Did public health campaigns reinforce heteronormative gender norms?
We start by examining the campaign items that Brazilian governmental agencies produced in 2016 and 2017, aimed at haltering the Zika virus epidemic. Descriptive statistics are available on Table 1. Out of 94 pieces, about a third (32) were short internet or print posts (Figure 1), followed by folders (16), posters (14) and TV ads (11).
Brazil’s Ministry of Health generated around 70% (68 of 94) of the analyzed material and has produced a more diverse range of materials compared to the other institutions (Table 1, Panel A). Although state and municipal administrations also have their own campaign materials, they more often reproduced the materials made available by the Ministry of Health[1].
Table 1, panel B brings a description of the main topic or messages being delivered by the type of communication strategy. As each communication piece may carry more than one message the total count (188) refers to the number of messages, not the number of pieces.
The same communication strategies against dengue and the mosquito Aedes aegypti were used amidst the Zika emergency. Seventy-nine of 94 pieces (almost 85%) contained information on how to destroy mosquito breeding sites by not allowing standing water to occur (Table 1, panel B). A mosquito is present in 68 out of the 94 pieces, either as a picture or drawing (not shown). The colors used in these pieces usually remained gender-neutral, typically bright yellow and red conveying urgency (percentage not shown).
The fact that Zika can be transmitted from a pregnant woman to her fetus, causing microcephaly, is a vital distinction between the Zika threat and dengue. Nevertheless, much fewer are the pieces containing information on microcephaly (22), Zika symptoms (21), personal protection measures against mosquito bites and information about importance of seeking health care (17 each) and taking additional care during pregnancy (16) (Table 1, Panel B). Only 6 pieces mention the necessity of speaking to a physician if one wishes to get pregnant and only 3 out of 94 pieces mentions the necessity of wearing condom or contraception during the epidemics. Not a single TV or Radio ad, or even short post mention the necessity of using condom or contraceptive or the importance of talking to a health professional in case one wishes to get pregnant during the Zika epidemics. Importantly, none of the pieces, not even the ones about contraceptive use provides information about sexual and reproductive health (SRH) services free of charge in public health clinics. Besides, none addresses contraceptive negotiation in intimate partner union.
In order to evaluate the main perceived audience (Table 1, panel C), each piece was recoded in order to assign a single category of main perceived audience. Further, we applied the following order of importance: woman, person responsible for household, general public. Thus, if a piece contained information targeted at both woman and/or a person responsible for the household, the category was classified as “woman” as this category is more relevant for the analysis. None of the 94 pieces were targeted to men. Taken as a whole, campaign pieces using a single phrase to promote mosquito eradication (posts, billboards and busdoors) did not target one specific gender, as the proportion of pieces targeting the general population and sometimes the person responsible for the household were much higher (Table 1, panel C). However, posters, folders and TV ads seem to aggregate more messages towards women.
On Table 2, the 188 Zika public health dissemination campaign materials´ main messages were then analyzed according to their main perceived audience and presence of female and male figures on the piece. The 79 messages regarding eliminating standing water, a recommendation categorized as housework, almost equally targeted the general population (35) and the person responsible for the household (31) without having a strict gendered responsibility expressed. Nevertheless, 13 of those 79 pieces depicted women as a perceived audience (none depicted men). Regarding messages about Zika symptoms: out of 21 messages, 12 were targeted at the general public, 4 the responsible for the household and 5 to women.
But when it comes to messages about seeking health care, taking special care during pregnancy, talking to physician if wishes to get pregnant, condom use or contraception, information about microcephaly or measures of personal protection against bites, the messages are heavily gendered as women (especially pregnant) are the main perceived audience of those messages and were also more often illustrated at the pieces by the utilization of images, drawing or narrating voices (Table 2). Out of 22 total items tackling microcephaly, 11 targeted women directly. Women were portrayed in 13 of those pieces, being depicted by themselves in five of them. In the 17 pieces about personal protection about mosquito bites (last column on Table 2), women are depicted 13 times, almost double the times that males were depicted (7). Babies, microcephalic or not, appear in 7 pieces (not shown).
Since some announcements were more informational or educational about the disease, they sometimes encompassed lengthy text. However, others directed the audience using a single phrase (“Get rid of standing water in your backyard”) without telling them why to do it. Table 1 at the Additional file 2 brings an analysis of 72 pieces that were in print format (excluding TV and Radio of any sort) comparing the 21 pieces that included lengthy texts conveying more information (brochure, folder and infographic) with the 51 remaining pieces which contain short messages. Lengthy materials require more effort from the reader to extract information. In the lengthy ones, women continue to be portrayed more often than men and the concern with Zika symptoms (14 out of 21) and the information about the measures of protection against mosquito bites (10 out of 21) receive substantial attention.
Lengthier pieces. We now dive into campaigns where the scenario of gender becomes even more evident. First, we will discuss the 21 print media with long texts, and then we will analyze some examples that include TV ad.
For print media with long texts only (comprised of brochure, folder and infographic), Table 3 shows the proportion of pieces in which females and males are depicted and also the main perceived audience for campaigns handling personal protection against bites (Table 3, panel A), microcephaly (Table 3, panel B), and special care during pregnancy (Table 3, panel C).
Women are the stated audience in 60% (6 out of 10) of pieces about personal protection about bites. When it comes to pieces containing microcephaly in its subject (6 pieces in total), the presence of females is more pronounced than in comparison with males, who tend to be more absent from those pieces (Table 3, panel B). Four out of 6 long-length pieces about microcephaly were perceived as being intended for females (66%).
For pregnancy, the story is even more striking and those pieces drastically target women, placing the responsibility for protecting a potential fetus from the disease on females. Seven out of 8 pieces (85%) only targeted women (Table 3, panel C). Besides content, these pieces typically used pastel colors, a decision further communicating the perceived audience: pregnant women (not shown).
We next present some examples of communication pieces. Figure 2a presents one pamphlet with the headline “Women against Zika.” Other typical headlines read “Pregnant Lady: Protect Yourself” (Figure 3) and “If you are pregnant, protect yourself and go to prenatal care. If you want to get pregnant, talk to your doctor”. Using female pronouns exclusively, the announcements directly referenced women (see Figures 2b and 4b) and intensively focus on pregnancy (5,35).
The pamphlets displayed in Figures 3 and 4a portray pregnant women with hands placed on their bellies.
One Brazilian federal campaign TV ad [See pictures in Additional File 3, Figures 1a-1c] displayed the protagonist— a young pregnant woman— walking around her home explaining the fetal microcephaly risk and how to prevent mosquito breeding within the dwelling, as well as mosquito bites. Her husband carried a bucket in the background. The piece concludes with the protagonist sitting with two male family members, likely her partner and adolescent son, watching TV. Only she (the protagonist) talked to and engaged with the audience, addressing women exclusively. Therefore, the piece clearly charged women with Zika containment and presented females as family health prevention experts while men remained disengaged, even as prevention subjects.
We uncovered further pieces explicitly assigning women the familial protection responsibility (16,30). Thus, the flier portrayed in Figures 4a-4b openly advised a pregnant woman to protect her dwelling against the mosquito. These campaigns situated women as competently dealing with pregnancy and caring during the Zika epidemics while the male remained detached from caring and parenting responsibilities (63). Across all materials we examined, we did not find a single piece speaking directly to men.
Males were often depicted in as, as can be seen on Table 2, but were rarely the protagonists, sometimes just lending parts of their bodies or assuming a secondary role. In many cases, they lent their voices to narrate a radio ad or posed on print materials as a physician, both roles that imply a position of power, not of victimization or responsibility.
When men were illustrated doing chores, they were performing typically gendered activities, like physically lifting heavy loads. In a widely broadcasted 2015 TV campaign, gender roles were portrayed separately when the narrator suggested the audience should “spend part of their Saturdays doing activities to contain the spread of the mosquito.” While the woman filled the flower vase with sand, her partner was fixing the roof (Figures 5a and 5b), portraying gendered stereotypical abilities (5,49,50).
Other important aspects of the ads we examine such as pregnancy and contraception management were tacitly communicated. The pamphlet in Figure 2b includes specific advice directed to females wishing to get pregnant (Se Deseja Engravidar) and those who do not (Se Nao Deseja Engravidar). In both scenarios, women were advised to visit a health center accompanied by their partners to discuss their options together, with a health professional. The underlying communication message assumed women bore the responsibility of contraception (16,51), which encompasses informing themselves about the risk Zika imposed on pregnancy, explaining it to their partners and persuading them to discuss Zika prevention with a healthcare professional. Despite the limitations of this piece, it is the only one that portrays contraception management as a couple issue. Most pieces that addressed contraception only presented women.
Additionally, few Zika campaign pieces stated the virus could be transmitted through sex (Figure 2b). The third paragraph in the 2nd column (pamphlet back) mentioned this possibility and recommended condom use. This content included in the section ‘For those who are Pregnant’ (Gestante) neglected women who are not pregnant. The challenges of implementing safe sex, discussed in the next sections, also remained unaddressed.
We now turn to the analysis of focus groups in Recife and Belo Horizonte. Unsurprisingly, women overwhelmingly felt targeted by the Zika campaign.
Participant 1: That’s all that was discussed [Zika campaigns focused more on women] Never it was said: ‘fathers, please, if your wife is…’ That it was never said, in no form of communication. (…) I did not see anything [any campaign piece] that talked about it, ‘parents or husbands who intend to have children, be careful not to have Zika, not to transmit to their wives through sex.’ This was never said.
Participant 2: The [campaign] image, I remember the posters I saw, in institutional environments, even at work, there are two [campaign] images: the mosquito and the woman. You do not see a male figure shown. It's either the mosquito or the woman. [High SES]
Participant 3: At least my husband associates Zika with babies. Microcephaly.
Participant 5: You would only had heard one thing if you had this session with men. "What there is to talk about Zika? That produces malformations on babies.” Done, it's over. Only that. Men do not have that much interest [on the topic of Zika]. They say: "ah, I will not get it; it will not reach me."
Participant 10: But then I think it is a matter of information because you hear a lot that it causes microcephaly, so men create a barrier in his mind, that he does not need to protect himself because it affects the baby [not himself]. [Low SES]
Importantly, most women in the focus groups, regardless of social class, criticized this approach, challenging traditional gender arrangements charging women with family healthcare and prevention. Interestingly, some participants tied this communication strategy with the broader public health campaign issue of typically reaching women and not men:
Participant: I think public health should invest in men. Here in my neighborhood`s health clinic, you see they are having focus groups for pregnant women, diabetics, people with hypertension, adolescents…but if you go in the day, they are having focus groups for adolescents when they have family planning, how many of those adolescents are men? [Low SES]
This finding summarizes the affirmation that Zika campaigns profoundly relied on heteronormative gender norms.
What role did gender play in shaping how women navigated Zika and pregnancy prevention during the epidemic with their partners?
“Women suffer more [than men]. Women are born to suffer.” [Low SES]
We address our second and third research questions by examining the individual level via focus groups. While most women in our focus groups expressed frustration at being targeted by the campaigns, they also expressed essentialist views on why women shouldered the burden associated with family health prevention. That is, the same participants who complained about the focus of the campaigns also elaborated on womanhood intrinsically being tied to care work. For several participants, regardless of SES, motherhood informs female identity even before bearing a child, and the fact that women (and not men) can become pregnant makes them more aware, interested or responsible for dealing with health-related matters. Participants further reflected on why they thought female characters remained more prevalent in the campaigns than men:
Participant: Because women live the pregnancy more intensely. Because she is carrying, she has to change her diet, and men do not. (…) I think a mother would feel guiltier if she gets bitten and transmits [Zika] to her baby [High SES].
Participant 1: They [men] do not even want to know. The woman is the one who gets worried, same in case of illnesses. You seldom see a man concerned with illness. Is the woman who cares.
Moderator: Why?
Participant 1: Because the one who gets pregnant is the woman.
Participant 3: A woman is more concerned more about her health [than a man]. Men do not like going to the doctor.
Participant 1: A woman, when she becomes pregnant, she becomes a mother. So, she cares about the baby.
Participant 3: When you have a child to raise, you think about yourself. You do your exams regularly. Men do not; if a man goes to the doctor, it's because he's about to die. [Low SES]
Furthermore, we observed gender norms regarding the care and household labor division were described as ‘cultural’ traits instead of socially constructed differences. These testimonials were more prevalent among high-SES participants than their lower SES counterparts and oftentimes are spoken with a fatalistic tone.
Moderator: We are going to talk about women and men now. If your [female] friends were not using repellent, would their husbands use it (repellent)?
Participant: No.
Moderator: Why?
Participant: Because of this culture [High SES]
Participant 6: It is culturally unfortunate that this is still the case; the responsibility is of the mother. If a father abandons his child, nobody judges him or says anything against him, but if a mother abandons her child, [it is] everyone, Oh My God, everyone is against her. There is no one who would defend her; it is always like this. [High SES]
Clearly, culture was connected to the same female-assigned duties and characteristics—family caring and childcare responsibility. Male partners carrying out their desires despite women’s opposition also emerged subtly through the focus groups. While not prevalent, participants spoke of women discussing an issue in hopes of changing partner behavior. This attempt likely resulted in a conflict, demonstrating women failed in their attempt.
Participant 4: I think it should be the same [men and women have the same level of responsibility over contraceptives]. But in reality, it is not. The woman is the one who takes more attitudes and more responsibility for herself, sometimes (…) Because if she takes the condom to her husband's hand and he does not want to use it, because since she is married, she will give in. That is, she does her part, but he does not cooperate. So folks, ‘we will not be fighting, we won’t keep arguing over a condom.’ We think it is a silly thing, but in reality, it is not. [Low SES]
Moderator: And have you two talked about sexual transmission [of Zika]?
Participant 5: Yes
Moderator: And did you start using condoms?
Participant 5: No
Participant 6: I told my partner: ‘I am with Zika, you will get it.’
Moderator: And what happened?
Participant 6: He did so much and got it.
[Parallel talk, laughter]
[Low SES]
All groups asserted a defeatist tone. Yet, the way women navigated this challenge differed by social class.
Did social class variations significantly affect how women negotiated the Zika infection threat?
‘Since they do not have that burden on their side, the woman is the one who has to protect herself.’ [High SES]
We face everything in silence. [Low-SES]
Many working-class women expressed how enforcing condom practice with a stable partner had proven challenging. Since men generally disliked condoms, women feared endangering their relationship if they insisted on condom use.
Moderator: And why does the woman end up giving up? [having sex without using a condom]
Participant 1: [Because they] Like the man
Participant 2: To please the partner.
Participant 3: Because it's that thing: will he get annoyed and just not want you anymore? So he says: Never mind. He gets angry and does not want you. [Low SES]
Commonly, low-SES women in our focus groups discussed these difficulties (using the first person) indicating their partners did not like condoms, so they as a couple did not use them despite women expressing opposition, in line with previous studies (17–23). Many females blamed their unintended pregnancies on their partner’s inflexibility.
In contrast, high-SES women often elaborate extensively on their empowerment on this subject. While high-SES women referenced profound gender inequalities across all aspects of Brazilian society, they also described themselves as financially independent, controlling their sexuality and negotiating condom use successfully. Among high-SES women, experiences of low empowerment were articulated subtly, in the third person, referring to friends or family-members’ experiences. High-SES women did not reveal complications associated with contraception management. Nevertheless, some participants acknowledged men did not like condoms, so women had to resort to other methods (63–65):
Participant 6: [If asked about Zika, some men] might say, ‘my girlfriend protects herself.’ Done. I have nothing to do with it; she protects herself. Mainly because many men hate to use condoms, it is a very common thing among them [men], the use of condoms, they detest, then compel the woman to use contraceptives, they practically oblige [women] because they hate to use condoms. I've seen a lot of this, I have a lot of male friends, and they always say that: ‘I hate using condoms. (…) If she gets pregnant, it's not my fault; she is the one who got pregnant.’ [High SES]
When partner sexual fidelity was brought up, most women expressed that their partners could be unfaithful. Although the result of such negotiations remained unclear, some women even discussed imposing condom use in extra-marital relationships. Often women described those conversations with their partners using light-hearted or playful language.
Participant 1: So, for me, whatever is fine [wearing a condom or not]. I think so…for women, whatever. ... as people say here, when they [men] use condoms they feel like chewing gum with the plastic wrap, my husband says that. Then I do not know.
Moderator: And do you think condoms are bad for women?
Participant 1: So, we do not know what partners are doing on the streets, do you understand? They can pick up other women who have diseases and pass them on to people at home. So, with a condom, if they [men] accepted, it would be pretty safe. For people at home, for example. For instance, in my case, because I do not trust mine [my partner].
Moderator: Got it. Do you trust yours?
Participant 4: No.
Participant 7: I trust with suspicion.
Moderator: So, in connection to the fact that you ‘trust distrusting?’ Do you change your behavior?
Participant7: No [Low SES]
Consequently, these testimonials suggested men did not openly face conflict with their partners due to refusal to wear condoms. Therefore, the Zika emergency did not threaten masculine privilege.
[1] Unfortunately, we are unable to track how many of the pieces produced by the federal government were reproduced by the local agencies and in which frequency.