Background
In November of 2015, the Brazilian Minister of Health declared the Zika epidemic a Public Health Emergency of National Concern due to the critical increase of microcephaly cases in the Northeast of the country [
1]. By February 1st, 2017, 76 countries have reported the presence of Zika. Of the 205,013 cumulative confirmed cases of Zika infection across the world, 130,840 were in Brazil [
2], where differences by region and level of education in access to and use of health services persist. In fact, most microcephaly cases were concentrated in Northeastern Brazil, where health inequities are higher.
Although news media outlets are no longer concerned with Zika, transmission continues in 87 countries and the U.S. [
3]. Puerto Rico has witnessed the most negative known outcomes of ZIKV infection in the U.S. [
4]. Concerns should be raised not only regarding the likelihood of the virus persisting in currently affected areas, but also the danger of its spreading to new areas throughout the globe.
The
Aedes aegypti mosquito is the principal vector responsible for the widespread transmission of the virus [
5]. The ZIKV usually causes only a mild infection in humans, but it is also associated with severe cases of Guillain-Barré syndrome and death. For women who are pregnant it can produce severe neurological complications and adverse fetal outcomes [
6]. During pregnancy it can trigger congenital brain abnormalities [
7]. Sexual transmission of Zika from both male and female partners can occur [
6,
8] and the virus can remain viable in semen for months [
9]. These unique adverse effects of Zika for maternal and perinatal health call for a broad spectrum of public health interventions.
Governments and multilateral agencies issued general advice and recommendations to protect women [
10]. Most of these messages where focused only on women. Many governments in Zika-affected areas strongly advised women to avoid becoming pregnant [
11], whereas others stressed the importance of obtaining counseling and adequate access to family planning resources [
12]. However, populations do not have equal access to information on contraception and in a number of countries in the Americas, such as Brazil, the country most affected by the Zika outbreak, abortion is illegal. However, to date the changes in legislation in either country have yet to take shape [
13]. Preventive measures also included recommendations such as avoiding locations likely to contain infected mosquitos, covering oneself completely with clothing, and applying repellents, among other individual level preventative measures [
14,
15].
The public health response to the Zika outbreak mostly focused on epidemiological surveillance and vector control, together with individual level behavioral change campaigns However, women had to deal with the harrowing threat of mosquito infection and lived in communities exposed to upstream factors such as media, public policies, and political circumstances that determined how the epidemic influenced their daily lives [5,17, 18]. These factors subjected women to a degree of greater or lesser vulnerability. We described elsewhere how the lives of women were deeply affected by the emotional impact caused by the Zika epidemic [
16]. However, to have a comprehensive understanding of the impact on women of the ZIKV pandemic, studies have to identify and analyze how the upstream or macro-level factors interact with individual-level maternal and child health outcomes.
During an infectious disease outbreak, particularly one that involves a new or previously unseen health threat, it is important to know how information influences and is perceived by the public. Years of research in communication and psychology show that public opinion change is much more challenging than opinion formation [
17]. To be most effective, public health campaigns must provide information that helps the public understand the causes of the disease in media formats that are accessible to various ethnic and socioeconomic segments of the population. Another important factor to consider is how the political contexts and history of a country influence the population reaction to an epidemic such as Zika. Many countries in the Americas where Zika was present had challenging political and economic circumstances. For instance, Brazil, which had the greatest number of Zika cases, is a country with high levels of economic inequality and structural deficiencies in sanitation and health care. Most women and children affected by Zika lived in arduous conditions. As the Zika epidemic evolved, Brazil went through one of the greatest economic and political crises in its history [
18]. Puerto Rico, also greatly affected by the epidemic, suffered from socioeconomic inequality and a strong economic crisis. Women in Puerto Rico have historically suffered the effects of forced sterilization [
19]. Such legacies are still felt in the current Zika epidemic, since
“effective action has been complicated by lingering suspicions related to historical activities…. Misinformation has clouded… the best ways to protect individuals and communities” [
20].
Women, on whom the responsibility and weight of public policies to control the Zika epidemic rested, must have a role in making informed reproductive decisions, protecting their health, and understanding the implementation of public health policies. The public health response to Zika should consider how women’s organizations interact with the overall society, how they support each other, and whether networks between them do exist. The ability of local communities to mobilize and collaborate for action influences the success of strategies to control infectious disease [
21]. Community engagement could be an essential tool to minimize suffering, increase emotional and mental health and support among ZIKV patients and families with affected children.
While broad socio-ecological models have been previously employed to account for the links between individual, community, and broader structural factors, and informed multi-sectorial responses to other epidemics, such as AIDS [
22,
23], they have been insufficiently employed to inform the response to the Zika epidemic [
24]. In addition, few studies have so far been conducted to address the impacts that the Zika epidemic had on women’s lives at the transnational level, and the ways in which women dealt with Zika outbreaks have yet to be documented. The psychosocial implications of the Zika epidemic are essential for a complete understanding of its long-term repercussions. To our knowledge, few studies discussed the impacts on women who are indirectly affected and less vulnerable to Zika [
16,
25]. Women indirectly affected by the epidemic suffered indirect effects from it without being directly exposed to the virus by personal contacts or infected by it.
This qualitative study aimed at furthering our understanding of the impacts of the Zika epidemic on women living in different contexts. Informed by social-ecological frameworks, we identify how macro (historical, political, legislative, socioeconomic factors), meso (sources of information, social support, and social mobilization) and micro level factors (individual actions, behavioural changes) interacted to influence the response and behavior of women in different contexts.
Discussion
Individuals’ responses to the epidemic depend on the sources of information received, and how these are perceived, which is in turn influenced by broader political, historical, legislative and socioeconomic contexts (Fig.
1). Few studies in the literature [
28‐
31] address the experiences of women indirectly affected and less vulnerable to the effects of the Zika epidemic. Our study demonstrate that the social effects of the epidemic affect more women than had been thought before and at deeper levels. They are coping with feelings of fear, helplessness, and uncertainty by taking drastic precautions to avoid infection that affect all areas of their lives. Coping strategies pose obstacles in professional life, lead to social isolation, including from family and partner, and threaten the emotional and physical well-being of women [
16].
The first step in responding to any health epidemic involves having adequate information on the causes, how the disease may be contracted, and what steps should be taken to ensure one’s safety and health. Dissemination of information plays an important role in epidemics, especially with those comparable to Zika, where all aspects of it were new and there was ignorance among citizens and health professionals alike [
32]. Legacy and social media respectively influence risk perceptions and protective behaviors during emerging health threats [
33].
During the Zika outbreak, women in our study deemed the information provided by public health officials as insufficient, which led them to actively reach out and access many media sources to counterbalance information gaps and shortcomings. Social networks played a vital role in sharing information but also resulted in the spread of hoaxes or rumors. It has been reported that Public Information Officers who were monitoring social media felt better prepared for Zika and were more satisfied with their crisis management since social media facilitates the spread of both accurate and false information [
34]. Understanding these media effects is essential to communicate public health information and engage different populations in the community [
35]. Above all, the need to access social media to gain knowledge about the debilitating virus clearly demonstrates the lack of satisfaction with then available official information about Zika.
There was a banalization of Zika by the average women and also health professionals, who were unclear about the health effects of the virus. When a disease is endemic in a particular population, reactions tend to be much more subdued, and it is harder to induce protective behavior [
36]. As an example, while international media attention has focused squarely on the risks posed by the Zika epidemic— prompting extreme reactions in some cases, such as Olympic athletes pulling out of the Rio games— evidence suggest that Brazilian residents may have viewed it differently, using the frame of reference of a familiar endemic disease, dengue, to evaluate the risk of the new and unknown Zika [
37]. Several studies of dengue in the developing world have underscored the difficulties of stimulating a strong public response or sustaining one after that epidemic subsided [
38,
39].
In the case of Puerto Rico, the history of government sanctioned medical trials [
40,
41] and forced sterilization [
42] caused the population to become vulnerable, because it perceived current and future health epidemics as unpredictable. Such effects are so long-lasting that even in the current Zika epidemic, segments of the population not only doubted government intentions, but also refused to adopt any advice provided by the Department of Public Health. The voices of participants suggested that there are individuals and populations that resist the idea that government can truly be sympathetic to their well-being, whether the issue at hand is health, safety, or security. In fact, Zika brought to the forefront the interpretation that government abuses on a given population can have long-term harmful consequences.
The interaction between women and society as a whole is crucial to understand how stigma, classism and gendered inequalities happened during the Zika epidemic. We focused on how women perceived stigma, since during past epidemics, a negative social attitude had been reported [
43,
44]. In our case, it became clear that the mosquito was perceived as an equalizer; the mosquito does not discriminate between rich and poor, biting everyone equally. Quite a different reaction was experienced in other epidemics, such as Ebola, where a definitive association of the disease with only “poor people” was patent [
45], or in the case of HIV where stigma has persisted even after provision of effective treatment [
22].
Given the social inequities in the U.S. and Brazil, one would assume that social stigma surrounding Zika would be prevalent; however, there were contrasting experiences among women depending on their geographic location. Brazilian women showed no such stigma about Zika infections. Conversely, U.S. women argued that stigma towards the ZIKV was, in fact, prevalent. This lack of stigma could be explained by the fact that Brazilian women are more accustomed and knowledgeable about these kind of mosquito transmitted diseases, such as dengue, chikungunya, which are rather common where they live.
Discrimination played a part in feelings of stigma whereby women felt targeted for their ethnic background. The U.S. government claimed that Zika was associated with immigrants from Central and South America, after Zika was recognized as a public health emergency in the U.S. The blame for the virus infection was again placed on individuals from a few nationalities as opposed to mosquitoes.
The Ebola infection also had similar impacts. Most of the individuals infected resided in poorer nations in the African continent. Women in these areas were the most affected as they had inferior access to healthcare [
44,
45]. Information was either limited or the sources of knowledge were not culturally competent enough to be shared with the population. Although the virus could indeed be contracted via exchange of bodily fluids from person to person, individuals were charged with the responsibility to maintaining a clean bill of health [
46].
Participants in our study understood that anybody could be bitten by the mosquito, but most were aware that they were privileged while others were in much more vulnerable situation. They clearly perceived the ethnic and socioeconomic inequities deeply rooted in their different contexts. However, they mainly focused on how to remedy their microenvironments.
Social movements to support and defend women’s reproductive health rights because of the Zika epidemic might have happened, but many women did not realize that the connection they were fostering with each another might have evolved into a massive push for better access to birth control and better health care services. Surprisingly, women’s activism in Brazil and other Latin American countries revolved around the creation of an underground movement for health care - women with children affected by Zika formed non-profit organizations and informal networks to defend their rights [
47,
48]; abortion activists carried out many activities and studies [
2,
49,
50] in countries where abortion was illegal [
29].
Some women resisted but a movement for real change was invisible, maybe because advocacy efforts were top-down and thus unsuccessful at generating grassroots mobilization. The views of advocates might not be aligned with women’s’ views regarding abortion, for example. In a previous transnational study that provided insights into women’s views and attitudes towards their reproductive rights in times of the Zika epidemic, we reported that reproductive decisions were intimately related to personal convictions and cultural beliefs, and their actions and thoughts were embedded in their sociocultural norms [
25]. Thus, it is important for the advocacy to be culturally sensitive, so it reaches a broad spectrum of the population.
The lack of social mobilization seriously addressing Zika as a global health matter is the biggest difference with other global epidemics. In the case of HIV there were huge mobilizations to get free treatment for all [
51], tackle stigma [
52] and to investigate women controlled prevention measures such as microbicides [
53]. Also, since Zika has similar symptoms to dengue and chikungunya, some participants of our study reported feelings of resignation to the ongoing epidemics. Another factor that might have contributed to the lack of massive social response is the lack of support for women’s reproductive health and rights that have historically been neglected aspects of Public Health [
54,
55].
Political contexts also affected the social response, as reported by women in Puerto Rico and Brazil. In the end, the responses ended up becoming for the most part individual efforts to manage their own microenvironments. It is clear that the women more affected by the ZIKV infection, are the poor ones, traditionally neglected in their living conditions and health [
56]; but our study shows that all women were affected in some way. We indicate that the social impacts of the epidemic affected more people, directly and indirectly, than had previously been thought and at deeper levels. Zika is a vast and far-reaching epidemic that altered the lives of women of all social positions.
Regardless of the downgrade issued by the World Health Organization in November 2016, there are many other non-medical impacts of the ZIKV. Those impacts derived from the failed or insufficient response of health and government administrations to ensure population wellbeing by focusing almost exclusively on biomedical approaches. As the case of HIV has shown [
57], a broader socio-ecological approach must be adopted for successful implementation of public health policies to control an epidemic.
Our qualitative research is limited by the small number of participants, which does not allow for statistical generalization. However, it is conceptually generalizable in the sense that the themes that emerged are relevant to analyze and guide the response to the epidemic in different contexts. This is study analyzed the impact of the Zika epidemic on women who were indirectly and/or directly affected by it and considered the particularities of different contexts.
The strategies to canyontrol Zika in different communities should vary depending on their assets, vulnerabilities, and public health environments. On the one hand, the epidemic may stress public health systems and highlight weaker points that need comprehensive improvements. On the other, the socioeconomic, cultural, and political determinants of the epidemic may also have some bearing on the successes or setbacks of the emergency response to Zika.
An epidemic is a social phenomenon as much as a biological one. Thus, understanding people’s behaviors and fears, their cultural norms and values, and their political and economic realities is essential. Having social scientists and academics working alongside governments and public health authorities would contribute to the introduction of crucial media messages, policies and guidelines to support the affected population. We hope that our work will lead to new guidelines and policies to ensure that the emergency response and the messages are delivered in the most effective way.
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