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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.45 no.5 São Paulo Oct. 2011
Racism and health: social representation of women and professionals about the color/race issue*
Racismo y salud: representaciones sociales de mujeres y profesionales sobre la cuestión color/raza
Amália Nascimento do SacramentoI; Enilda Rosendo do NascimentoII
Master in Nursing. Professor at Universidade Federal do Recôncavo da Bahia.
Cruz das Almas, BA, Brasil. firstname.lastname@example.org
IINurse. Ph.D. in Nursing. Associate Professor at Federal University of Bahia. Salvador, BA, Brasil. email@example.com
This is a multimethodology study founded on the Social Representations Theory, with the objective of learning the representations that the color issue has for the users and professionals of public health care services. The study was performed at Public Basic Health Units in Salvador, with 103 subjects. Data collection was performed using the Free Word-Association Test and semi-structured interviews. Factorial Correspondence Analysis and thematic analysis was used. Results showed an opposition of answers among people who classified themselves as white and black, and an opposition between the younger and older people. Representations about the color issue portray the complexity involved in racial classification and the need to implement studies on health policies and Brazilian races.
DESCRIPTORS: Ethnic group and health; Health policy; Women's health; Public health nursing.
Se trata de un estudio con abordaje multimétodos, apoyado en la Teoría de las Representaciones Sociales, objetivando entender las representaciones que ostenta la cuestión color para pacientes y profesionales de servicios públicos de salud. Se realizó en Unidades Básicas de Salud del municipio de Salvador, con 103 sujetos. Datos recolectados mediante Test de Asociación Libre de Palabras y de entrevista semiestructurada. Se utilizó Análisis Factorial de Correspondencia y análisis temático. Los resultados muestran oposición de respuestas entre personas autoclasificadas como blancas y negras y oposición entre las personas mayores y menores del estudio. Las representaciones sobre la cuestión color retratan la complejidad de la clasificación racial y la necesidad de efectivización de trabajos sobre políticas sanitarias y raciales brasileñas.
DESCRIPTORES: Etnia y salud; Política de salud; Salud de la mujer; Enfermería en salud pública.
Over the last years there has been an improvement to the analysis of Brazilian population health issues due to the increasing information on the self-identification of race or color, thus permitting different epidemiological profiles to be established. In many situations, dissociating data by race/color reveals that black people have worse health conditions compared to white people, either regarding the risk of falling ill and dying, or regarding the opportunities of accessibility to health care.
Black people have the lowest income, especially women, but although the aforementioned disadvantaged can be related to poverty, it has been acknowledged that there is institutional racism in health care. That prejudice is accounted for the inequalities in health care and other aspects.
In this sense, the document created by the Black Population Occupational Health Group with the Municipal Health Department of Salvador/Bahia(1) states that institutional racism is expressed both in the care relationship as well as in its accessibility and in the institutional practice itself; furthermore, it lists examples such as the violent form that black women are treated at maternity hospitals, the poor information that is provided to this specific population, and their difficult accessibility to health care services.
In fact, compared to white women, black women have a higher risk of death, a 7.4 score(2). Studies have shown that non-white women have a greater chance of dying by direct obstetric death(3); and black women face greater difficulty in finding labor/delivery health care(4-5). It has been identified that, regarding the care relationship, black women received about 40% of the prenatal guidance that was given to white women(4).
There has been an increase in the number of studies that aim at establishing relationships between color/race and health problems, but in Brazil it is still rather difficult to obtain information about color/race identification in health documents, namely patient records.
In this sense, two situations are recurrently reported: the documents do not have a specific field to register the patient's color/race like those existing for other demographic data such as age, gender, origin; or in cases a specific field does exist, the color is not registered.
Methodological and conceptual reasons have been raised to explain the facts, such as questioning what would be the best way to collect color/race information: if through self-classification, or by being classified by the researcher or health care worker. On the other hand, the miscegenation characteristic of our society brings into discussion who can be considered black or white.
It appears that self-declaration is the most common form used for racial identification in health, but it has also been pointed out as problematic in interviews, as it has caused embarrassment. However, that constraint is manifested only when the interviewee is black.
We understand that the ideas and representations about race/color that prevail in our society affect the behavior of the people involved in obtaining this information, as black people are seen as inferior to white people, thus generating racial inequalities.
However, in Brazil, such inequalities are frequently concealed by the myth of racial democracy, therefore the absence or difficulty to register patients' color in health documents is one of the ways that the population expresses the social representations of race and racism.
Color/race and ethnicity are categories that continue to be undervalued in health care services and in the analysis of scientific production in health in Brazil. Only recently, especially after the 1990s, due to the battles of civil society movements, have these categories began to be discussed or used in reflections and in health care models.
The introduction of the color issue was standardized by the Ministry of Health in 1996, which determined that it must be included in important documents, such as: live birth declarations, birth registrations, civil and military identification, reserve soldier certificate, hospitalization authorization, and patient records, voter identification, police reports, death declarations and death certificates(6).
We believe that the representations that color or race have for health workers may be related to discriminatory health care practices, just as the patients' representations may affect their search for care, because
representation functions as a system to identify the reality that rules the relationships between individuals and their physical and social environment, hence it determines one's behaviors and practices(7).
It should be stressed that social representations are created based on a variety of information, images, conscious and unconscious feelings, and attitudes rather than only by cognitive mechanisms. This assigns a dynamic character to social representations, and, therefore, its contents depend mostly on the position that groups or individuals maintain in each society(8). For that reason, individual characteristics such as age and educational level can also promote one's greater or smaller exposure to the information or images about certain phenomena available in society.
Therefore, considering the social representations that public health service users have about using the color information in health care records, the objectives of this study are: to learn and analyze the social representations that health workers and users have about race/color, and verify the importance that they assign to the use/implementation of the color information in health care service documents and patient records.
The racial issue in Brazil is very complex; it is both old and emergent. Its complexity is due to the diversification of opinions and methodologies regarding the classification of individuals as to their color/race, as well as the ideologies that permeate racial relations.
It is essential to understand the meaning of race, color, and other aspects that surround social relationships in Brazil in order to realize the implications that they have in people's lives, with a view to overcome a series of prejudice, discriminations and oppressions to which the black population, especially women, are submitted.
The idea of race began being disseminated more systematically in the 20th century among European scientists, under the influence of Charles Darwin thoughts on the evolution of the human species.
However, there is no universal concept for race(9-10), which can refer to aspects associated with genetic inheritance as well as visual characteristics such as skin complexion, type of hair, and height. In this sense it differs from the term ethnicity, which appeared after the second world war, with the purpose of indicating cultural and religious differences that could characterize the existence of a population, therefore not focusing on individual features(11).
In Brazil, color is a social construction structured around an ideology(12) to justify social inequalities, and the current preferable race classification standard has been the phenotype(13), which in part justifies the option for the self-attribution of color in social studies, including health research.
The importance of studies addressing the racial issue in Brazil lies mainly on the fact that there is a prevalence of ideas and representations regarding the inferiority of black people to others (non-black), which has been reproduced over time in interpersonal and institutional relationships, thus characterizing racism.
While the concept of race began to be used more often in the 19th century, racism, however, began to be more noticed, as a doctrine, in the 20th century, between the two world wars, becoming consolidated with the advance of Nazism.
Racism can be understood as a doctrine, scientific or not, that states the existence of human races, with different qualities and abilities, ordered hierarchically based on physical, moral, psychological and intellectual features; a body of attitudes, preferences and tastes instructed by the idea of race and racial superiority, in either the esthetic, physical or intellectual level(12).
In this context, racism converts into a system of unequal opportunities that can be observed in the many social environments, i.e. education, work, income, housing, health, and others(12).
Health, understood as quality of life, results from the combination of one's conditions of eating, housing, education, income, environment, work, transportation, employment, leisure, accessibility to and owning land, accessibility to heath care, and overcoming the inequality imposed by racism; it is, above all, the result of social ways to organize production, which can generate severe inequalities in life levels.
Health is an inherent right of every citizen and a duty of the State. In Brazil, it represents a great conquest leveraged during the whole trajectory of social fights in the 20th century. The achievement of the right to health was disseminated especially in the 1980s through a social approach to the health-disease process, which culminated with the construction of the SUS (Brazilian Public Health System) and the special chapter in the 1988 Constitution.
Nevertheless, establishing health as the social asset of the whole population regardless of race/color or gender is yet to become a reality, as studies show that black women face greater difficulties in accessibility to health care compared to non-black women, even among populations with similar personal or family income levels(14).
The identification of people according to race/color becomes, therefore, an important resource to support equal public policies, especially considering the intersections of gender and race/color as a new product of social exclusion relations. Furthermore, it permits to identify differentiated morbi-mortality profiles in the female population, according to color, among other aspects(6-10).
The Color issue is a topic of Brazilian Ministry of Health decree of March 1996, which addresses the standardization of information about the race and color of Brazilian citizens and foreigners living in the country, thus representing an important achievement of the Black Movement (Movimento Negro)(6).
Nevertheless, we have observed that the identification of color in health care service documents is barely inexistent, if we take into consideration the quality of the record and the method used for racial classification(6). The current state of the implementation of the color item reveals significant issues linked to characteristics of Brazilian racism.
Brazil presents a Latin type that has a racial relation different from the current standards in United States and the Caribbean. Brazil and other Latin-American countries share the whitening ideal and the myth of racial democracy(15).
Whitening or the whitening ideal is understood as a national project implemented by means of selective miscegenation and population policies and European migration(16). As a harmonious solution of the racial problem of Latin countries, it proposed a gradual disappearance of black people by being absorbed by the white population.
Racial relations in Latin America are characterized by a high level of miscegenation that favors the creation of spaces to manipulate ethnical identity and conceal ethnic mobilization(15).
Whitening can also be understood as a cultural pressure exerted by the white hegemony, especially after the abolition of slavery, for black people to deny themselves, in their body and mind, as a condition to become integrated in the new social order.
In populations characterized by a secular racial blend, as is Brazil, Hawaii, and Mexico, the forms of racism acquire the particularity of a camouflaged existence and of being institutionally denied.
The representations about racial democracy, a harmonious rather than conflicting feature of racial relations in Brazil began to be disassembled in the field of social sciences in the 1950's, when UNESCO sponsored research on the theme racist dogmas, culminating with the Declaration on Race and Racial Prejudice on November 27, 1978(10-17).
This is a descriptive exploratory study, using a multi-method approach, founded on Moscovici's Theory of Social Representations(8). The field of study consisted of six Basic Health Units of two Health Districts in Salvador, Bahia, Brazil.
Data collection was performed during the first six months of 2004, through semi-structured interviews and the Free Word Association Test, following previously designed scripts.
There were a total 103 participants, defined by the saturation criteria, when the themes and/or arguments began to repeat themselves. Of all participants, 16 were health workers - physicians, nutritionists, nurses and social workers - and 87 were prenatal health care service users, which all answered the Free Word Association Test. A total 32 subjects participated in the in the semi-structured interview: 20 pregnant patients and 12 health care workers.
The decision to perform the study with women who sought prenatal care was due to their easy accessibility to the service, because due to the characteristics of this type of service, women keep better contact with the service because of the appointments, laboratory exams, and other services, thus making it easier to schedule the interviews.
Data collection was performed using the Free Word Association Test and semi-structured interviews.
The Free Word Association Test (FWAT) is a projective technique, through which the psychological structure of the subject becomes palpable by the manifestations of behaviors and reactions, evocations, choices and creation, constituting in revealing indexes of the whole personality(18). The FWAT involves four basic conditions: stimulate, make observable, register and achieve communication.
The triggering stimuli in this study were race/color and the register of color in the service form (patient record), operationalized in the following way: the FWAT was initiated with identification questions of which color/race was the last question in this item, formulated as follows: What comes up on your mind when I ask you about your color? (stimulus 1). The next questions was What comes up on your mind when I mention the field to register color in the health service form? (stimulus 2).
The semi-structured interview addressed the same questions of the FWAT under the form of two questions directed to health care workers and users, respectively: What does it represent to you to ask and register in the record the color/race of the women you assist? What does it mean to you to declare your color to a health worker in an appointment and have it (color) registered on your record?
As for data statistics and analysis procedures, the information obtained using the Free Word Association Test was submitted to statistical analyses using Correspondence Factor Analysis (CFA) processed by Tri-deux-mots 2.2/1995 software. CFA permitted to reveal the opposition game in the answers (evocations) as a response to the triggering stimuli.
This way, it was possible to identify the oppositions to the triggering stimuli answers between the two subject groups (users and health workers), between and intra groups, considering the variables color, age, education level, and gender.
The interviews were analyzed using thematic content analysis.
This study involved human beings, therefore all subjects provided written consent, and was approved by the Research Ethics Committee at the State of Bahia Health Department (CEP-SESAB), through Review number 012/2004. Furthermore, the interviews were kept anonymous by using codes to represent their order (E1 to E7).
The study subjects' characterization according to the studied variables indicates that most were health service users (81%), between 20 and 34 years old (69%), and almost all women (99%), which is justified by the fact that the study was performed with women who seek prenatal care and that there are less health care workers than patients. Also, most were black, accounting for 80.6% of the sample.
Using Correspondence Factor Analysis, it was identified that among the studied variables, color and age were statistically significant in the oppositions of answers evoked by the participants. No opposition group was identified for the people who classified themselves as indigenous. Analogously, the representations of the workers group did not have a corresponding opposition group, which, in this case, would be that of pregnant women. Therefore, oppositions between the representations of pregnant women and health workers, as well as the indigenous category did not show statistical significance.
The opposition of answers to the triggering stimuli according to subjects' color explained 38.2% of the total answer variance, whereas the factor that evinces the opposition between subjects' ages explained 17.9% of the variance, totaling 56.1% of total variance. This represents the percentage of data statistically contemplated to be explained.
A total 588 words were evoked by the triggering stimuli, with 194 different words. For the first stimulus - what comes up on your mind when I ask your color? - the answers of people who classified themselves as white were the following group of representative evocations: beauty, social level and prejudice, color is not the important thing, self-discrimination of the black, complicated to classify and origin. On the other hand, for the people who classified themselves as black, the representative answers were: it is important to know the color, good, nothing, pride, knowing the reason.
Also representing the data referring to the first stimulus, there were different answers between the subjects with ages between 14 and 19 years and those who were 35 years old or older. Adolescents presented the following group of answers: beauty, social level, race, prejudice, important to know the color. Among the older people, the following evocations prevailed: color is not the important thing, self-discrimination of the black, complicated to classify, origin, nothing, pride, knowing the reason.
In this sense, an opposition of answers is observed between people self-classified as white and those who classified themselves as black. A contrast is also observed between the younger an older group in this study, i.e., between adolescents and people older than 35 years.
In the second stimulus - registering the color on the health care records - for the group self-classified as white, the following evocations are representative: investigate diseases, research, color has no influence, social level and difficult to classify. On the other hand, the group self-classified as black, the following answers are representative: valuing, important, normal, better, knowing the reason and also racism, separation, unnecessary.
For the adolescents, registering the color on the health care record is stated as important and valued, but is also associated with prejudice, discrimination and complicated to classify. On the other hand, the older group, of 35 years of age or more, represents the register as: investigate diseases, research, has no influence, racism, separation, unnecessary and it is necessary to know the reason.
White workers and users reported the color register was important because of the need to investigate about diseases, for research purposes. They do, however, state that color does not influence people's life situation, though it affects the social level; they also report the difficulty to identify race or color through the expression it is complicated to classify.
On the other hand, based on the group of words that were mentioned, it is observed there is a more consistent stand, with the people self-classified as black tending more towards acceptance of the question about color.
Nevertheless, it is observed that there still are contradictions/oppositions in the words of one same group of people, regarding either self-classified color (black or white) or age (adolescents or adults). Hence, it is observed that, somehow, people find it difficult to make a categorical stance about the color/race issue.
The discourses of the study participants, obtained through the interviews, permitted to construct the following analysis themes: color/race has no influence on the quality of care or on the health/disease process; the color issue as a possibility to fight against racial prejudice; the color issue as a source of discrimination and prejudice.
The discourses ratify and broaden the ideas learnt through the FWAT, with mutual complementation. The representation of color as something that has no influence or importance on health care service neither on the disease processes can be learnt in the following reports:
My forms? I never asked about color... for me there is no influence because color to me, I never included the color item, what I ask is the age just to identify high risk pregnancies, but to me there is no influence form color because the guidance we provide is the same, I'm the one who implemented the form, I reviewed the form and I never included the color item, but I did include age... (E1).
There is really not much meaning, there isn't much to do with it, I think that what you really should add, in my opinion, is the educational level, which is still not included, it is how one lives socially, their family income, because that will influence their transit during the pregnancy period [...] (E2).
Discriminating the person's color? I don't think it's necessary. What is my color to you? There is no importance, color, the color issue, what is its importance? To discriminate a person's color like that, I think you have to discriminate the disease, what the person is feeling, but not their color, I don't see any importance in that (E3).
The second theme raised by registering the patient's color/race on the medical records refers to the implementation/use of the color item as a positive action, anchored on the thought of reverting into a benefit for the population in general, translated into awareness, learning, being involved in fights and social movements and, also, a global perspective of the country's improvement, towards adopting new values, such as respecting others:
I think it is significant because people self-identify themselves and also try to become involved in the fights, you know, seek their difficulties, and join the fights to reduce those difficulties, so I think it is really important... (E4).
I think people should fight for this to happen... I think it's a good idea, at least it will have an influence on more people, and they will take a stance, because, usually, black people, they want to do something, but they thinki if it will work, and this is something that you, you are one step ahead... (E5).
I think it's good, it's a way that the Ministry of Health is working for our country to improve regarding our race, right? And we see there is still a lot of prejudice against our race, white, black, yellow, there is prejudice against them all, so I think this is good, it's a way for people to understand better about themselves as human beings... (E6).
One of the aspects that may make the encouragement of implementing the color item more difficult, for workers and pregnant patients the same, is implied in the constraint that the question may cause, for either the interviewer or the interviewee. In one patient report, the constraint was attributed to the possibility of the fact being used for discrimination or to promote prejudiced attitudes. Perhaps for this reason some evocations learned through the FWAT link the issue of using the color item to knowing the reason of the question. On the other hand, this constraint is linked to the method used to collect information on color, through the self-attribution of one's race, as concluded by reading the following report (Interviewee 7):
I would feel really bad, you see? As a health worker, standing there with the patient's record, and ask him or her, why should we do this in a country like ours, where there is discrimination, you see? I don't know how a person might react, you see, if they have a good relationship with his or her color, it won't be a problem, but what if they don't? What if they have already been victims of prejudice? Or what if they know the situation they live in is because of prejudice?... Won't they be seeing me also as someone... I don't know... I wouldn't feel good doing that, honestly (E7).
An opposition is observed between the answers of people who classified themselves as white and those who were self-classified as black. The color issue is not valued by the white group, because, for them, color is not important to determine people's life conditions, rather, it helps define their social class, referenced in the FWAT as social level. Furthermore, there is a clear representation that the idea that white people think that the racial issue as a problem that only involves black people, as the expression self-discrimination of black people was representative, when stimulated by the question about color.
This posture regarding self-discrimination of black individuals is portrayed by Brazilian authors, and is considered to be one of the great tonics in the discourses on prejudice in Brazil. It is discussed that projections valuing the white gained prestige in the conscious of black people in detriment to their projections of their own value. The consequent reflects are expressed in the most various attitudes of black people, conscious or not, of violence towards themselves, their non accepting or attempt to change their physical features and deny their cultural origins(16-20).
These feelings originate from a historical-cultural process in which whitening is understood by the society as some kind of condition to integrate a new hegemonically white social class (16).
It should also be stressed that the way that black people refer to knowing the reason why they are being asked about their color, as they strongly clarify the need to introduce the color item in every service followed by a well-planned process to build awareness/sensitization of the general population.
Understanding the reason why you are being questioned about your color may involve a positive result in one's joining the fight against negative discrimination. That reflection is well documented by other authors:
Human beings, on the other hand, need to know with rigor and social responsibility why they are being inquired about something that affects them deeply in all dimensions of their lives, why name it, and, especially, because this invasive act, in the country of the so-called racial democracy can become a powerful weapon in the fight for equality and anti-racist education(13).
For the young study subjects, there are two distinct representations for the question on color: one that assumes a positive feature in the answer, referred to as beauty and race, and another that assumes a negative feature, referring to color as prejudice.
For people of age, however, the question about color recollects their origin (which implies the condensation of words such as ancestors and roots), which also reveals that it remains difficult to classify people according to their color/race.
The difficulty of classifying realized by the study subjects recalls the reflections in the processes of self-identification of color and identification by others in Brazil. This complexity is due to the diversification existing in the classification of individuals' color/race, as well as the ideology involved in racial classification, i.e., if should be though from a phenotypic view or with a view to one's origin, descent(20).
Color collection in Brazil has also always been complex, always triggering instabilities and constraint for collectors and declarants. Between attributing color and naming it there are numerous factors determined by social and regional conditions, among others. The main complexity involved apparently focuses on the relationships established between the collector and the declarant or person classified(13).
It is observed that both asking about color and registering it in health care does not have a significant expression for white people. Although they refer some possible objectives (investigate diseases and research), they do not approve the color item as an important category and value more the socio-economic situation more, as they evoke the social level as an answer.
To investigate the diseases reported by the subjects, other authors point at this importance and state that racial classification in health is an essential epidemiological data, because it permits to see the diseases that appear most or are exclusive to certain groups, i.e., black, white, yellow, Jews, Gypsies, etc. and in people of mixed origins, and can therefore interfere in the reality and reduce social inequalities (10).
As to the social class, social level, we agree with the Brazilian literature, because trying to dissolve the debate on race/color, analyzing only the social class is an permanently used emergency exit, although tall the maps that compare the situation of black and white workers over the last twenty years stress there is a much greater deficit among black and poor workers for all life dimensions - health, education, and work. The repetitive jargon is that the problem is limited to the social class. Indeed, social class is important, but it is necessary to combine it with other categories, for example, gender, age and color/race(16). For black people, however, the representation of the color item is revealed as a controversial situation, with antonymic meanings. Therefore, they refer "it is normal to ask color", but also make associations with racism, separation and unnecessary.
The approaches brought by the subjects, revealing the color item as an issue that is still complex, outlines the importance of initiating some serious and effective work to raise awareness in the population about racial issues, for an effective anti-racist education, with a multidisciplinary character; a anti-racist fight in schools, health centers and hospitals, also at gyms and most effectively in social movements. Hence, it means a fight against the lack of indignation from the population wit the subtle and harsh ways that racism takes place in our society.
Among other categories, color/ethnicity, gender, health-disease process, education, and socio-economical level are interrelated and are expressed in the lives of population groups and individuals in different levels and forms. Therefore, it is rather relevant that these categories be included as analysis dimensions in studies addressing the processes of morbidity and mortality and social inequalities.
That incorporation should, therefore, be part of the social science and health investigations that should deepen the knowledge on the multiple interfaces of the effects of the ethnic-racial domain on health.
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Received: 11/24/2009 Support: National
Council for Scientific and Technological Development - CNPq *
Extracted from the dissertation "Importância do quesito cor na assistência
pré-natal: representações sociais de gestantes e profissionais",
Federal University of Bahia, 2006.
Support: National Council for Scientific and Technological Development - CNPq
* Extracted from the dissertation "Importância do quesito cor na assistência pré-natal: representações sociais de gestantes e profissionais", Federal University of Bahia, 2006.