Representation of the black woman on the Brazilian Ministry of Heath advertising posters

www.ee.usp.br/reeusp Rev Esc Enferm USP · 2018;52:e03399 1 Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Programa de Pós-Graduação de Enfermagem em Saúde Pública, Ribeirão Preto, SP, Brazil. ABSTRACT Objective: To describe and analyze the forms of representation of black women in posters used by the Brazilian Ministry of Health for advertising campaigns on women’s sexual and reproductive health. Method: Descriptive, exploratory and documentary study with advertising posters addressing the promotion of women’s sexual and reproductive health, available at the Virtual Health Library Brazil. For the analysis of data, the thematic content analysis was used. Results: Out of the 498 identified posters, 161 addressed women’s sexual and reproductive health. After applying the exclusion criteria, 41 posters remained, of which 31 (75.6%) represented a white woman, nine (21.9%) a black woman, and one an indigenous woman (2.4%). Data analysis converged to two analytical categories: the pseudo representation of black women; and women’s sexual and reproductive health limited to pregnancy and postpartum. Conclusion: The representation of the black woman in the advertising posters of the Brazilian Ministry of Health is low, and the themes addressed in the posters do not contemplate all the phenomena that make up the sexual and reproductive health of women during their life cycle.


INTRODUCTION
The scarcity of studies on the health of Brazilian black women is a reflection of the racial inequalities in the country (1) .In Brazil, black women are less educated, have lower socioeconomic status, have less access to good quality health services, and are more at risk of illness and death than white women (2)(3) .
Recently, a study (4) with the objective of evaluating the inequities in prenatal and childbirth care according to race/color, with data from the research "Birth in Brazil: National Survey Into Labour And Birth" , demonstrated that, compared to white women, postpartum black women were more likely to receive inadequate prenatal care, to have no link with a maternity, to have no companion during delivery, to seek more than one hospital for childbirth and were less likely to receive local anesthesia for the episiotomy.These cumulative disadvantages caused by the intersection of class, race and gender discriminations aggravates the scenario of black women's health, making them more vulnerable to early pregnancy and to the human immunodeficiency virus (HIV ) (5) .
In order to deal with the unfavorable conditions experienced by black Brazilian women, it is necessary to recognize racism as one of the central reasons for the health inequalities that mark the lives of these women (1) .In addition, it is necessary to further comprehend the multiple dimensions of racism in society's power relationships (1,6) .Some authors (1,6) discuss about the three main dimensions of racism in the lives of groups and individualsinternalized, institutional and personally-mediated racism.Internalized racism occurs when individuals incorporate socially established racist notions, perceiving themselves as inferior; personally-mediated racism is defined by prejudice and discrimination between individuals; and institutionalized racism is manifested when an institution fails to provide professional and qualified service to a person due to their color, ethnicity or culture (1,6) .
Considering that the culture of a group is not its primary characteristic, but a consequence of its form of organization (7) , and understanding racism in all its dimensions as a cultural phenomenon that is historically constructed and transmitted (1) , to change this scenario implies intervening in actors influencing the constructions and organizational forms of society.In this sense, it is necessary to reflect on the role of media in the perpetuation and reproduction of social conventions about race and ethnicity.More specifically, communication media stands out as a significant source of information for the public, and this information reflects and influences social norms and values and can also generate changes in the cultural structure of a country (8) .
Communication media includes several different platforms that can disseminate varied information and content.Television, radio, the press, the music industry, advertising and the internet are examples that can be cited.Thus, the posters used in the campaigns of the Brazilian Ministry of Health (MH) are part of this universe as instruments that transmit knowledge and information.
Reality is built by its subjects, not only through words, but through various means, which include visual images (9) .To define the content of a poster, it is necessary to start from the message it wants to convey and the audience it wants to reach (10) .It should also be considered that the message received goes beyond the one that is transmitted, because the impact generated in the receiver is the result of several subjective factors.Therefore, all parts of the posters are essential to consider, including text, context and even the layout, so that each of these elements can contribute to lead the reader to question paradigms and acquire new knowledge (10) .
Given this reflection and with the support of the Social Representations theory (11) articulated to the category of race and color, in the context of the MH campaigns, it is understood that, the representation and the way this representation occurs can influence the social construction of the image of black women and contribute to the perpetuation of the social inequities that mark the life of these women.
It is through social representations that individuals communicate and construct the meanings they attribute to the world.Spontaneously originated in everyday life, these representations are dynamic and transform according to time and space (11) .A systematic literature review (12) demonstrated that several researchers have emphasized the role of the mass media in the construction and dissemination of social representations.Based on their review, the authors were able to conclude that "1) The media has an important role in the construction and dissemination of social representations; it is able to manufacture, produce, reproduce and, at the same time, disseminate a large amount of information, recognized as social representations; and 2) The media has the pragmatic function of forming and guiding the thoughts and attitudes of human beings" (12) .
Given the above, it is necessary to emphasize the importance of discussions on racism, aiming at overcoming obstacles and inequalities in the health care provided for the black population and, particularly, black women.As visual artifacts, posters used in health campaigns can disseminate social and ethnic values (10) .When seeing images that do not contemplate their reality on health posters, black women may feel unmotivated and insecure to pursue health care and perform self-care practices.Thus, the present study sheds light on the importance of black representation on health promotion campaigns.The objectives of this study are to describe and analyze the forms of representation of black women in advertising campaigns addressing women's sexual and reproductive health, using the theory of Social Representations and based on posters available in the Virtual Health Library (VHL; in Portuguese BVS -Biblioteca Virtual em Saúde) and used by the MH.

Study type
Descriptive, exploratory, qualitative and documentary study with advertising posters aimed at promoting sexual and reproductive health of women, available in the VHL.The data were interpreted based on the theory of Social Representations articulated to the category race and color.

data Source
The material of the present study was composed of all posters elaborated for the MH advertising campaigns that were available in the VHL.The inclusion criteria were posters aimed at promoting women's sexual and reproductive health.Exclusion criteria were posters that were duplicated, difficult to download, only displayed written information, did not contain a representation of a woman's face or were monochromatic.

data collection
The data were collected online on the website of the VHL of the MH in June, 2017.Data collection began with the choice of material to be analyzed, that is, the advertising posters on women's sexual and reproductive health.This choice followed the specific inclusion criteria and, for the purpose of this analysis, only the posters that represented a black woman were considered.For this, race was assessed by a method of hetero-classification of racial belonging, which considered the following phenotypic characteristics: skin color, hair and facial features (nose shape, eye shape, mouth shape and lip thickness) (13) .The racial classification used was from the Brazilian Institute of Geography and Statistics (IBGE -Instituito Brasileiro de Geografia e Estatística).In this classification system, five categories of color or ethnicity are used: white, black, brown (mixture of color, racial miscegenation), yellow and indigenous, and the Brazilian black population is comprised of black and brown subjects (13) .

analySiS and treatment of data
The analysis of the data used the method of thematic content analysis (14) .This method comprises a set of techniques of communication analysis aimed at obtaining indicators (quantitative or not) that allow inferring knowledge related to the conditions of production/ reception of these messages, through systematic procedures and objectives of description of the content of the messages (14) .The stages of the content analysis were: pre-analysis; exploration of material or coding; treatment of results, inference and interpretation (14) .In the first stage of the research, all the posters available in the VHL were analyzed, and those that met the inclusion criteria of the study were downloaded.After applying the exclusion criteria, the remaining posters were classified regarding the representation of the black woman.Then the elements and ideas contained in the posters were grouped in broader concepts, and then analyzed.

ethical aSpectS
Because it is a documentary study that only used data from public domain, the research did not require the approval of the Research Ethics Committee.

RESULTS
Out of the 498 posters available on the VHL website, 161 were related to women's sexual and reproductive health.After applying the exclusion criteria, 41 posters remained, of which 31 (75.6%)represented a white woman, nine (21.9%) a black woman, and one an indigenous woman (2.4%), as shown in Figure 1.Table 1 shows the description of the black women portrayed in the posters, according to the name of the poster as it appears in the VHL, year of publication and thematic context.
In most posters, black women were portrayed in contexts related to pregnancy and postnatal care.Among the nine posters that represented a black woman, seven (77.7%) addressed prenatal, delivery and postpartum women's care.One (11.1%) poster promoted the use of condoms during Carnival, and one (11.1%)addressed the prevention of cervical cancer in women aged 35 to 49 years.Regarding the physical characteristics of the black women presented, straightened hair was observed in three (33.3%) of the nine posters, and brown skin, in eight (88.8%).Except for one poster, all the others portrayed an image of a black woman smiling.
The data analysis allowed the identification of thematic units that converged to two analytical categories: the pseudo representation of black women; and women's sexual and reproductive health limited to pregnancy and postpartum.

DISCUSSION the pSeudo repreSentation of the black woman
Women make up more than half of the Brazilian population (51.5%), and half of these women (51.7%) are black (black and brown) (2) .It is understood that the representation of black women would be real if this percentage was also present in the publicity campaigns in question.That is, 51.7% of the posters produced by the MH for the promotion of women's sexual and reproductive health should portray an image of a black woman.However, the image of the black woman was only present in 21.9% of the posters.On the other hand, white women, who represent 47.5% (2) of the Brazilian population, were observed in 75.6% of the posters.
The advertising posters, as products of the cultural industry, provide images, discourses, materials and models for people to construct their sense of class, ethnicity, sexuality, as well as their identity (16) .In this sense, the lack of representation of black women hinders their recognition as a person with a valid body worthy of receiving health care.
The erasure of the black woman from the MH advertising posters is an extension of what already happens in spaces of prestige in society.In the hierarchical social structure, the space reserved for black women is one of less power, since, in addition to the vicious dynamic of ethnic-racial relations, there are also gender and social inequalities (5) .
Therefore, the MH campaigns contribute to the perpetuation of a social structure in which black women are invisible and silenced.This fact hinders their social and intellectual advancement and contributes to the submission of these women who, even though they do not receive the same treatment and opportunities as white people, do not protest this scenario, because they do not see themselves as worthy of these rights and attribute their situation to themselves and to their color (17) .This lack of awareness as subjects of law further exposes these women to diseases, with repercussions on their physical and psychological health (17) .
The discrimination and stereotyping experienced by the Brazilian black population, especially by black women, is the result of constructions driven by the myth of racial democracy, which was strategically implanted in the Brazilian social imaginary (18) .The fallacy of harmony between races denied the existence of socially established racism, which, in a veiled way, is perpetuated up to the present day (18) .However, the myth of racial democracy still reigns in the Brazilian social imaginary.
A study on the meanings attributed by health professionals to the Comprehensive Health Care National Policy of Black Population (In Portuguese Política Nacional de Saúde Integral da População Negra -PNSIPN) (19) demonstrated that, in the participant's perception, "actions aimed at racial equality are unjustifiable" (19) , meaning that "there are no racial inequities that justify a different treatment for the black population, evidencing that discrimination is not perceived or is affirmed as non-existent, which contributes to the inertia of the system regarding this scenario and, consequently, to its perpetuation and expansion" (19) .
The social invisibility of black women makes their biopsychosocial necessities invisible as well.The representations identified in the speeches of the professionals participating in the aforementioned study are daily reinforced by advertising and by the media, as they exclude and reinforce stereotypes Chart 1 -Description of the posters in which black women were portrayed, according to the name of the poster as it appears in the VHL, year of publication, and thematic context -Ribeirão Preto, SP.Brazil, 2017.

Name of the poster Year Description of the black women portrayed in the poster Thematic context
New journal for the pregnant woman: SUS care everyday with you.2014 Poster about the new journal for pregnant women with the figure of an adult young woman, identified as black by her brown skin, curly hair and nose and lip shape.She is smiling while presenting the new pregnant woman's journal.

Pregnancy and postpartum
You are pregnant!: pregnancy journal (woman with her hand on her chin).2014 Poster about the new pregnancy journal with the figure of an adult young woman, identified as black by her brown skin, hair (straightened) and nose and lips shape.She is smiling while reading the new pregnant woman's journal.

Pregnancy and postpartum
Having a companion contributes to a good pregnancy and a good delivery: the pregnant woman's journal.

2014
Poster about the new pregnant woman's journal with the figure of a young adult woman, identified as black by her brown skin, hair (straightened) and nose and lips shape.She smiles, touching the back of a black man who appears to be her partner, and reading the new pregnant woman's journal.

Pregnancy and postpartum
No condom, no sex.Whatever the fantasy, always use a condom (black lady).

2011
Poster about condom, with the figure of a young woman, identified as black by her black skin color and curly hair.She smiles and wear Carnival accessories made with condoms.

Sexual health
Breastfeed: give your child the best.Breastfeeding is much more than feeding the child.It is an important step towards a healthier life.

2010
Poster about breastfeeding with the figure of a young adult woman, identified as black by her brown skin, hair (straightened), shape of the nose and lips.She smiles holding her son and standing between two pregnant white women.

Pregnancy and postpartum
A woman can prevent cervical cancer.
Long live the women.Get examined at the health clinic.Women between 35 and 49 years old. n.d.
Poster about cervical cancer prevention, with the figure of 11 adult women in the form of drawings.Among them is a black woman, identified as such by the curly hair and the shape of the lips.She smiles, hugging the other 10 white women.
Women's health in the life cycle Postpartum care.n.d.
Poster about postpartum care, with women represented as drawings receiving care from health professionals.It is possible to identify four white women and two black women, identified by their brown skin color and curly hair.

Ciclo gravídico e pós-natal
Be natural in your first encounter.Natural birth.Let life happen naturally.n.d.
Poster about natural birth, with the figure of an adult woman, identified as black by her brown skin color and shape of nose and lips, accompanied by her partner, also black.She smiles holding her child.

Pregnancy and postpartum
Prenatal: Every pregnant woman needs at least six visits.She has that right.
Poster about prenatal care, with the figure of an adult woman, identified as black by her brown skin color and curly hair.She smiles as she receives orientation from a white man who appears to be a doctor.

Pregnancy and postpartum
Source of the posters: Virtual Health Library (15) .
www.ee.usp.br/reeuspRev Esc Enferm USP • 2018;52:e03399 related to black women (19) .The media, through a vertical discourse that does not listen, not only affirms, but also has the power to define whether a given phenomenon is real or not, whether something is good or bad, and can determine, to some extent, what is discussed in the daily life of society, highlighting or excluding social aspects as it suits (12) .
A study (16) on black women's places in Brazilian advertising demonstrated how, for decades, advertising has neglected the presence of black women, as have other media sectors.When they were represented, this representation was full of stereotypes that disseminated prejudiced historical ideas (16) .Similar findings were observed in another study (20) on the erasure and pseudo-inclusion of black women in Brazilian advertising.The study draws attention to the disproportional representation of black women compared to white women, and to the negation of relevant identity traits of black women, such as skin color, type of mouth and hair (20) .
In this sense, it should be emphasized that, in addition to the low appearance of black women on the posters analyzed, the posters also gave preference to models with brown skin and non-curly hair, which points to a media vision based on racial whitening of Brazilian society (21) .A historical tour through the post-abolitionist period can explain the origin of this whitening policy, based on racist theories brought from Europe, which proclaimed the superiority of the European population over any other ethnic group (21) .The identity of the Brazilian black woman has been structured over the years based on these constructions, which the media significantly helps spreading (21) .Seeing themselves represented as inferior, black women tend to internalize racism by denying their blackness, abandoning their traditions and assuming the hegemonic culture for themselves, believing that this will increase their chance to feel integrated in society and to rise socially (17,21) .
Therefore, the low representation of the black woman reveals contradictions between the information conveyed in the posters and the implicit discourse of the images, which can reiterate racial inequalities and represent a potential threat to the health-disease process of black women.
women'S Sexual and reproductive health limited to pregnancy and poStpartum.
Brazilian policies directed at women's health are guided by principles that consider them as a whole, that is, as a biological and social being throughout their life cycle.However, what is observed is a dichotomy between the formulation and implementation of these policies (22) .Likewise, health work processes have been ineffective regarding the comprehensiveness of women's health care, since they are still focused on the biological aspects of the female body (23) .
Biologically, all organs have a function, that is, a role to play (24) .However, what is observed throughout history is that the reproductive function of the uterus is attributed to the woman, that is, it has historically been determined that reproduction is, by its nature, a feminine activity (22) , and not a capacity that a woman may or may not want to exert.The claim to guarantee women's health care beyond reproductive issues has fueled the discussions that culminated in the launch of the Women's Comprehensive Health Care Program (PAISM -Programa de Atenção Integral à Saúde da Mulher) in Brazil in 1984 (22) .The recognition of sexual and reproductive rights as human rights in the Cairo Conference in 1994 and in the Women's Conference in Beijing in 1995 strengthen the struggle for women's autonomy (25) .Among these rights are: the right to freely live and express sexuality in all phases of the life cycle, free from fear, guilt, false beliefs, violence, discrimination and coercion; the right to choose whether or not to have sexual intercourse; the right to freely express sexuality; the right to have sexual intercourse independent of reproduction; the right to have safe sex to prevent pregnancy and STDs; the couple's right to decide whether or not, how many and when to have children; the right to access health services with guaranteed privacy, confidentiality and without discrimination; among others (25) .Therefore, there is a range of themes that could have been explored by the MH publicity campaigns on women's sexual and reproductive health but were not.Instead, in the posters analyzed, the most present theme is pregnancy and postpartum, specially the former.
The scientific literature has shown that, despite the recognition of the sexual and reproductive women's rights, it does not mean that these rights are fulfilled by women (25)(26) .In this sense, giving visibility to the issue in a broad way is a strategy to consolidate these rights.In this same logic, the representation of women's sexual and reproductive health as only prenatal, childbirth and postpartum reinforces the submission of women's sexuality to reproduction, strengthening the historical power relationship between men and women in society (25) .

CONCLUSION
The representation of black women in the MH advertising posters on women's sexual and reproductive health is low, and the themes addressed in the posters do not cover all the phenomena that make up women's sexual and reproductive health during their life cycle.
The low representation of black women identified in the study is a result of the veiled racism that exists in Brazil, which, camouflaged by the myth of racial democracy, finds subtle ways to stay alive within Brazilian society.This phenomenon is clear when one observes the significant difference between the representation of white women and of black women.Moreover, observing the black women who were represented, it is possible to notice characteristics that are closer to Eurocentric ethnicities, showing that the effects of the archaic policy of population whitening still persist.
Another phenomenon observed was the focus given to the promotion of care addressed only to the female reproductive capacity, which reinforces the social role attributed to women, limited to maternity.
Despite the fact that the Brazilian Ministry of Health has several policies addressing the comprehensiveness of care, without any kind of discrimination, its advertising posters continue to reproduce and reinforce the social invisibility of black women, contributing to the perpetuation of inequities instead of exploiting the potential of publicity to form constructive opinions that could contribute to the implementation of the guidelines of the Unified National Health System.

RESUMEN
Objetivo: Describir y analizar la representatividad de la mujer negra en los carteles utilizados por el Ministerio de Salud en campañas publicitarias volcadas a la promoción de la salud sexual y reproductiva de la mujer.Método: Estudio descriptivo, exploratorio y documental de los carteles publicitarios dirigidos a la promoción de la salud sexual y reproductiva de la mujer, facilitados en la Biblioteca Virtual en Salud.Para el análisis de los datos, se adaptó el método de análisis de contenido en la modalidad temática.Resultados: De los 498 carteles identificados, 161 eran referentes a la promoción de la salud sexual y reproductiva de las mujeres.Aplicando los criterios de exclusión, restaron 41 carteles, de los que 31 (75,6%) traían la representación de la mujer blanca, nueve (21,9%) de la mujer negra y uno de la mujer indígena (2,4%).El análisis de los datos convergió a dos categorías analíticas: la pseudorrepresentación de la mujer negra y la salud sexual y reproductiva de la mujer limitada al ciclo del embarazo y post parto.Conclusión: La representación de la mujer negra en los carteles publicitarios del Ministerio de la Salud es baja, y las temáticas promovidas en los carteles no contemplan todos los fenómenos que componen la salud sexual y reproductiva femenina durante su ciclo vital.As limitations of this study, it is possible to point to the restriction of the analysis to national posters, referring only to women's sexual and reproductive health.Therefore, new studies should be carried out covering all the topics related to women's health, as well as analyzing Latin American and worldwide works to compare the results.

DESCRIPTORES
The contribution of this study to the health area is based on the visibility of ethnic-racial relations and its interface with black women's health, who are underrepresented in the MH health promotion campaigns, despite representing the majority of the Brazilian population.
This study provides support for reflection on the role of advertising campaigns in the perpetuation of ethnic and gender inequality, highlighting the need for representation of the black population in its diversity and for valorization of comprehensiveness in women's health.

Figure 1 -
Figure 1 -Data collection and organization.