Did public health campaigns reinforce heteronormative gender norms?
We examined the campaign items the Brazilian governmental agencies produced in 2016 and 2017, aimed at eradicating the Zika virus spreading. The Federal Ministry of Health generated around 70% (68 of 94) of the analyzed material. Although state and municipal administrations also have their own campaign materials, they more often reproduced the materials made available by the Federal Ministry of Health.
The same communication strategies against dengue and the mosquito Aedes aegypti were used amidst the Zika emergency. Seventy-five of 94 pieces (almost 80%) contained information on how to destroy mosquito breeding sites. While most items offered recommendations categorized as housework, a strict gendered responsibility was not explicitly vocalized (6 of 55 pieces on mosquito breeding prevention depicted women as a perceived audience, none contained men). The colors used in these pieces usually remained gender-neutral, typically bright yellow and red conveying urgency. Taken as a whole, campaign pieces using a single phrase to promote mosquito eradication (internet pop-ups, street banners) did not target one specific gender.
[Figure 1 about here]
[Figure 1: Internet/print media pop up. Translation: Attention! Everything that accumulates water is a focus for mosquito breeding. One mosquito isn´t stronger than a whole country.]
Nevertheless, when it came to the 20 unique pieces employing longer text and information on mosquito bite prevention in addition to information on destroying mosquito breeding sites, 9 of 20 portrayed women as perceived or stated audiences, none contained men.
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. Television video announcements, folders and pamphlets (more expensive but conveying more information than pop-ups or street banners), dealt exclusively with the primary microcephaly risk or at least highlighted the microcephaly danger.
In that line, we observed that campaign pieces handling pregnancy and microcephaly demonstrated robust gendering, drastically targeting women, placing the responsibility for protecting a potential fetus from the disease on females (7 of 15 ads entailed women as the stated audience, none comprised men) as found in Dengue campaigns analyzed by Campos (50) and gender advertising analyzed in Corrêa (71). Besides content, these pieces typically used pastel colors, a decision further communicating the intended audience: pregnant women.
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). Of 15 items tackling microcephaly, women were portrayed in nine pieces and depicted by themselves in seven. The pamphlets displayed in Figure 4a and Figure 3 portray pregnant women with hands placed on their bellies. Three items show a male figure, but only one male partner or family member is addressed.
[Figures 2a and 2b about here]
[Figure 2a: Front side of the folder prepared by the city of Recife.]
[Figure 2b: Backside of the folder prepared by the city of Recife.]
[Figure 3 about here]
[Figure 3: Folder prepared by the Ministry of Health]
[Figure 4a and 4b about here]
[Figure 4a: Front side of the folder prepared by the Municipal Government in Belo Horizonte.]
[Figure 4b: Backside of the folder prepared by the Municipal Government in Belo Horizonte.]
One Brazilian federal campaign TV ad [See pictures in Additional File 2, 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 concluded 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 the family health prevention expert while men remained disengaged, even as prevention subjects. The item tone resembled women's testimonials in our focus groups, who described their partners as ‘another child to look after.’
We, moreover, uncovered 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. The Brazilian communication situated women as competently dealing with pregnancy and caring during the Zika epidemics while the male remained detached from caring and parenting responsibilities (60). Across all material studied, we did not discover a single piece speaking directly to men.
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 “separate part of their Saturday from combatting the mosquito.” While the woman filled the flower vase with sand, her partner stood on the roof (Figures 5a and 5b), so the stereotypical abilities were portraid in the media pieces (5,50,71).
[Figure 5a and 5b about here]
[Figure 5a: woman places sand inside the flower vases.]
[Figure 5b: A man uses a ladder to reach the roof and clean the gutters.]
Other important aspects were tacitly communicated: pregnancy and contraception management. 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). For both scenarios, the items advised women 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 (16,53), 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 that piece, it is the only one to indicate contraception management within couples. Nevertheless, the ad relied on the perplexing assumption women would be able to implement their fertility decisions, giving ample information on the country’s high rates of unintended pregnancy, as well as the sparse condom use reported by disadvantaged women (46).
Additionally, few Zika campaign pieces stated the virus could be transmitted through sex, as Figure 2b depicts. 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.
Men could become infected with Zika by failing to take the measures widely recommended for women (such as wearing long sleeves), or by engaging in sex with someone infected. Besides, a woman could become infected through her partner, even if she diligently followed all recommendations for preventing the disease. Hence, we postulated since the emergency tapped into pregnancy and childrearing, both quintessentially female tasks, competencies were assigned to women as predicted by gender scholars (5,16,27–33).
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 arrangements charging women with family healthcare and prevention. Interestingly, some participants tied this communicational strategy with the broader public health campaign issue, 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 the 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]
Answering the second and third research questions involved the individual level via focus groups.
While most women in our focus group 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. The participants 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]
These biological, essentialist perceptions, legitimized traditionally gendered labor in which women were responsible for preventing the Zika virus from spreading because those responsibilities fell into the female realm. As Campo-Engelstein (58) also demonstrated, dominant masculine ideologies have inhibited female trust in males engaging with sexual and reproductive health. This widely-held view presented an ideological consensus between men and women, solidifying the status quo and, likely, averting conflict (63).
Furthermore, we observed gender norms regarding the care and labor division were described as ‘cultural’ traits instead of due to biological differences. These testimonials were more common among high-SES participants than their lower SES counterparts.
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: 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. While these women did not describe such differences as biological, they articulated the word culture with a similar fatalistic tone.
Males carrying out their desires despite women expressed 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]
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 sharing their experiences (using the first person) and indicating their partners did not like condoms, so they as a couple did not use them despite women expressing opposition, as previously found in the Brazilian literature (17–23). Many females blamed their unintended pregnancies on their partner’s inflexibility.
In contrast, high-SES women often elaborated extensively on their empowerment. While typically advantaged women referenced profound gender inequalities across all Brazilian society, these women also described themselves as financially independent, controlling their sexuality and negotiating condom practice successfully. Among high-SES women, experiences of low empowerment were articulated subtly, in the third person, referring to friends or family experiences. Advantaged women did not reveal complications associated with contraception management. Nevertheless, some participants acknowledged men did not like condoms, so women had resort to other methods (5,30,34,58–60,63):
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]
Crucially, the umbalanced dynamic ‘compelled’ women to use the pill or another contraception method. Pregnancy presented the foremost Zika threat, so high-SES women successfully prevented pregnancy through other methods.
When partner sexual fidelity was brought up, most low-SES women supposed their partners could be unfaithful. Although the result of such negotiations remained unclear, some women even discussed sexual infidelity with their partners asking them to impose condoms habits in the extra-marital relationship. 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]
Women in our focus groups expressed discontent with their partners’ prone to sexual infidelity, yet, some remained unable to negotiate or contest their behavior (27,29,32). Consequently, these testimonials suggested men did not openly face conflict with their partners due to sexual unfaithfulness. Besides, women voiced they would like to use condoms, but they refrained from asking since they already knew their partners’ answers. Therefore, according to these females, the Zika emergency did not threaten masculine privilege, including condom negotiations.