INTRODUCTION

The approaches from which health has been defined are very diverse. They have ranged from physical-biological perspectives, which define it on the basis of disease; to others that emphasize its social dimension. It was not until the mid-20th century that greater attention began to be paid to social aspects and their role as determinants of health. (Del Pino, 2010) (Gavidia & Talavera, 2012) (Palomino, Grande, & Linares, 2014).

Thus, in 1946, the World Health Organization (WHO) conceives it as "a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity." (WHO, 2006) . This notion places the focus on a process in which the psychological, social and biological are key components of health. Although this conception has been labeled by some specialists as static, subjective and idealistic, it marks a necessary shift towards a positive vision of health. (Gavidia & Talavera, 2012). .

According to Palomino, Grande and Linares, since the 1970s, studies that have reaffirmed the relevance of social determinants have increased and diversified so that they became a priority focus of attention in health. At the same time, this perspective was key to the momentum of the health promotion movement at the end of the 20th century, its founding moment was the First International Conference on Health Promotion, held on November 21, 1986. (Palomino, Grande, & Linares, 2014).

There it was stated, more specifically, that economic, political, social, cultural, behavioral and biological factors could have a positive or negative impact on health. This was reflected in the Ottawa Charter, which also included a series of preconditions as a guarantee for a healthy life: peace, education, housing, food, a stable ecosystem, social justice and equity. Accordingly, the document emphasizes the need for coordinated action by various institutional and social actors, together with the health sector, as the best way to guarantee the prerequisites for health. (Ottawa Charter for Health Promotion, 1986). From this perspective, health is a phenomenon conditioned not only by biological factors, but also by social determinants.

In this sense, gender, understood as a set of sociocultural constructs that define and attribute characteristics to the feminine and masculine on the basis of biological differences between the sexes, also constitutes a social determinant of health.

The analysis of health from a gender perspective makes it possible to make visible unequal power relations between men and women, which may be giving rise to inequities and generate differentiated impacts on the health of men and women. At the same time, it can bring to light social problems inscribed in or derived from health situations that might otherwise be hidden or overlooked in the face of other priorities that are better positioned or socially or institutionally recognized.

This starts from the recognition that, in addition to biological differences determined by sex, there are others derived from social, cultural, and psychological factors with a differentiated impact on the health of men and women (Artazcoz, Chilet, Escartín, & Fernández, 2018) (Corral, Castañeda, Barzaga, & Santana, 2010) . Such differences constitute health inequalities, which are avoidable and unjust, and should be made visible in order to promote actions to improve the health of men and women. (Corral, Castañeda, Barzaga, & Santana, 2010) (Palomino, Grande, & Linares, 2014) and should be made visible in order to promote actions and decisions that will make it possible to achieve equity, i.e., the elimination of these differences.

Health emergencies are scenarios in which, taking into account the extraordinary nature of the events that generate them, such sensitive realities as the possible negative impacts on vulnerable sectors of society, such as women, the elderly and children, might be relegated to the background.

This is a reality that is being experienced in the current scenario of COVID-19. Some international organizations have been warning about this. According to data provided by the International Labor Organization (ILO), 40% of women work in the sectors most affected by the pandemic (hotels, gastronomy and commerce). This figure is 18.9% higher in Central America (58.9%). Among them, those engaged in paid domestic work - 88.5 % in the Americas - are at high risk of losing their jobs. They are also among the groups most at risk of infection, accounting for 70 % of healthcare workers globally. Added to this is the increasing burden of unpaid domestic and care work, which affects job performance and increases the demand for social care services. (ILO Observatory, 2020). .

According to the Economic Commission for Latin America and the Caribbean (ECLAC) (ECLAC, 2020) , gender inequalities are more marked in lower-income households where problems are exacerbated, such as: a greater demand for care due to a greater number of dependents, housing infrastructures that do not guarantee the necessary physical distance, unequal access to basic services such as water and the unavailability of technological resources, as well as difficulties in managing distance education.

Given the complexity of this scenario, it is urgent to strengthen intersectoriality so that different formal, non-formal and informal social actors act in a coordinated manner in order to address, from their specificity, the various problems arising from the current pandemic situation, particularly those related to gender inequalities.

In this sense, health risk communication (HRC) processes are strategic in order to inform, educate, raise awareness, mobilize, articulate, persuade, promote behavioral changes and encourage the participation of all in the response to health risk situations.

OBJECTIVES

From this perspective, the present proposal is articulated around the following objectives:

• Identify the distinctive elements associated with health risk communication from a gender perspective

• To characterize the conditions under which health risk communication takes place in the Cuban context during the COVID-19 pandemic.

• To analyze the scope of gender mainstreaming in health in Cuba

• To identify health risk communication practices in the context of the COVID-19 pandemic in the Cuban context.

• Define alternatives to improve health risk communication with a gender perspective, taking into account the particularities of the Cuban case.

For this purpose, a qualitative methodology with a descriptive approach is proposed, based on a literature review and the analysis of the particular context in which the theoretical articulations between the categories that are the focus of this study: gender, communication and COVID-19 are produced.

HEALTH RISK COMMUNICATION FROM A GENDER PERSPECTIVE

Health communication is a social, educational and political process that applies communication resources in a planned and systematic way to:

• Influence individual, institutional and community decisions (Rodriguez, Cabrera, & Calero, 2018

• Promote public awareness about health, healthy lifestyles, and community action (Perez & Ochoa, 2015) y

• Seek the formation of environments, systems and policies favorable to health. (Pérez & Ochoa, 2015) .

Díaz and Uranga point out that although communication has always been linked to health processes, it only began to position itself as part of strategies and programs as the concept of health evolved towards a biopsychosocial perspective. They also point out that its incorporation as a key component of health received its most significant impetus during the 1st World Conference on Health Promotion. Both authors, in analyzing the various objectives of health communication, emphasize that it is not limited only to the generation of individual or collective behavioral changes, but also seeks to create new scenarios based on collective construction and the participation of various social actors, including the community. (Díaz & Uranga, 2011). .

CRS is part of health communication and includes "decision making that takes into consideration political, social, and economic factors, which analyzes risk as a potential hazard in order to formulate, study, and compare control options with a view to selecting the best response for the safety of the population in the face of a probable hazard." (PAHO, 2011) .

Its specificity lies in the fact that it is a communicative process that is developed in health risk contexts, with the aim of avoiding and mitigating the associated negative consequences. Thus, CRS contributes to:

• Generate an adequate risk perception

• Reduce uncertainties

• To guide the behaviors to be followed in the different stages of the emergency

• Facilitate recovery processes

Therefore, the confluence of informative, educational and communicative actions, in a synergic manner, is indispensable.

Even when developed in emergency scenarios, it must be strategically planned on the basis of in-depth and multidimensional analyses of the contexts, which make it possible to foresee the potential health risks and the possible communication strategies to be followed. This is the only way to ensure timely decision making and a coherent, articulated and effective response to health incidents.

Cuban researcher Liliana Gómez Castro stresses that the incorporation of risk communication in a systematic way to public health systems is essential to improve prevention and health education, as well as to achieve the consequent reduction of material and human losses. She also insists that this is a type of communication that focuses on risk prevention. (Gómez L. , 2017) .

CRS strategies can be designed, implemented and evaluated from three possible communication paradigms: transmissive, persuasive or participatory. The first two are based on more traditional and unidirectional conceptions of communication, focused on information and behavioral change; while the third takes into account a relational and bidirectional perspective, based on the participation and interaction of institutional and non-formal stakeholders at all levels.

In reference to the broader field of health communication, Diaz and Uranga point out that these perspectives coexist and delimit them into instrumental (transmissive and persuasive paradigm) and relational (participatory paradigm): the former, more focused on the transmission of information, as well as on the manipulation and control of behaviors and the latter, focused on "the social production of meaning in the framework of a social and cultural context." (Díaz & Uranga, 2011). .

Although the three paradigms can contribute, depending on the situation, to the proper development of CRS, the ideal would be to study in depth the relevance of actions ascribed to each one, according to the specific communicative needs that may exist. In particular, PAHO recommends not losing sight of dialogue (participatory paradigm/relational perspective) as an essential element in CRS decision-making. This recommendation points to two essential aspects: the articulation of the different actors involved in the health processes and the recognition of the culture and daily life of the protagonists as something to be taken into account. (Díaz & Uranga, 2011). .

Gender inequalities can be exacerbated in emergency scenarios because a significant part of the attention and resources are concentrated on resolving the most specific risk situation as soon as possible. For this reason, the incorporation of the gender approach into CRS strategies should be done consciously and be present in each of the stages defined by PAHO: preparedness, initiation, control, recovery and evaluation.

In each one, the application of this approach, in a cross-cutting manner, will make it possible to identify gender-based inequalities from which more inclusive communication strategies can be designed, implemented and evaluated. To this end, it is recommended that:

• Incorporate gender, communication and health specialists in risk communication teams

• Include, in the context analysis, the identification of risks and impacts differentiated by gender; in addition to the visualization of potential collaborators sensitive to the issue.

• Plan, produce and implement communication actions and messages differentiated by gender, taking into account the detection of specific vulnerabilities in the previous contextual analysis. This also applies to the definition of communication channels for these messages and to the articulation mechanisms that facilitate decision-making at different levels and synergic work.

• Characterize audiences by incorporating the gender dimension

• Take into account the application of gender analysis in the monitoring and evaluation of communication processes.

• Train the different actors involved in the CRS on gender and health issues

CUBA: BRIEF CONTEXTUALIZATION IN TIMES OF COVID-19

In general, CRS in Cuba has been characterized by having clearly defined and contextualized objectives, being intersectoral and multidisciplinary and generating differentiated messages for the various sectors involved -health personnel, population and other social actors.

Based on a research conducted in 2010 by Tania del Pino Mas, PhD in Communication Sciences, the researcher states that in the Cuban health system, an approach based on damage is often privileged, that is, oriented to repairing the damage caused by diseases and that this tends to happen in health emergency situations in which actions are usually centralized. (Del Pino, 2010) .

This conception coexists with others such as: the notion of health as a problem with health and social dimensions involving a multiplicity of actors and the risk-based conception, which foresees possible dangers and ways to neutralize them.

In the particular case of COVID-19, the Cuban strategy of confrontation has been articulated with emphasis on the latter two concepts, since it has taken into account the differentiated attention of vulnerable groups and was conceived in anticipation of the arrival of the first case in the country and the subsequent spread of the disease. It is a strategy that was initially designed taking into account the analysis of the best international experiences, its feasibility and possible adaptations to the national context, according to statements made by the Ministry of Public Health (MINSAP).

Its design and implementation has benefited from extensive experience in the management of disasters and health emergencies. In this regard, the prevention of arbovirosis and the participation in the containment of the Ebola epidemic in Africa, practices in which solid communication strategies were designed, stand out as precedents. The country has also created protocols that have been used in the fight against the H1N1 and cholera epidemics.

María Isabel Domínguez, a CLACSO specialist, says that the strategy has four basic pillars:

• The prioritized attention of the government and the State to the search for resources and solutions.

• The protagonism and strength of the national public health system and the scientific sector

• The intersectoral work of State institutions and agencies in order to respond comprehensively to the disease and the social and economic consequences of the pandemic.

Citizen and community participation, as well as that of social organizations (Domínguez, 2020

In this scenario, the CRS has been vital and has been aimed at increasing the population's perception of risk; generating institutional and citizen, individual and collective responsibility to prevent the spread of the disease; informing and guiding about the care protocols to be followed; publicizing the work and main results of the national health and scientific sector in relation to the coronavirus and counteracting false information. Scientific communication, in particular, has contributed to an objective understanding of the disease, its consequences and forms of treatment, an important aspect for decision-making at all levels, including the grassroots.

WHO has identified some best practices for health risk communication, which have been present in the Cuban communication strategy: confidence building, early announcement, transparency and public understanding. There has been a systematic, updated and transparent management of information; and the discourses at national, territorial and local levels have been coherent with each other and adequate to their scope.

After five months with the new coronavirus in Cuba, the CRS must face the challenge of readjusting its messages, without losing sight of the strategic objectives already defined. To this end, it must pay attention to the reduction of risk perception due to the improvement of care protocols, the scientific advances in the search for a vaccine and the fact that most of the country is in the last phase of recovery. Added to this, there are people's eagerness to leave confinement after a long period. It is a process that must be derived from the monitoring and evaluation of communication strategies.

The confrontation strategy followed on the Island has generated an integral response to the pandemic, because it has worked from an intersectoral approach, with the participation of the agencies of the central state administration, institutions, social organizations and the community. A generational and gender perspective has also been taken into account. For example: social and community support networks have been set up for the elderly; salary guarantees were established for women workers with children who must remain at home to care for their offspring; and children's circles were kept open so that economically active mothers, if they so decided, could bring their children with them.

The gender focus in the communication associated with this strategy has been evidenced in:

1. The presentation of cases of infection disaggregated by sex in the daily epidemiological reports. In this regard, it is still necessary to apply more in-depth gender analyses of these figures, beyond the biological examination, to make the results known through various channels and to implement gender-differentiated communication strategies based on the information collected, if necessary.

2. Communication of differentiated measures for women based on specific vulnerabilities, mainly in the labor sector. Although worker protection includes both men and women, there are specific measures that favor economically active mothers.

3. The visibility of women as protagonists in health and science during the fight against the coronavirus, in parity with men. This is also related to some achievements in gender equity in Cuba, which include the active incorporation of women into the labor market and high educational levels achieved by women. They are also in the majority (71.2%) in the health sector. (MINSAP, 2020) .

This is a macro look at the issue, taking into account the messages that are channeled centrally, mainly through television and the official print and digital media.

A study on good practices of hypermedia communication in Cuba during the pandemic reveals that, although no concrete examples of inclusive communication were identified, neither was the reproduction of traditional gender roles and stereotypes noticeable. It affirms that a balance of sources and perspectives of men and women has predominated. However, in the treatment of the stories of overcoming the disease, a hegemonic male context was detected (Gómez, et al., 2020).

In parallel, social organizations, sensitized citizens, researchers, official media and campaigns have called attention to the danger of an increase in gender violence due to the conditions of confinement. This is one of the possible social impacts of the pandemic scenario. Its treatment has been addressed by national media and has had an active participation of civil society, which has worked intensively through social networks, with numerous initiatives.

It would be opportune to promote research that explores and analyzes the levels of articulation of these more specific communication strategies with each other and with the national CRS strategy, as well as the impact they have had on the detection and reduction of cases of violence, the awareness achieved in this regard and the recognition of this as a public health problem.

GENDER AND HEALTH IN CUBA

In 2016, the first national survey on gender equality (ENIG-2016) was applied in Cuba. Its results were made public in 2019 and made it possible to visualize a set of aspects of progress and others, which still need to be improved, around gender equality.

• Some of the points of progress highlighted by the ENIG-2016 are:

• Greater recognition of women's abilities to lead

• Greater recognition of the role and capacity of fathers in child care

• A more equitable distribution of power in economic or family decision making in the couple. (CEM-FMC, CEPDE-ONEI, 2019).

In a study published in 2010, Castañeda, Corral and Barzaga, professors at the National School of Public Health, cite several studies that place Cuba as a country with more advantages in gender equality compared to its peers in the continent. Among the reasons that have favored this evolution are equal access to education and work, as well as parity in the salaries received when men and women are engaged in similar jobs. (Castañeda, Corral, & Barzaga, 2010) .

Data published in the Statistical Yearbook of Cuba, regarding the level of schooling of the economically active population, confirm that this is a space conquered by women, since in 2018 these (33.8% of the total number of women) held university degrees in greater quantity than men (14, 9% of the total number of men) (ONEI, 2019) .

Progress can be seen in other aspects such as the incorporation of women into the labor market and the occupation of management positions, although total parity with men has not yet been achieved. Thus, 35.6 % of women occupy managerial positions, in contrast to 64.4 % held by men. (ONEI, 2019) . It is worth noting that the composition of the Cuban parliament is more balanced, since 53.2% of its members are women. (National Report on the Implementation of the 2030 Agenda, 2019). .

Also, economic activity rates are 49.5% for women and 76.9% for men, while unemployment rates are 1.8% and 1.6% respectively. (ONEI, 2019) . Although there is a significant incorporation of women into economically active life, the male presence continues to predominate, which could be associated with gender stereotypes that affirm the male role as provider and the reproductive role of women, whose fundamental space is the domestic one.

These stereotypes, although to a lesser extent, coexist with others that still persist in the imaginary of Cuban men and women, according to results of the ENIG-2016, such as:

1. Women should not do activities that involve a lot of physical effort and, therefore, there are less suitable occupations for them (electrician, bricklayer, mechanic, carpenter, plumber, firefighter, airplane pilot).

2. Men are still considered unsuitable to work as secretaries, cleaning assistants, teachers of children or caregivers.

3. The majority of men believe they are better at negotiating (53.6%) and a good proportion still say they are better at making decisions (45%).

4. The main conflicts within the couple are associated with the persistence of traditional gender roles. For men, the main causes of arguments are jealousy, economic issues and time spent at work, while for women, domestic overload, infidelity and excessive alcohol consumption prevail.

5. For a significant portion of the men surveyed (48 %), the woman should always please her partner sexually (CEM-FMC, CEPDE-ONEI, 2019) .

One of the main manifestations of inequality is in the use of time. It is men who dedicate more hours to paid work (12 hours more per week than women). For their part, women spend 14 hours more than men in unpaid work inside and outside the home: housework, care and attention of children or the elderly or disabled. In particular, domestic work takes up the most hours: 27 hours per week for women and 17 hours per week for men.

Even those women who work in paid sectors tend to work 9 hours more than their male counterparts, due to the double burden of unpaid activities.

The type of domestic activities usually assumed by women require daily responsibility and effort, which generates greater psychological wear and tear in this sector of the population (support and accompaniment of schoolwork, cooking, cleaning, washing). This burden is less evident in the case of men, as they tend to take responsibility for household tasks that are performed more sporadically (home repairs, grocery shopping or running errands).

Some regional differences were evident. In the eastern part of the country, more traditional perceptions and practices regarding gender roles prevail, while in Havana, men tend to share more domestic tasks such as washing, washing, cleaning and cooking.

Of the unpaid tasks, caring for children under 14 years of age consumes 5.41 hours of women's time per week. They dedicate a good part of this time to accompanying the youngest members of the household to school.

Another gender inequity that has an impact on women's physical and psychological health is gender-based violence. In Cuba, there are no systematic statistics to monitor this type of phenomenon. However, it is an issue that has been gaining visibility through the work of official or independent media, denunciations in social networks, communication campaigns, non-governmental organizations and public institutions.

A step forward is the recognition in the Constitution of the Republic of Cuba, approved in February 2019, of the protection of women against gender violence as a right to be guaranteed. Also that year, the first statistics on femicides on the island were made public, through a national report on the implementation of the 2030 Agenda, which indicated that during 2016 there were 0.99 crimes of this type, per 100,000 inhabitants women aged 15 years or more, 33% less than in 2013. (National Report on the Implementation of the 2030 Agenda, 2019).

From the perception of Cubans, there are manifestations of violence against women in the country although the majority consider that it is little (51.9 %). Meanwhile, 30 % perceive it to be a lot. Among the types of violence that women suffer the most during their life as a couple, they refer to psychological violence. (CEM-FMC, CEPDE-ONEI, 2019) .

As with the use of time, there are territorial disparities. In the 12 months prior to the application of the ENIG-2016, more women in central (28.1 %) and eastern Cuba (30.9 %) reported having suffered some type of violence than in western Cuba (23.7 %). (CEM-FMC, CEPDE-ONEI, 2019).

When faced with situations of violence, women do not usually seek institutional support, despite the existence of spaces for their attention. This may indicate a lack of knowledge or trust in these structures, as well as the persistence of the shared imaginary that this is a private matter.

The institutions normally approached by the small group of women who seek support from such spaces include the police, the prosecutor's office and the Women's and Family Guidance Centers, which belong to the Federation of Cuban Women (FMC), a mass organization whose mission is to promote women's equality and emancipation.

Traditional gender roles and stereotypes are associated with behaviors that have a differential impact on the health of men and women. In a study carried out with the intention of identifying the aspects of life that most strongly mark differences between women and men in the stages of the life cycle in Cuba, it was concluded that the main inequities are manifested in daily life and that these lead to health problems differentiated by sex. (Castañeda, Corral, & Barzaga, 2010).

For example, this research affirms that the overload of responsibilities spread throughout life leads women to suffer more from depression and psychological problems in later life or to have a lower quality of life, as they tend to suffer from physical and mental disabilities. She also points out the emotional and sexual damage caused by domestic violence.

As for men, it indicates that the stereotype of strength and competitiveness, associated with hegemonic masculinity causes them to suffer more injuries due to the careless practice of sports or to acquire toxic consumption habits such as alcohol more frequently.

These realities are consistent with those manifested in other latitudes, evidenced in scientific works by researchers from Chile, Mexico and Ecuador. In these works it is stated that women tend to suffer from depression (Proaño, 2019) stress and anxiety (Ceballos-Vázquez, Jofré-Aravena, & Mendoza-Parra, 2016) (Soria & Lara, 2017) as a result of the overload generated by domestic and care work.

On the other hand, analyses and research in Mexico, Spain and Brazil confirm that dominant constructions of masculinity mediate risk perceptions and influence men to seek health services less or later. (Bolaños, Granados, & Garduño, 2018) (Artazcoz, Chilet, Escartín, & Fernández, 2018) die at a younger age and suffer more accidents. (Marcos-Marcos, Mateos, Gasch-Gallén, & Álvarez-Dardet, 2020) (Reis, Batista, Lopes, & Fernandes, 2020) . In fact, one of these studies reports that this is one of the reasons why Brazilian men have been less adherent to preventive measures during the pandemic and have been less likely to seek psychosocial support services. (Reis, Batista, Lopes, & Fernandes, 2020) .

The data on gender in the Cuban context lead us to affirm that there are advances towards equity due to universal access to health and education, some of the guarantees offered by social security and the growing incorporation of women into the labor market and decision-making spaces. However, there are still disparities that must be addressed, such as the unequal sexual division of labor and the manifestations of violence that still persist. This is based on a patriarchal culture with various manifestations in everyday life.

Communication is an essential process for the transformation of these realities and, to this end, should give an emphatic and differentiated treatment to these problems. Thus, communication strategies should not be limited to the enunciation of the associated situations; they should also have an impact on decision-making and policy (re)formulation. At the same time, it would be appropriate for them to promote the accompaniment and change of perceptions and to propose or make transformation alternatives feasible.

The confinement decreed at the time of COVID-19, creates conditions for these pre-existing problems to worsen. Therefore, it is more necessary than ever to monitor and analyze situations of this nature that may be occurring.

ALTERNATIVES FOR GENDER EQUITY

With the appearance of COVID-19 in Cuba, a set of outbreak control measures began to be implemented at the end of March, including the confinement of the entire country (closure of schools and universities and suspension of transportation, limitation of mobility, among others).

When schools closed, children and adolescents continued to receive classes at home through television, which has undoubtedly generated a greater demand for care and school accompaniment by adults in the home. If we analyze the statistics before the outbreak of the pandemic, this type of care usually is taken by mothers; therefore, in these circumstances, we can deduce a significant increase in the hours dedicated to this activity.

Ana Laura Escalona, psychologist member of the PsicoGrupos initiative in WhatsApp ¹ , refers that in the work oriented to families with children and adolescents were recurrent behavioral imbalances associated "to disorders of schedules and routines of family life". She also pointed out an increase in work tensions and the incorporation of the teaching role in the parents' routines, with greater weight in the case of women. (SEMlac Editorial Office, 2020) .

In addition, many economically active women have begun to work as teleworkers or telecommuters, which poses an enormous challenge for the reconciliation of these tasks with the multiple domestic and caregiving tasks for which they are responsible. Bearing in mind that Cuba has an aging population and that the elderly are more vulnerable to the COVID-19; in the homes where they live together, the care responsibilities that they generally assume increase.

This can lead to increased stress and anxiety among women and to heightened tensions within the home if more equitable family collaboration is not managed. In turn, these tensions can trigger gender violence in any of its manifestations.

The WHO has stated that, in the face of stay-at-home measures, with increased domestic and care burdens and the impact on livelihoods, the risk of domestic and intimate partner violence is also increasing, especially if women are in abusive relationships, which also affect their children. (WHO, 2020) .

Such consequences of the pandemic require a differentiated treatment with specific care, support, guidance and communication strategies and should not be relegated to the background, as they may aggravate existing inequalities and even mark social setbacks in gender and health.

Gender violence has increased its visibility in the media as a sensitive issue in the current context of health emergency due to the real risk of its multiplication. Numerous initiatives have been re-organized to tackle the possible impacts of an increase in acts of this nature. Among them are the telephone and e-mail counseling services provided by the Christian Center for Reflection and Dialogue, the YosíteCreoenCuba Platform and the Oscar Arnulfo Romero Center (OAR) ² . There are also public channels of contact with institutions to alert or denounce cases of violence: National Revolutionary Police; FMC, Attorney General's Office, National Center for Sex Education (CENESEX). On the other hand, Evoluciona, Cuban Campaign for Non-Violence against women and girls has maintained an intense activity in social networks.

In terms of communication, there has been an intention to make this problem visible as part of the epidemic scenario, to establish channels of contact with potential victims, as well as to disseminate information through social networks and traditional media about the spaces or institutions to which a woman involved in this type of situation can turn.

However, communication efforts have been less evident in terms of promoting family collaboration in domestic and care activities in order to distribute responsibilities in the home more equitably and thus reduce the harmful impacts on women's health. The United Nations Population Fund in Cuba (UNFPA Cuba) is one of the organizations that has this issue on its agenda and has shared related messages on its social networks.

PsychoGroups on WhatsApp could be a viable alternative to identify the prevalence of these specific situations in the COVID-19 setting. Ana Laura Escalona notes that gender-based violence is a topic that is addressed in a cross-cutting manner and that the gender perspective is applied to the work they do (personal communication, August 12, 2020). Although the function of these groups is orienting, the socialization of information on identified gender inequalities with key actors would be a necessary impulse and starting point to think of communication strategies and actions that make visible, raise awareness and commit to action. Hence, the importance of generating articulation networks, basic for intersectoral work.

The problems described above are not usually addressed in depth in national CRS strategies. In a health emergency of these dimensions, the central focus is the mitigation and elimination of more global biological and social risks derived from the sudden emergence of an unknown disease, as in the case of the new coronavirus. This does not mean that such strategies neglect the gender approach or attention to other vulnerabilities, but rather that the various social impacts are taken into account in a more general way.

However, at the regional and community levels, it is more feasible to work on communication strategies that, in parallel with the strategy to confront the disease, address more specifically the gender inequalities and their effects on health. This will make it possible to design communication processes that are more appropriate to the contexts in which they will be implemented and to take advantage of the resources and opportunities that exist in these areas.

The integration, from the health risk communication approach, of the alternatives described above and others that include issues that have not yet been worked on, such as disparities in the sexual distribution of work, is vital to foresee the impacts that gender inequalities may have on health during the pandemic. Although the study of the transformations that may be generated by the experiences implemented is a pending task, there is evidence of the capacity for mobilization, action and adaptation in the context of a health emergency. Likewise, the importance of a plural participation in these communicative processes has been demonstrated, integrating the work of institutions, civil society organizations and citizen representatives in the visibility of these problems; as a way to mitigate or stop, from multiple fronts and levels, the inequities in health, derived from gender inequalities.

This is not a task that is exclusive to the health sector; it requires the joint work of different social actors who, from their experience, knowledge and areas of action, can contribute an integral treatment to the problems identified. In other words, the approach must be intersectoral and for this it is important to create systematic double-flow communication channels among all those who can be part of the communicative action.

It is very difficult to achieve this necessary synergy and intersectorality if there is no gender sensitivity and knowledge of the relationships between gender, communication and health. Therefore, it is not something that can be achieved from one day to the next. It requires prior processes of diagnosis, organization, training and articulation. The fact that the CRS is implemented in health emergency contexts does not mean that it is improvised. There are scenarios that can be foreseen and recorded in risk and resource maps, which should always include a gender approach and these are a necessary starting point for the design of communication strategies.

It is also important that the strategies are not only developed with the opinion and participation of specialists in the subject. Their contributions are as important as those of potential audiences. The voices of the latter are the ones that help to precisely orient the target. They can even be key players in the implementation of strategies.

The creation of gender observatories in Cuba would be an ideal tool for initiatives throughout the country to learn about what is being done in other national spaces. They would contribute to the integrated analysis of the context, generate learning and links between the different experiences. They could be part of networking.

Finally, there must be coherence between the objectives, channels, message lines, communication actions and scope of the communication strategies. The media can be more or less effective, depending on whether the scope is national, regional or local, or on the specific audience using them. There are also access gaps that should not be overlooked.

Communication is not limited to the mass media and the dissemination of information; it also includes articulation processes and group work, which in the COVID-19 scenario may be mediated by communication technologies.

CONCLUSIONS

In times of coronavirus, CRS from a gender perspective is key to avoid the deepening of inequalities with an impact on health. For this reason, it should be planned in all its stages, implemented and evaluated taking into account the risks derived from this type of inequalities.

Cuba's previous experiences in the CRS have favored that the COVID-19 strategy is being successful in containing the pandemic. It has been characterized as timely, intersectoral, systematic and transparent.

In the Cuban context, in addition, there are several communication alternatives of institutions, civil society organizations and citizens focused mainly on the problem of gender-based violence. These cover, and work in a more focused manner on situations that may worsen during the pandemic and are very necessary for the attention of issues that do not constitute the central axis of the national CRS strategy.

Due to the social impacts of COVID-19, it is urgent for the CRS, in addition to addressing the most immediate and global health problems, to strengthen the articulation with those other communication alternatives that deal more specifically with these effects, particularly those that deepen gender gaps. In this way, a multidimensional and integrated treatment is guaranteed, from different actors, potentials, perspectives, levels and areas of action. Positive impacts on people's health will depend on the effectiveness of the results.

The increase in gender gaps in times of COVID-19 is a reality. The existence of previous gender inequalities that have not been overcome triggers warnings about their deepening. Cuba does not escape this reality and communication is key to ensure that this issue is not neglected or kept on the sidelines. Postponing the work to reduce gender and health inequities would mean a greater effort once the pandemic is over, and a setback in the achievement of equality.

Communication, strategically thought out and with a cross-cutting gender approach, is essential to make visible, inform, raise awareness, mobilize and commit to mitigate the health impacts that this type of inequity generates.

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