Representation of black women in educational leaflets on women's health

ABSTRACT

Objective

To identify the educational leaflets of the Brazilian Ministry of Health on women's health available in the Virtual Health Library; to classify the representation of women in these leaflets according to ethnicity / race / color; to analyze the representation of black women in these leaflets.

Method

Documentary, descriptive, exploratory study.

Results

From 2007 to 2019, 19 educational brochures related to women's health were identified, ten of which had images of women. White women were observed in the ten leaflets (100%) that contained images and illustrations, whereas black women were identified in three (30%) of the 10 leaflets. Two analytical categories emerged from the data analysis: “the underrepresented black woman” and “deconstructing stereotypes: the prominent role of black women”.

Conclusion

This study shows a low representation of black women in educational leaflets. However, when represented, black women are portrayed positively and equally in relation to women of other racial and ethnic groups.

Keywords:
Communication in health; health education; flyers; black population; women's health

RESUMO

Objetivo

Identificar folhetos educativos do Ministério da Saúde sobre saúde da mulher disponibilizados na Biblioteca Virtual em Saúde; classificar a representação da mulher nesses folhetos de acordo com a etnia/raça/cor; analisar a representatividade da mulher negra nesses folhetos.

Método

Estudo documental, descritivo, exploratório.

Resultados

No período de 2007 a 2019, identificaram-se 19 folhetos educativos relacionados à saúde da mulher, sendo que 10 traziam imagens de mulheres. As mulheres brancas foram observadas nos 10 folhetos (100%) que continham imagens e ilustrações, enquanto mulheres negras foram identificadas em três (30%) dos 10 folhetos. Da análise dos dados, emergiram duas categorias analíticas: “a mulher negra sub-representada” e “desconstruindo estereótipos: o papel de destaque da mulher negra”.

Conclusão

O estudo evidencia uma baixa representação da mulher negra nos folhetos educativos. Entretanto, quando representada, a imagem da mulher negra surge de modo positivo e igualitário em relação às mulheres de outros grupos étnico-raciais.

Descritores:
Comunicação em saúde; educação em saúde; folhetos; população negra; saúde da mulher

RESUMEN

Objetivo

Identificar los folletos educativos del Ministerio de Salud brasileño sobre la salud de la mujer disponibles en la Biblioteca Virtual de Salud; clasificar la representación de las mujeres en estos folletos según etnia / raza / color; Analizar la representatividad de las mujeres negras en estos folletos.

Método

Estudio documental, descriptivo, exploratorio.

Resultados

En el período de 2007 a 2019, se identificaron 19 folletos educativos relacionados con la salud de la mujer, 10 de los cuales tenían imágenes de mujeres. Se observaron mujeres blancas en los 10 folletos (100%) que contenían imágenes e ilustraciones, mientras que se identificaron mujeres negras en tres (30%) de los 10 folletos. Del análisis de datos surgieron dos categorías analíticas: “la mujer negra subrepresentada” y “la deconstrucción de los estereotipos: el papel destacado de la mujer negra”.

Conclusión

El estudio muestra una baja representación de las mujeres negras en folletos educativos. Sin embargo, cuando se representa, la imagen de las mujeres negras emerge de manera positiva e igual en relación con las mujeres de otros grupos étnico-raciales.

Palabras clave:
Comunicación en salud; educación en salud; volantes; población negra; salud de la mujer

INTRODUCTION

The scientific literature has been showing the impacts of race and gender inequality on population health, as demonstrated by the fact that the female black population is in disadvantage in most economic and health indicators when compared to white women.^1,2

Considering the variables race/color and gender, studies have shown that Brazilian black women are doubly undervalued, presenting lower socioeconomic levels, reduced access to good quality health services, and a higher risk of morbidity and mortality.^1,3 Racial discrimination, poverty, low education, and gender violence are some of the factors that potentialize the vulnerability to physical and mental disease to which black women are exposed.⁴

The perspective of intersectionality in the analysis of population health emphasizes the importance of how diverse identity categories may impact people's lives.⁵ Considering that subjects identify simultaneously with different social categories, such as race and gender, they may be simultaneously privileged and/or marginalized depending on the identified social category and intersecting them is required to contemplate the complexity of identity overlap and possible types of oppression.⁵ In the United States of America, white women may be privileged for not suffering racial discrimination but are oppressed by androcentric social norms.⁶

From this perspective, it is important to emphasize that, due to being in spaces where racism and gender inequality overlap, Brazilian black women are more prone to experience damage by these axes of power, suffering direct impacts on their sexual and reproductive health. This is so because the weight of unequal race and gender relations preclude women from achieving autonomy for health self-care, putting them in a situation of vulnerability for unsafe sexual relations and unplanned pregnancy.⁷

Understanding racism as a main driving force of inequalities that scar the lives of Brazilian black women,⁸ we call attention to the role of communication media in the dissemination of messages that reinforce racism in the social imaginary.

The educational leaflets of the Brazilian Ministry of Health (MH) are available at the Virtual Health Library (VHL) and may be unrestrictedly accessed on the internet. These leaflets may also be found in printed format at health services and are thus one of the various platforms that constitute the media, an important tool to educate and orient people's thoughts and attitudes, influencing society⁹ and playing an important role in health communication; a continuous analysis of how they portray black women, who are historically affected by racial stereotypes,¹⁰ is required.

Educational leaflets, in addition to disseminating health information, are useful to complement verbal orientation by professionals at health services, which makes them an important resource for providing health education and promoting the population's physical and mental well-being.¹¹ While educational leaflets may be valuable tools for health promotion,¹¹ they may reinforce and disseminate racial and gender stereotypes¹².

Thus, in this study we pose the following question: how are black women portrayed in educational leaflets targeted at women's health made available at the VHL by the MH? Based on this research question and considering that a progressive exposure to biased and stereotyped information on certain social groups may lead subjects to adjust their perceptions, judgments, and behavior towards these groups,¹³ we tried to understand whether leaflets' images reinforce racial and gender inequalities.

This study aims at shedding light on the representation of black women in images published in official women's health leaflets by the MH and made available at the VHL. Black women, when faced with images that are not part of their reality in educational health leaflets, may feel unmotivated, insecure, and uncapable of performing health and self-care practices. For this reason, this study offers resources for improving the approaches and representations of black women in the media concerning health information. Its objective is to identify the educational health leaflets of the MH available at the VHL, to classify the representation of women in these leaflets according to their ethnicity/race/color, and to analyze the representation of black women in these leaflets.

Following this rationale, the Theory of Social Representations (TSR) was adopted as this study’s theoretical framework. The TSR emerged in social psychology and was subsequently extended to health, environment, and education. Serge Moscovici deepened Durkheim’s Collective Representations Theory to deal with the complexity of the mutually constructed relations between perceptions and concept, encompassing the figurative and symbolic facets of sociocultural relations within groups.¹⁴ The SRT deals with the analysis of a socially constructed and shared type of knowledge. Through Social Representations, it is possible for a group to achieve collectively a better comprehension of its own reality, having as an object of analysis individuals and their social interactions with groups, social surroundings, the environment, and the possible transformations due to this culturally relevant interaction. Thus, using this framework with a Moscovician outlook is justified to analyze how a social group, here black women, build its knowledge through reconstruction and representation of its reality in the media, considering the health leaflets.^14-16

METHODOLOGY

This is a documental, descriptive, and exploratory study about the representation of black women in educational leaflets of the MH available at the VHL.

The educational leaflets produced by the MH and available for download at the VHL were chosen as the data collection source. A leaflet is defined as a non-periodical publication containing from 5 to 48 pages, aiming at providing information on a particular topic.¹⁷ This type of material consists of three textual categories: preliminary, which is a brief introduction to the theme; textual, corresponding to the text itself; and references, which indicate the bibliography.¹⁷

The data source for this research comprises all educational leaflets produced by the MH and available at the VHL. The inclusion criterion was leaflets on women's health published from 2007 to May 2020. The exclusion criteria for leaflets were duplication, download difficulties, and containing only written information.

For data organization and collection, a limitation to the last ten years was followed for a first identification of the leaflets, which was conducted online on the VHL website in October 2017; in May 2020, new research was conducted to update for 2017, 2018, and 2019. However, no new leaflets were found on the VHL website.

All leaflets matching the inclusion criteria were downloaded. After applying the exclusion criteria, the remaining leaflets contained illustrations and images of women.

The data were analyzed based on thematic content analysis,¹⁸ which consists of describing, interpreting, and understanding how the message conveyed by a given material is produced and received. Content analysis is characterized by presenting a set of techniques which are not fixed, but basically abide by the following steps: pre-analysis, exploration of material and result treatment, inference, and interpretation.¹⁹ With the objective of systematizing the information to be analyzed, a chart with a description through observation of all images in the leaflets was elaborated (Table 100). This observation included: number of women, their position and background, a brief description of the scenario, color patterns, use of image editing, and other characteristics. Additionally, it should be emphasized that this work analyzed only leaflets containing images of black women. To identify them, the method of racial hetero-identification was employed, considering the following phenotypic characteristics: skin color, hair, and facial traits (nose shape; eye shape; mouth shape and lip thickness).²⁰ The employed racial classification was that of the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística – IBGE). In this classification system, five color or ethnicity categories are employed: white, black, brown, Asian, and Indigenous; the Brazilian black population comprises black and brown subjects.²⁰ From data analysis, two analytical categories were identified: “The underrepresented black woman” and “Deconstructing stereotypes: the prominent role of black women”. These categories are subsequently described.

Table 1
Description of the leaflets identified at the VHL.

	Image description
Leaflet 1	- This leaflet's cover has a photograph of four adult women.
	- There is a famous Brazilian actress, identified as black based on her skin color, hair, and facial traits; she is on the front and more prominent in relation to the others.
	- Two women were identified as white based on skin color.
	- An Indigenous woman was identified by skin color, straight, black hair, and facial traits.
	- All of them are smiling, wearing casual, colorful clothes, and little make-up.
	- On page 13, two women are represented through a drawing with white background, grey contours, and some pink shadings, making it impossible to identify their race and ethnicity.
Leaflet 2	- This leaflet's cover has the image of three adult women holding and kissing a baby.
	- There is no focus on the body, only the faces of the women and babies.
	- This image has a greenish color and black background; however, it is possible to identify the ethnicity of the bodies which are represented.
	- One woman was identified as black from her hair and facial traits.
	- Two women were identified as white from their skin color and facial traits.
	- The same images are distributed in the other pages of this leaflet.
Leaflet 3	- All photographs were submitted to manipulation and treatment in an image editor to lose focus and resolution.
	- The cover has black and white women with LGBTQ+ flags.
	- On page six, there are five women side by side close to a table; one of them was identified as black from her skin color, hair, and facial traits.
	- On page nine, there are two separate images with women holding a microphone; one of them is black, identified by skin color and hair.
	- On page 10, the image of a black woman talking is observed; she was identified as such from her skin color, hair, and facial traits.
	- Page 11 presents a photograph of four women sitting, two of whom are black, one identified from her skin color and the other from skin color and hair.
	- On page 12, there are two women, one of whom is black, identified by her skin color; she has an atabaque drum in front of her.
	- On page 15, there are three women hugging, one of whom is black, characterized as such from her skin color and facial traits.
	- On page 16, four women are sitting side by side; two of them are black, as identified from their hair, skin color, and facial traits.
	- On page 20, seven women are grouped, with their arms raised, and seem to be dancing; one of them was identified as black from her skin color.
	- On page 22, there are twelve women forming a circle, holding one another's shoulders, one behind the other; three of them were identified as black from their skin color and hair.
	- On page 23, there is a picture of fifteen women sitting in chairs forming a circle, five of whom are black; three are identified as such from their hair and skin color, and two only from skin color.
	- On page 27, there are five women around a table, two standing and three sitting; the black woman is sitting and was identified as such from her skin color and hair.
	- On page 28, nine women are standing, forming a circle; three of them are black, one of whom was identified as such from her skin color, and two from their skin color and hair.
	- On page 30, three women are sitting, apparently holding and looking at some printed material. One of them was identified as black from her hair and skin color.

• Source: the authors.

Regarding ethical aspects, according to Resolution n. 510, dated April 7, 2016, by the Brazilian National Health Council, research using only public domain data with no participant identification requires no registration or assessment by the CEP-CONEP System.²¹

RESULTS

During data collection, there were 898 leaflets available at the VHL website. Considering the period from 2007 to 2016, 279 leaflets were identified. After the application of the descriptor “women's health”, nineteen publications were identified to be related to this theme. Out of the nineteen, only ten included images of women in their layouts. White women were observed in ten leaflets (100%) containing images and illustrations, whereas black women were identified in three (30%) of the ten leaflets.

The three leaflets containing representations of black women were the object of this study, identified by the ordinal numbers 1, 2, and 3. An illustrative image of each leaflet is provided in Figure 1, after this article’s references.

Figure 1
Mosaic with an image illustrating the leaflets identified in this study.

Leaflet 1 (Figure 1) is about breast cancer and was published in 2014. It is targeted at female users of health services and aims at informing and raising awareness of breast cancer, its risk factors, mortality rates, signs, and symptoms, as well as the importance of examination and early diagnosis for an effective treatment.

Leaflet 2 (Figure 1) is about the vertical transmission of the Human Immunodeficiency Virus (HIV) and syphilis, published in 2007. It is targeted at health professionals and encourages action by managers in the three government levels and civil society organizations to fight these diseases. It aims at providing information on goals and actions in women and children’s healthcare to reduce vertical transmission of HIV and syphilis in Brazil.

Leaflet 3 (Figure 1), published in 2013, discusses points in health, rights, and social participation of lesbian and bisexual women. The target public of this material is composed of managers and health professionals. This leaflet has the objective of sensitizing professionals to what it is like to be a lesbian or bisexual woman, with information that enables a reflection on care to improve welcoming and healthcare for this population.

A description of the images of black women identified in the leaflets is presented in Table 100.

The analysis of these leaflets identified an underrepresentation of black women, given that only 30% of the identified leaflets had such a representation. However, it is important to emphasize the central role of black women in one of the leaflets, and the equality with which they are represented in the other two. These remarks are further discussed hereinafter based on the identified analytical categories.

DISCUSSION

The underrepresented black woman

In Brazil, black women (comprising both black and brown) correspond to 54.6% of the female population.² The search on the VHL led to ten leaflets on women's health with illustrations of women; black women were observed in 30% of these leaflets, indicating that representation is far from corresponding to the number of Brazilian black females.

An unequal exposure to the health information available in the media may be among the environmental factors which contribute to ethnic and racial inequalities in health results.⁹ Considering that individual levels of health education and awareness may be influenced by publicity, it would be desirable for black women to be represented in more leaflets.⁹ This is because variation in amount, information content, and representation in the material in the media observed by different ethnic groups may contribute to decreased racial inequalities in behavior and health status.⁹ An increase in amount should be followed by an increased quality of representation, which should be distanced from negative stereotypes.

Currently, the attempt at consolidating affirmative actions as policies for the correction of ethnic and racial inequalities is an important demand of the Brazilian black movement. The revindication of affirmative actions does not aim only at racial quotas for university entry, but also at racial inequality in the job market, access to health services, the media, and in several social sectors with ongoing inequalities.²³

Particularly in relation to the media, when it comes to social identity, authors suggest that people like to see characters which resemble themselves and are more likely to search for informational content presenting these characters.²⁴ This perspective of social identity in the media extends to other domains, such as race, gender, and nationality.²⁴ As an example, an American study has shown that African-Americans with a strong ethnic identity are more likely to watch television content targeted at black people and with a positive portrayal of black characters, avoiding them when characterization is negative.²⁵ In this sense, in Brazil, the social place of black women in the leaflets by the Ministry of Health still falls short of being representative of the Brazilian black female population.

The leaflet identification had the period from 2007 to 2019 as a temporal restriction, which is justified by the importance of analyzing recent leaflets. Remarkably, in this period, some strategies were launched by the federal government to promote health equality for the black population. These include the National Policy for Integral Health of the black Population (Política Nacional de Saúde Integral da População Negra),²⁶ launched in 2009, aimed at fighting inequalities in the Unified Health System and promoting integral health to the black population, recognizing that health inequalities are the result of unfair socioeconomic and cultural processes, such as racism, which contribute to an increased morbidity and mortality of this population.²⁶ In addition, in 2014, the federal government launched an advertisement campaign to engage users and health professionals of the public health network in the fight against racism. This campaign had the objective of fighting institutional racism and reinforcing the Black Population Integral Health Policy.²⁷ Although these are important strategies, they had no impact on the results of this study; however, they provide possibilities to increase visibility to the health and representation of the black population.

Deconstructing stereotypes: the prominent role of black women

Although low representation is a noticeable problem, the three analyzed leaflets present black women prominently, in the foreground, or in positions of leadership, fighting for their rights.

In Brazil, the analysis of the representation of black women in the media shows that this population is disregarded and suffers with the reinforcement of racial stereotypes, mainly in television, in which black people are nonexistent or a minority, generally portrayed in subaltern positions.^10,28 Internationally, black actors have become frequent in shows targeted at the black population, which draw more attention and audience from black teenagers searching for positive representations of their equals.²⁴ However, representations of black people, particularly black women, are still loaded with hypersexualized or aggressive stereotypes, denoting a need for quality of representation in addition to quantity.¹⁰

One of the racial stereotypes which is most reinforced by the media is that of sexy black women with only physical attributes. In Brazil, the word mulata (female Portuguese word for “mulatto”) is still commonly used to characterize black women represented through this stereotype.²⁸ Representing black people in the Brazilian context – in which European beauty standards are predominant and phenotypes of people of African descent are not contemplated – is still a major challenge for publicity and advertising in all types of media.²⁸

In addition to this mediatic issue, the absence of women and black people in several knowledge domains have been questioned by researchers who emphasize, among other factors, a harmful belief in cultural stereotypes as a reason for this absence. These stereotypes portray the intellectual abilities of these groups negatively, impeding them from achieving professional success.^29,30 Thus, the reinforcement of these stereotypes may discourage participation and harm access of women and black people to better life conditions; on the other hand, directing efforts to increasing opportunities for these groups, enabling continuous possibilities for their success, may bring improvements for diversity in several knowledge domains.³⁰

In this sense, the analyzed leaflets are emphasized to have deconstructed racial stereotypes related to black women, showing that the challenge may be overcome as black women are positively portrayed, not reinforcing stereotypes which are rooted in Brazilian culture, with equality in relation to other ethnicities and races.

This study had as a limitation the restricted analysis of the educational leaflets made available for download at the VHL, since this platform provides other types of educational publications, such as folders, e-books, images, and other resources. Thus, an analysis of other types of material published by the MH is suggested for a comprehension of black representation.

CONCLUSION

This study focused on the representation of black women in educational leaflets of the Brazilian Ministry of Health related to women's health.

The study quantitatively shows the low representation of black women in these leaflets, although those represented are portrayed positively and in equality with women of other ethnicities and races.

The low representation points out a need for more official leaflets portraying black women in accordance with their numbers in the Brazilian population, i.e., over half of it. Representing women with no reinforcement of negative stereotypes shows a change of view in governmental publicity campaigns, which give more visibility to black women, removing them from subaltern positions and placing them in leadership roles in health issues.

This study enables the elaboration of public policies and programs targeted at women's health actions to value the specificities of different populations. Thus, this study draws attention to the health of the black population, which, due to corresponding to most of the Brazilian population, deserves more representation in official health campaigns, pointing out to a change in the standards of black women representation.

Reassessing the importance of the representation of ethnic and racial groups in health education materials enables the social identification of the represented groups and may enable the improvement of self-care and a higher adherence to health treatment. More studies on the ethnic and racial factor are suggested to be developed and explored to provide resources which contribute to improvements in quality of health of different ethnical and racial groups, particularly the health of the black population. The limitations of this study are related to its analysis, which was conducted only on leaflets available for download at the Virtual Health Library website, possibly leaving aside other leaflets matching this study's inclusion criteria and used by health services which were not published on this website or available for download.

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Edited by

ASSOCIATED EDITOR

Beatriz Rosana Gonçalves de Oliveira Toso 0000-0001-7366-077X

SCIENTIFIC EDITOR

Ivone Evangelista Cabral 0000-0002-1522-9516

Publication Dates

• Publication in this collection
  09 May 2022
• Date of issue
  2022

History

• Received
  13 Oct 2021
• Accepted
  15 Mar 2022