization (WHO) subsidiaries/outlets, and other health related or government organizations (23 government, 131 health). Further data cleaning, resulted in 382 representative tweets (148 Easter based and 234 Ramadan based) from NHS led organizations, WHO subsidiaries/outlets, and other health related or government organizations. The majority of tweets were from organizations based in predominantly English-speaking countries. Approximately 70% were from the United Kingdom, with another 15% from the United States, Canada, and Australia.

Once the data was collected, the data (both text and images) was uploaded to ATLAS.TI software for coding and analysis. We used thematic analysis of text and images for both holidays, allowing for context-rich information. ²¹ Inductive coding was employed, grounding the themes in both the text and imagery of the selected tweets.

We first familiarized ourselves with the data by reviewing all tweets. To reduce systematic bias in the analysis and ensure between-coder reliability and conceptual clarity, both researchers independently began open coding of both texts and images of 20 tweets and then met to compare classification schemes. Categories, or code families, were created through a process of cycling back and forth between the data and the codes. Code families were created for organization and to help develop structures and themes. The researchers then independently coded 55 remaining tweets and met again to prevent “an idiosyncratic sense” of the codes,^21(p64) repeating this process multiple times until all tweets were coded and code families were refined. Images and text were analyzed using content analysis to determine the number of times particular codes appeared and co-occurrences to identify themes. Discussion and negotiation allowed for further clarification of the themes. To establish trustworthiness of the data, the researchers established a dialectical and iterative relationship in which we met constantly as well as exchanged dialogue about our reflections and insights on the meaning of the data. ²²

Results

Results revealed 3 Major Themes related to COVID-19 and Easter and 4 Major Themes associated with Ramadan. While the themes are distinct, there was some overlap in messaging within each of the 2 holiday groupings.

Easter Themes

Get vaccinated

The majority of tweets conveyed the importance of vaccination (doses and boosters) for safe gatherings. Hashtags included #StaySafe #CelebrateSafely #saferHolidays #covid19. These tweets seemed to be focused on 2 populations; that is, adults and children.

Adult focused

These tweets invoked scientific information to convey the message that gatherings of people who are vaccinated are safer and reduce anxieties relative to gatherings of the unvaccinated. Tweets also conveyed information about vaccination availability and locations, encouraging people to get vaccinated before Easter or providing days and times of testing and vaccination clinic locations during the Easter holiday. The use of slang and pithy slogans such as “grab your jab” or “get your whole family jabbed in one go” were also prevalent.

Child focused

Child friendly texts included cartoon images of superheroes with messages such as “be a vax hero” to promote vaccinations for children. These tweets utilized slang or fun phrases. One tweet included a cartoon character flying in the clouds with the words “I’m vaccinated & helping fight covid19.” Another tweet showed a smiling boy wearing a heroic costume and posing after getting vaccinated.

Celebrate Easter safely

These tweets focused on family and friends and invoked the value of caring for those close to you. Many tweets indicated the importance of getting vaccinated to keep people safe during gatherings, wearing masks, celebrating in ventilated spaces, sanitizing or washing hands often, and staying home and self-isolating when unwell. Hashtags included “#DoItAll to keep you & your loved ones safe from covid19,” #ForUsAll, and #HealthForAllByAll. Texts also included “By vaccinating you make family gatherings safe for you & family,” and “Take extra measures for ‘vulnerable’ & ‘immunocompromised’ family members.” Texts contained messages such as “Easter can be a time that brings friends & family together, so get vaccinated to keep everyone safe.” Tweets also promoted virtual gatherings and celebrations. Images portrayed families celebrating Easter outdoors while wearing masks as well as sitting at a distance from each other. The theme of caring for others, central to the Easter message of love and renewal, was highlighted.

Easter Bunnies and Painted Eggs Tweets used colorful pastel colors and playful symbols traditionally associated with Easter to convey safety messages about COVID-19. As such, eggs and bunnies which traditionally represent themes of new life and rebirth were prevalent. Images portrayed children playing with decorated eggs, flowers, plants, chicks, and Easter eggs decorated with drawings indicating COVID-19 safety measures such as masks, social distancing, ventilated spaces, etc. Images included a caricature of a bunny getting tested for COVID-19. These images were also paired with cute and catchy phrases such as “Hop your way to a covid19 vaccination clinic to keep Covid19 away this Easter,” “protect yourself & somebunny you love.”

Ramadan Themes

COVID-19 safety during Ramadan

The majority of these tweets focused on being safe, careful, and staying healthy during Ramadan. Tweets included messages to wear a mask when attending a place of worship if physical distancing is not possible, gathering outdoors rather than indoors when feasible to reduce the risk of COVID-19, suggestions to distribute individual pre-packaged boxes instead of holding mass meal events, use of one’s own prayer mat, and performing rituals like Wudu at home. Other pronouncements included not neglecting one’s health during Ramadan and having a “well-balanced diet and wholesome lifestyle to boost one’s immunity against viruses.” The tweets were associated with the values of the holiday such as “the holy month reminds us to stay safe from harm.” In addition, tweets encouraged people to not attend gatherings or events if they were feeling unwell or having COVID-19 symptoms. Images contained families packing hygiene kits such as masks and sanitizers for travel. Other images showed women helping children self-test at home. Hashtags included #celebrateSafely, #safeRamadan, combined with #covid19.

Crescent moon, stars, and lanterns

Images of traditional/ religious clothing such as hijabs, kurthas, and Kufis were prevalent in all tweets. In addition, religious symbols such as the crescent moon, lamps, and decorative stars, the Quran, mosques, and prayer rugs/mats were prevalent. Images included men and women in prayer with eyes closed and heads down and hands raised holding a string of prayer beads in their hand. Tweets contained phrases like “Ramadan Kareem,” “Ramadan Mubarak,” and “Iftar.” Emojis with text representing safety and religious symbols were used such as a closed gate indicating self-isolation and the use of a hands emoji to depict clean and praying hands.

Vaccine and social responsibility

Many tweets invoked the Quran and religious precepts regarding protecting oneself as well as those in the community by following safety measures such as getting the COVID-19 vaccine and encouraging loved ones to get vaccinated, especially those most at risk for severe disease and death. For example, tweets expressed Quranic precepts such as the importance of saving one’s life, the Islamic “duty to keep ourselves and our loved ones and communities safe,” and Ramadan being a time “when the smallest acts of kindness matter.” Community values were prevalent such as helping the elderly to get vaccinated, “doing your part,” and being “a champion in your community and help others get vaccinated, especially the elders & people at high-risk group.” Images included a man directing an elderly person to a vaccination center.

Myth busters

These tweets focused on combating vaccine related myths. Text included information such as COVID-19 vaccinations don’t contain pork, animal, and alcohol products and will not break the Ramadan fast. Other tweets referenced Islamic scholars, Muslim doctors, or professional societies such as the British Islamic Medical Association to promote a message that COVID-19 vaccines are acceptable for Muslims. Other tweets indicated that it is safe to get a COVID-19 vaccine and booster while fasting, though an afternoon or evening appointment might make it easier. A few tweets acknowledged concerns/hesitancy about getting a COVID-19 vaccine or vaccine side effects. These tweets encouraged people to get information from reliable sources and speaking to one’s healthcare provider.

Discussion

Misinformation has plagued COVID-19 vaccination campaigns, as well as other health related vaccination campaigns. For example, misinformation regarding the safety and efficacy of COVID-19 vaccine and dangers such as infertility and miscarriages in pregnant women has been prevalent. ²³ Accurate messages are essential to effective health strategies. ²⁴ Moreover, social media messages must consider cultural and religious elements, living and working conditions, and cultural attitudes. Such messages, especially in the context of a pandemic or other crisis, must also consider the disinformation and misinformation that has hindered preventative and proactive behavior.

General interventions and approaches to lower vaccine hesitancy and improve vaccine acceptance have primarily focused on promoting public trust and campaigns that offer transparent information about its safety and efficacy.^25,26 These foci were apparent in the tweets analyzed. In addition, the majority of tweets geared to people celebrating Easter and Ramadan included images of communities and families, which is consistent with the nature of both holidays. Most of the tweets were associated with positive/solution-based messaging and attended to culture, especially the ones associated with Ramadan.

Several differences emerged in messaging between the two holidays. For example, messages tailored to debunking myths about the COVID-19 vaccine were prevalent in Ramadan related messages but not in Easter messaging. In addition, Ramadan related messaging included more salient religious based text and images such as references to Inman’s, mosques, and the Quran, whereas references to the church, pastors, ministers, or the bible were relatively absent in Easter tweets. Bunnies AND Easter eggs, while representative of new life and rebirth, have become more commercial representations of the holiday. Relatedly, cartoon like images were prevalent in Easter messages. While Easter tweets promoted messages about children getting vaccinated, this was absent in Ramadan messages. Moreover, use of the term “jab” and cute and pithy phrases were prevalent in the Easter related messages.

Visual images were prevalent in the data analyzed, as is characteristic of tweets. Research indicates that visual images often stay longer in people’s minds and are especially important during high-stress situations where information-processing may be compromised. ²⁷ Given the multimedia nature of social media, attention to both the use of text and images in health communications is vital to fostering healthy behavior.

This research has significant implications for health-related messages and improving health communication which may positively impact diverse ethnic and religious populations. Online health information influences medical decisions. ²⁸ Previous research on mental health care has found that a lack of services adapted to the linguistic and cultural backgrounds of patients may account for lower utilization rates of primary care mental health services among immigrants and ethnocultural minorities.^29,30 Similarly, inattention to culture and contextual factors in messaging and online communications about COVID and vaccination may negatively impact perceptions of the vaccine and other protective behaviors. ³¹ Strategic use of health and risk communications is associated with public engagement and should be considered by public health organizations when designing messaging and communication campaigns. ¹⁰ For example, health education activities should not induce fear and anxiety already present due to the pandemic. ³²

Interestingly, most of the images, especially for Easter, depicted White communities. Images of Black or African American individuals, groups, or families were relatively absent. Considering the history of mistrust in the medical field, the relatively low level of vaccinations in Black communities, and high mortality and morbidity rates ³³ this seemed striking.

Limitations and Directions for Future Research

Several limitations should be noted. First, the analysis was focused on Twitter data. Similar and future studies may examine other social media platforms to build a more robust understanding of culturally relevant health related messaging on social media platforms. Second, this information was collected during a specific point in time and may have changed at different points in the pandemic. Third, our study aimed to analyze COVID-19 related tweets from verified health organizations to ensure the reliability and authenticity of the data. This focus inherently limited our dataset to tweets predominantly in English, as verified health organizations from predominantly English-speaking countries, along with international bodies like the who frequently use English in their communications. Inclusion of non-English tweets may have resulted in a more nuanced analysis.

It is important to consider that some populations may not use conventional media or social media. ¹² Understanding the degree to which relevant and accessible channels for communication with the intended audiences during pandemics and other health emergencies is crucial. In addition, it must always be recognized that no group is a monolith and there are significant differences within each religious community. Future research may test the relationship between both the text and images of social media messages and health related beliefs, attitudes, and behaviors. Persuasion is most effective when the frame of the message delivered and the recipient of the message are culturally congruent.^34,35 Consideration to the importance of co-creating messages with communities ³³ is warranted. Moreover, to capture a broader spectrum of cultural and religious influences on public health messaging, future research would include tweets in multiple languages. This approach would provide a more comprehensive understanding of how different cultural and religious contexts impact public health communication during pandemics.

Conclusion

This study of covid-19 tweets during the overlapping holidays of Easter and Ramadan provided insights into the use of culturally relevant health messaging. The research highlighted the ways in which major health and government organizations address vaccine hesitancy and promote safety within different cultural contexts.

Tweets related to Easter and Ramadan employed varied messaging strategies, reflecting the unique aspects of each holiday. Easter-themed tweets often utilized playful symbols and child-friendly images to convey vaccination messages, emphasizing the importance of safe gatherings and community care. In contrast, Ramadan-related tweets focused more on religious precepts and community values, integrating Qur’anic references and traditional imagery to encourage vaccination and debunk myths about the covid-19 vaccine.

Overall, the research underscores the necessity of culturally sensitive health communication, especially during pandemics. The strategic use of text and imagery tailored to specific cultural and religious contexts can enhance public engagement and promote healthier behaviors. Future research should expand to include a broader range of social media platforms and non-English tweets to capture a more comprehensive understanding of health communication across diverse cultural and religious landscapes.