INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 2023, VOL. 18, 2172798 https://doi.org/10.1080/17482631.2023.2172798 Spanish residents’ experiences of care during the first wave of the COVID-19 syndemic: a photo-elicitation study Laura Medina-Peruchaa,b,c, Constanza Jacques-Aviñó a,b,c , Tomàs López-Jiméneza,b,c, Catuxa Maiza and Anna Berengueraa,b,c,d a Unitat Transversal de Recerca, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain; bUniversitat Autónoma de Barcelona Bellaterra, Cerdanyola del Vallès, Spain; cNetwork for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Spain; dDepartament d’Infermeria, Universitat de Girona, Girona, Spain ABSTRACT ARTICLE HISTORY Purpose: The main aim of this research was to explore experiences of care during the Received 16 December 2021 lockdown of the first wave of COVID-19 syndemic in Spain Accepted 20 January 2023 Methods: This is a qualitative and explorative study using self-photo-elicitation as a data KEYWORDS collection method. Fifteen participants (Twelve women and three men) shared 25 photo­ Care work; COVID-19; graphs and one video between the June 18 and August, 2020. Participants’ photographs and lockdown; gender; photo- texts were collected online. Data were analysed based on Thematic Analysis. elicitation; self-care; Results: Three emerging categories were constructed: 1) the deconstruction of care: self-care collective care; Spain and collective care 2) the crisis of care and gendered care, 2) beyond anthropocentrism: animalism and ecology. Findings indicate the need to understand “care” in terms of social reproduction, including self-care, care towards other humans and non-human animals, and collective care. Also, the need to care for planetary health and to be in contact with nature as a form of self-care and social care. Conclusions: Care in a period of social and health crisis puts human relationships and also non-human life at the centre. Care requires adopting taking an ecological one-health perspective. Introduction paper, to acknowledge and consider socio-environ­ mental that are linked to the development and con­ Research and sociopolitical debates around the sequences of COVID19. Also, as we understand the impact of the COVID-19 pandemic have mostly need to include social, structural and environmental focused on morbidity and mortality. However, the factors in COVID-19 policies. COVID-19 pandemic has also forced us to critically The current COVID-19 syndemic has been estab­ look into our systems’ health and the determinants lished as a crisis of care (Chatzisakis et al., 2020), which of health (Harish, 2021). Some academics are already inevitably links back to the crisis of care previously focusing their work on understanding how systemic theorized as the result of neoliberal politics (Fraser, social and political structures are connected to the 2016; Pérez Orozco, 2006). This political model implies COVID-19 pandemic (Chatzisakis et al., 2020; the prioritization of monetized economic powers and MacLeavy, 2020; Malherbe, 2020). Social health markets, considering people as mere tools to sustain inequities in the context of the COVID-19 pandemic systemic structures (Pérez Orozco, 2006). The crisis of are already well-documented (Fisher et al., 2020; care refers to the challenges that neoliberal societies Jacques-Aviñó et al., 2020), suggesting the need for face to ensure social reproduction, a term that encom­ social medicine (Ashton, 2006; Trout et al., 2018) and passes self-care and care for others (childcare, elder­ other social sciences to respond to what can be con­ care and healthcare) while maintaining physical sidered a social disease (Trout & Kleinman, 2020). Also, spaces and organizing required resources (cleaning, some authors are already referring to the COVID-19 shopping, repairing), and human reproduction (hav­ pandemic as a syndemic (Harish, 2021; Horton, 2020), ing and raising children) (Arruzza, 2016; Hester, 2018). a concept introduced by medical anthropologists to It is both a political and ethical crisis (Malherbe, 2020) conceptualize ill-health in complex pandemics by that comes with the peril of deepening intersecting understanding the intersection between socio-envir­ oppressions towards social agents (mostly women) onmental and biological factors (Singer et al., 2020). (Cohen & van der Meulen Rodgers, 2021) who are This is the term that will be used throughout this made socially and politically responsible for ensuring CONTACT Constanza Jacques-Aviñó cjacques@idiapjgol.info Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol) Gran Via de les Corts Catalanes, 587 attic, Barcelona 08007, Spain © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 L. MEDINA-PERUCHA ET AL. social reproduction to sustain the monetized spheres initiate, or rather continue, the conversation on the of our economies (European Commission, 2021). need to place care at the centre of the public and Studies conducted during the COVID-19 syndemic private response to the COVID-19 syndemic. Also, to have shown that this work overload has had impacts our knowledge, there is a gap qualitative studies con­ on mental health, both in terms of work-life balance ducted during this period, especially from non-verbal and the “mental burden” of caregiving responsibility technique. Therefore, our main aim was to explore (Fisher et al., 2020; Jacques-Aviñó et al., 2020, 2022; experiences of care during the lockdown of the first Matulevicius et al., 2021). Thus, we cannot afford to wave of the COVID-19 syndemic in Spain. This aim neglect it if we want to ensure individual and collec­ was formulated to address the following research tive survival. Especially, if we understand the experi­ questions: How do the images represent the experi­ ences of care (referring to the physical or symbolic ences of care in lockdown during the first wave of elements that allow people to survive in society) as a COVID-19 in Spain? What relationship do people make framework for understanding how to act in a crisis, as between the image and the text about their experi­ it encompasses all the heterogeneous practices that ences of care during the first COVID-19 lockdown? constitute the maintenance and repair of something This study is part of a larger mixed-methods project (Anigstein et al., 2021). that aims at evaluating the psychosocial impact of Therefore, the crisis of care has led to a destabiliza­ COVID-19 syndemic in Spain, taking a gender-based tion of the previous redistributions of social and mon­ approach (Jacques-Aviñó et al., 2020). etized reproduction (Malherbe, 2020; Pérez Orozco, 2006). In fact, the COVID-19 syndemic has led to a reorganization of labour due to the loss of job oppor­ Methods tunities, digital work and work-from-home policies (MacLeavy, 2020). These new realities may have a The work presented in this article is an exploratory higher negative impact on women, explained by the qualitative study using photo-elicitation (Collier, 1957; feminization of paid and unpaid care, higher unem­ Harper, 2002) as a method for data collection. Our ployment and employment insecurity, and the pay study has been conducted using a gender-based per­ associated with a gender-segregated workforce spective and a critical paradigm. The choice of photo- (MacLeavy, 2020). According to research carried out elicitation was justified by the possibility of capturing with heterosexual couples during 2021, women expressions of experience that could not be appre­ reported having fewer physical and temporal space hended in any other way. Using photographs could limits to manage productive and reproductive work be an advantage to evoke “deeper elements of human time than men. While men reported doing care work consciousness” (Harper, 2002), compared to the analy­ once they have finished their productive tasks sis of words or narratives. The use of photo-elicitation (Chauhan, 2022). This can be partly explained by has also been reported to enrich the research process. women’s web of culturally-assigned responsibilities This is especially relevant when combined with narra­ and role both in non-monetized and monetized activ­ tive data. Also, when participants are able to take ities. In fact, the closure of school and daycare centres photographs themselves, they can metaphorically has had particularly affected impacted female carers represent what is most important to them and thus (Alon et al., 2020). In addition, other research has guide researchers on what to focus on. Photo-elicita­ shown that some women would feel extraordinarily tion is helpful to promote rapport and enable vulnerable if they were faced with closed schools in researchers to understand participants’ perspectives the future, knowing that the need to reduce produc­ and narratives through their own lens (Berenguera tive working hours to care for dependents would be et al., 2017). This was useful as data were collected an aggravating factor for them (Soubelet-Fagoaga et under strict lockdown and all research data had to be al., 2021). collected virtually. Besides, photo-elicitation could Thus, we are living an unprecedented situation for allow the emergence of unexpected topics, which today's society and so we need to understand how we considered highly relevant given the lack of evi­ the population conceptualizes and experiences care dence on the impact of COVID-19 syndemic at the in the context of the current syndemic (Chatzisakis et time of data collection, and the need to conduct al., 2020). The current study was initiated to respond exploratory research on this topic. Photo-elicitation to the need to focus on “care” as a central element in could also aid data analysis and interpretation by the analysis of the impact of the COVID-19 syndemic including participants’ own photographs and narra­ in Spain. Especially considering the strict lockdown tives (Collier, 1957; Harper, 2002; Meo, 2010). This that occurred in Spain during the first wave of method was also deemed appropriate given that con­ COVID-19 and the existing (gendered) crisis of care ducting face-to-face research was not possible due to in our context prior to the syndemic (Río Lozano M et the COVID-19 public health measures at the time of al., 2021). Throughout this research we intend to data collection. INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 3 The quality and rigour of our study was assessed instruction: “Take a photograph that represents your by using the Guba & Lincoln’s criteria, ensuring the experience caring for others (children or adolescents, credibility, transferability, dependability and confirm­ people with disabilities, or other people) during lock­ ability of the research (Guba & Lincoln, 1994). We used down”. Besides, participants were asked to give mean­ the Standards for Reporting Qualitative Research ing to their photograph by choosing a title for the (SRQR) tool to ensure reporting standards for qualita­ photograph and including a short text explaining tive studies (O’brien et al., 2014). what the photograph represented for them. Participants shared 25 photographs and 1 video overall. This was because three participants sent Participants and recruitment strategy more than one photo; one of them also included a Participants were adults (>18 years old) who self-identi­ video. Data were collected by email from 18 June fied as “carers” and resided in Spain during the first wave 2020 to 7 August 2020. of the COVID-19 syndemic. Although the researchers planned a selective and purposive sampling, convenience sampling was followed due to limitations during recruit­ Data analysis ment. Participants were recruited based on their partici­ Data were analysed based on Thematic Analysis pation in a previous survey-based study (Jacques-Aviñó et (Berenguera et al., 2017; Braun & Clarke, 2006). al., 2020) on the psychosocial impact of the COVID-19 Although there are no particularly prescribed meth­ syndemic in Spain. Those participants who had identified ods for analysing and interpreting photo elicitation themselves as “caregivers for others” (minors and other research, Thematic Analysis (Braun & Clarke, 2006) is dependent people) in the survey were invited by email to one of the commonly applied methods to ensure take part in the photo-elicitation study. The invitation rigour in data analysis in photo elicitation studies email was sent three times to 392 people in total. (Murray & Nash, 2017). In this study all five authors Fifteen participants, 12 women and three men aged 22– participated in the analysis process. First, the 68, took part in the study (see Table 1 for participants’ researchers independently described and analysed socio-demographic data). The team considered suffi­ all photographs and identified themes in photo­ ciency and saturation criteria to determine the sample graphs’ titles and descriptions provided the partici­ size. A few potential participants declined taking part as pants. Visual and narrative elements for each they preferred not to share “personal” images or did not participant were combined, so that themes and have time to engage in the study. sub-themes could be identified for each case. This was an inductive and reflexive process that was later shared throughout several team meetings. Data collection These discussions were useful to triangulate the Data were collected through photo-elicitation meth­ analysis and to identify initial pre-analytic ideas ods (Collier, 1957; Harper, 2002). We specifically used and for the first author to construct an initial the­ a method called photo-self-elicitation method matic framework, based on the independent analy­ (Harper, 2002) or participant photography (Miller & sis conducted by the researchers. Thus, themes and Happell, 2006) which consisted in asking participants sub-themes were identified across participants’ to share a photograph based on the following data. A final joint analysis and discussion session Table I. Participant sociodemographic characteristics. Participant ID Sex Age Country of birth Completed education Employment status P1 W 38 Argentina University Unemployed, receiving unemployment benefits P2 W 65 Spain University Self-employed P3 W 51 Spain Technical education Other/Unknown P4 W 49 Spain A-level Full-time worker P5 M 22 Spain Secondary school Student P6 M 48 Spain Technical education Self-employed P7 W 44 Spain University Full-time worker P8 W 35 Spain University Full-time worker P9 M 44 Spain University Full-time worker P10 W 45 Argentina University Full-time worker P11 W 68 Spain University Retired, receiving State Pension P12 W 53 Spain University Full-time worker P13 W 65 Bolivia Technical education Retired, receiving State Pension P14 W 23 Spain University Full-time worker P15 W 48 Spain University Full-time worker 4 L. MEDINA-PERUCHA ET AL. was organized with all researchers to discuss final needs for social interaction, love and belonging, and thematic framework. freedom (Figure 1). However, self-care often seemed Individual and collective reflexivity was an impor­ to be relegated to other people’s needs, especially tant tool used by the research team throughout the among participants who were main carers for children study, and especially during data analysis. For or cared for someone with a disability. Besides, some instance, analysis meetings included discussions participants mentioned situations in which they had around how the researchers understood “care”, the opportunity to interact and establish relationships what their perspective was on what might be con­ of care with other people, situations that were rather sidered a rural context, or the researchers’ decon­ unusual or non-existent prior to the syndemic. It structions on anthropological privileges and the seems then that, despite the isolation, the syndemic focus on animalism. These discussions were highly had brought unexpected opportunities to connect valuable in situating the researchers’ perspective on with and care for other people. Somehow, care the research and the collected data. Hence, these seemed to turn into being more collective. Receiving collective insights were part of the analytical care appeared to be more valued at critical times, process. compared to before the COVID-19 syndemic. Seven in the evening in the emergency room after Ethical considerations nine hours of sweat, running around, two gowns, two gloves, two glasses without being able to touch our All participants were given information about the face and my supervisor arrives with cold drinks that, photo-elicitation study and were requested to give one of many organizations that expressed solidarity during lockdown, has donated to us. I would have their written consent prior to their participation. never thought that I would cry over a cold Coke; cry Although parental/legal guardian consent was soli­ out of thirst, cry of feeling so much neediness, cry of cited when photographs included minors or people emotion after the surprise that someone cares for with disabilities, identifiable photographs will not be me (P12) included in this article for ethical reasons. “Family moments together, reinventing activities with Photographs of those participants who refused to neighbours, who we barely knew until that make their photographs public will not be dissemi­ time” (P15) nated either. This study was granted ethical approval by the Institut de Recerca en Atenció Primària Jordi Gol i Gurina (IDIAPJGol) Ethical On the other hand, some participants explained how Committee on 4th of April 2020 (reference 20/ they had experienced a deep lack of care during lock­ 063-PCV). down. They shared moments of despair and helpless­ ness when trying to seek medical assistance, being isolated and/or left without a support system to Results ensure social reproduction. Their needs were repre­ Three themes were identified: (1) The deconstruction sented in the spaces and objects photographed. of care: self-care and collective care; (2) The crisis of “I am sending the image of the portrait called The care and gendered care; and (3) Beyond anthropo­ Scream of Munch. It represents the anguish because centrism: animalism and ecology. of the loneliness. There was no one on the other side. The doctors did not respond” (P11) The deconstruction of care: self-care and “I am sending a few photos of the hard lockdown, trying to entertain my grandchildren, while my collective care daughters worked at the Pharmacy. It was really Although the researchers explicitly asked participants very difficult … ” (13) to share their experiences of caring for others, some Related to the previous point, one participant of them discussed experiences of self-care and collec­ explained that new mutual support networks were tive care. In some cases, having more time for oneself created during lockdown. The aim of these networks during lockdown had become an opportunity to was to provide assistance to those who could not reflect on (and question) one’s life and to be grateful otherwise obtain it (eg. Elderly or chronically ill people for the new insights that this period of life was or those living with a chronic health condition). This bringing. participant called for the need of collective care, sug­ “But I had time to cook, look at the scenery, listen to gesting that institutions were not able to respond to and feed the birds that came to my terrace. Knowing some people’s needs during COVID-19 first lockdown that the previous life, was not a life” (P3) measures (Figure 2). Caring for others was often framed as a form of self- In the photograph I was delivering medicines to vul­ care, representing self-care through fulfilling one’s nerable people who could not leave their houses. I INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 5 Figure 1. “Cocinando con alegría” (Cooking with joy) (P10). participate in a mutual support network that has grandparents) were not available for being considered been created in my town with the objective that the high-risk populations, mobility restrictions or other people help the people during lockdown (P5) responsibilities. Participants shared their experiences of adapting to their new realities, which were sometimes Participants expressed fear, pain, and hardship, but also of perceived as “chaotic” (P1, P9) but also as opportunities resilience and joy. Some people shared their relief and joy for growth (P4, P7) and connection (P7, P10, P14). The of being reunited with loved ones, and their optimism narratives were often a mix between the perceived hard­ towards life itself. Thus, despite the adversity of syndemic ship of the situation and the resistance to change and the some participants decided to focus on what they were need to adjust to living in uncertainty. This chaos that grateful for, rather than on experiences of grief, sorrow or some participants referred to was in some cases repre­ dread. This could be interpreted in different ways. It could sented in the images shared. Some photographs also be that participants had not personally and/or con­ presented spaces that could be interpreted as signs that sciously experienced emotional distress. Another expla­ participants were living in a situation of social and eco­ nation could be that, at the time of data collection (when nomic deprivation (e.g., based on furniture in bad condi­ lockdown measures were significantly lessened), “posi­ tion or the size and light of photographed spaces), tive” feelings of appreciation of day-to-day and social (Figure 3). relationships became more powerful. “This image represents for me the context in which I “The first day we went out in the street after we got have lived more than two months locked in with two cured of Covid 19. [Name], 95 years old and me, her children who are 7 and 3 years old. It represents the daughter, 65 […] The first day that I saw my grandson idea that took hold of me regarding the suitability of after 3 months” (P2) not trying to tidy up the space permanently, because this was untidy after five minutes by the children. The “This photo represents in part the positives of what result consisted of living in a state of permanent this experience has meant … the resilience … the untidiness, but at least it did not mean a Sisyphus- ability human beings have to adapt is fantastic and type effort … ” (P9) unpredictable.my dad 86 years old living another way to celebrate his birthday” (P4) Participants expressed a sense of (inescapable) responsibility, stoicism and “emotional duty” towards caring. Although caring was sometimes framed as an The crisis of care and gendered care act of self-care, as discussed above, this could also Care networks were abruptly destabilized once educa­ relate to this stoicism and the powerlessness experi­ tional centres closed down and some carers (e.g., enced during the syndemic. This duty to care went 6 L. MEDINA-PERUCHA ET AL. Figure 2. “Apoyo mútuo” (Mutual support) (P5). Figure 3. “Su habitación” (Their room) (P9). INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 7 Figure 4. “Caos en casa” (Chaos at home) (P1). sometimes beyond caring for other individuals, and back and I was alone all the time (…) I share a flat extended to a sense of responsibility to comply with with 2 people but they were inexistent, pretty COVID-19 political measures to control the impact of much” (P1) the syndemic. “The photograph represents the brief time there was sun in the morning that illuminated the house’s bal­ cony in which we studied or just enjoyed the Beyond anthropocentrism: animalism and moment, and the responsibility of contributing for ecology everything to go well. Also the acknowledgement of those who, in my opinion, have been the only ones Some participants expressed the need for a deeper that have complied with lockdown measures with connection with nature and other beings, especially rigour and determination” (P6) as they had more time in their day-to-day to attend to these needs compared to pre-syndemic times: “(…) look at the scenery, listen to and feed the birds that It’s worth noting that most participants were women came to my terrace (…)” (P3). This connection was (N = 12) and most images and experiences shared seen as a way to cope with isolation and was symbo­ were related to social reproduction. Interestingly, it lically associated with freedom. Being more in contact seemed that male carers were more focused on the with nature and non-human animals was also a way impact that caring had on them during lockdown to connect and share time with loved ones. Green and (internal focus), while female carers’ photographs open spaces, even through a window, were photo­ and narratives appeared to be rather centred in the graphed in several occasions (Figure 5). experiences of the people they cared for (external focus). Men in our study (N = 3) disclosed more frus­ “I was lucky enough to be with my family during tration while women expressed their tiredness, lone­ lockdown in the countryside where we live and this liness and perceived lack of support. While they cared photo is just of one of the moments when we walked at sunset (…) To me this photo means the start of a for others they often felt (un)cared for. For one female new routine that lasted the months we were in lock­ participant, the closure of borders meant that she was down for COVID-19 and that now we maintained left alone caring for their two children and having to once in a while, the walks in nature together, the reorganize her day-to-day in order to ensure social importance of dedicate some time to share time reproduction. Although she was sharing her house together and be aware of that” (P14) with other people, she received no help with care “It was helpful to my son to think he had a cat’s life responsibilities. Even if we do not know the reasons during lockdown: not going outside, but enjoying the of this lack of support, it is interesting to consider that ‘terrace’ and the landscape” (P7) physical proximity does not ensure a supportive envir­ onment (Figure 4). Emotional support and care were not only perceived “My husband got stranded in Senegal, he is from as to be directed to (and received from) other there and there was no‘real’ possibility of coming humans, but also other animals such as dogs and 8 L. MEDINA-PERUCHA ET AL. Figure 5. “Tiempo de miedo” (Time of fear) (P3). cats with whom the participants shared living spaces violence towards non-human animals might increase, with during lockdown. There was a feeling of mutual given the impact of the syndemic on people’s emo­ care and gratitude towards animals. Caring for an tional health (Figure 7). animal had even created opportunities to meet, get “Taking care of a rescued dog during COVID-19 has and offer support to others (Figure 6). meant I have worried about the other thousand dogs that have been and are abused everyday—and particu­ “We were also lucky to have our cat! He has been his larly when people are frustrated and under stress” (P8) [participant’ son] best friend, playground buddy and partner these weeks and a great help to make sense The same participant expressed her frustration of the new routines” (P7) regarding public’s disregard for the intersection between planetary and human health “I have felt “Sharing my life with a dog during COVID-19 has defeated and I am really struggling to believe the meant I have had more emotional support and more structure thanks to my dog Hanna (…) it has COVID-19 pandemic will make us understand that also meant I have become friend of several dog-lovers human health depends on our environment” (P8). homeless people who live under the building next to my home and that suddenly became visible in the deserted city” (P8) Discussion One participant (P8) also perceived dogs as vulnerable This study contributed to research on social reproduction to COVID-19 and the effects of the crisis, and in the context of the COVID-19 syndemic. Participants’ expressed anger at the increased abandonment of accounts focused on the need to reorganize their day-to- animals during the beginning of the pandemic due day lives to ensure social reproduction, and the struggles to people’s fear of dogs as vectors of infection. This and impact of doing so after care networks had collapsed. lack of care, emotional and physical abandonment This inevitably links to the crisis of care previously intro­ was seen by her as a symbol of fear and the crisis of duced (Chatzisakis et al., 2020; Fraser, 2016; Pérez Orozco, care in today’s society. Also, she was worried that 2006), in which monetized reproduction is prioritized over INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 9 Figure 6. “Sort del gat” (Lucky we had the cat) (P7). Figure 7. “No olvidando a los que no han podido ser rescatados” (Not forgetting the ones who could not be rescued) (P8). social reproduction. The COVID-19 syndemic has meant a Another important discussion is around the profound institutionalization of social reproduction (e.g., through impact of the crisis of care on women. Previous research closures of schools and day care centres) (Alon et al., has already indicated the lack of attention to women’s 2020). While social reproduction was previously (at least unpaid labour and the costs of fulfilling care roles (Folbre, partly) institutionalized in Spain, it has turned into a 2006a), as well as women’s increased vulnerability in the merely private matter since the start of the COVID-19 context of health crises, especially among the racialized or syndemic. Public health and austerity measures due to migrant populations (Azcona et al., 2020; Cohen & van der Meulen Rodgers, 2021; Doyal, 1996; Jacques-Aviñó et al., global financial strains appear to have led to the loss of Harman, 2016; Jacques-Aviñó et al., 2020, 2022; Sherman, institutionalized care networks (Bergmann & Wagner, 2020; Smith et al., 2021; Wenham et al., 2020). However, a 2021), mostly affecting those who previously shared car­ generalized lack of gendered political and economic ing responsibilities and balanced care with paid labour. responses to the COVID-19 syndemic prevails (Smith et Based on participants’ narratives, this reorganization of al., 2021). In our research, it appeared that women may social reproduction has led to a reconceptualization and feel more responsible for caregiving and the wellbeing of restructuring of relationships within home units and was those who they cared for. In contrast, in our study, men’s associated with emotional struggles. This lack of institu­ focus was rather on their own experiences of caring for tional care was also visible through the challenges that a others, and how caring had an impact on themselves. This few participants experienced to access the healthcare suggests that women continue to feel compelled to social system during lockdown (Núñez et al., 2021) and receiv­ reproduction while their own experiences and needs are ing care (Bergmann & Wagner, 2021). neglected. Men’s more internal focus could be explained 10 L. MEDINA-PERUCHA ET AL. by the lessened social pressures to provide care, and not became during lockdown. This could have led partici­ being as used to balance paid and unpaid labour as pants to share more insights into their living spaces, women (Jacques-Aviñó et al., 2020). As Smith et al. related to self-care and emotional experience. (2021) argue “not only is COVID-19 a global health crisis, Considering that social reproduction encompasses it is also a global gender equity crisis transcending differ­ the maintenance of physical living spaces (Arruzza, ences in scale, response, and political-economic systems”. 2016; Hester, 2018), it is relevant to ensure affordable Thus, gender and feminist approaches need to be prior­ housing, housing quality, residential stability and itized and incorporated in public health strategies neighbour opportunity (context) to promote and pro­ (Kuhlmann, 2009; Smith et al., 2021) so that the value of tect the population’s health (Thomson et al., 2013) reproductive care can be socially and economically reas­ and social reproduction. Housing security should sessed. Despite the gender differences identified in our encompass tackling energy poverty (Vásquez-Vera et research are supported by evidence and gender-based al., 2019), which especially affected vulnerable popu­ theory, our findings need to be interpreted with caution lations in Spain during the COVID-19 syndemic given the small number of men included in the study. (Guiteras, 2020) while energy costs continue to rise In our research highlights the need to acknowl­ (FACUA, 2021). edge self-care and collective care. Participants Our research also includes the experience of a young referred to a lack of self-care associated with having man who was involved in collective care networks. to provide care. At the same time other participants Experiences of collective care through the participation shared how being able to dedicate more time to in community-based care networks created during the themselves during lockdown was an opportunity to COVID-19 syndemic are also particularly relevant. draw their attention inwards and practice self-care. In Accounting for informal collective care networks can both scenarios, the importance of self-care during be useful for policy making. It can lead to direct actions periods of lockdown and, overall, throughout the towards strengthening, not only healthcare systems, but COVID-19 syndemic needs to be discussed. An also community networks (Drury et al., 2019). Reicher increasing amount of evidence on the impact of and Bauld (2021) have argued how the context of COVID-19 on mental and emotional health has been COVID-19 has led to the development of collective resi­ published (Jacques-Aviñó et al., 2022; Gloster et al., lience, as the syndemic has accentuated a sense of 2020). Academics worldwide have made a call to shared identity and collective thinking. Encouraging to prioritize mental health science and public health rethink the relationship between the institutions and actions directed to protecting and promoting mental the public, and acknowledging the latter’s power of health and its determinants (Holmes et al., 2020). self-organization and the role of social capital can be Given that self-care is an important factor to protect key (Wong & Kohler, 2020). However, institutions need and promote health, including mental health (Lucock to provide enough resources and training to develop et al., 2011), we believe it becomes crucial that con­ and sustain social capital that guarantees social repro­ ceptualizations of care in social, political and research duction (Reicher & Bauld, 2021). spheres broaden their stance to include self-care. Interestingly, some participants shared experi­ Moreover, research on the associations between self- ences of caring for non-human animals during care and positive health outcomes should be further lockdown. Sharing life with a non-human animal encouraged (Pilkington & Wieland, 2020). was framed as a form of social support and as a Furthermore, the impact of social reproduction on protective factor to endure lockdown and to create mental and physical health among informal carers social networks. Attachment and relationships with needs to be acknowledged and investigated (Gérain non-human animals have actually been found to & Zech, 2019). protect and promote mental health (Brooks et al., Housing is a major determinant of health 2018), even during COVID-19 (Gasteiger et al., (Bonnefoy, 2007; Krieger, 2001; Vásquez-Vera et al., 2021; McDonald et al., 2021; Ratschen et al., 2019) and health equity (Swope & Hernández, 2019). 2020). Participants also referred to their need to Based on participants’ photographs, we could observe be in contact with nature as a way to alleviate the structural differences in housing conditions (size, fur­ psychological impact of lockdown, and as a form niture, etc.). Their narratives included housing condi­ of self- and social care. This collates with evidence tions in terms of the “chaos” and “untidiness” that on the positive link between the exposure to nat­ lockdown and caring responsibilities had brought. It ure and mental health outcomes before (Dillman- should also be considered that social life in Spain is Hasso, 2021; White et al., 2021) and during the mostly carried out outdoors and outside one’s home, COVID-19 syndemic (Ribeiro et al., 2021). Besides, due to good-weather conditions and culture (Bru- the need to promote planetary health was men­ Ronda & Lázaro-Fernández, 2016). Issues associated tioned by one participant, as the COVID-19 syn­ with suboptimal housing may not have been per­ demic was thought to be an outcome of ceived to be as serious prior to lockdown as they planetary dysbiosis (Hinchliffe et al., 2021). INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 11 Framing care from an ecological perspective, strategies need to place social reproduction at the including non-human animals, contact with nature centre and as a determinant of the public’s health, and planetary health, might be crucial to develop in order to alleviate the crisis of care that the COVID- effective public health strategies that also secure 19 syndemic has deepened. Future research should universal care (Hinchliffe et al., 2021). The current focus on conducting broader gender analyses of how planetary crisis will require a change in human social reproduction can be ensured during health and productive and consumerist practices, as well as social crises, alongside ensuring social equity. socio-economic policies that prioritize sustainable Methodological issues, such as equitable gender and ecological actions (Guzmán et al., 2021). representation, should be addressed. This should not This research has limitations. First, we need to only include people who identify within a gender acknowledge the potential impact of the digital binary (i.e., woman/man) but represent a diverse divide. Despite the team’s effort to reach popula­ range of gender identities. We believe that this tions that may have limited access to computers research could support policymaking to ensure social and the Internet, participation may not have been reproduction. Also, to promote human health from a possible for some people. Besides, not being able to one-health perspective. contact participants through non-digital tools may have hindered building enough rapport to encou­ rage participation. Despite the researchers’ efforts Acknowledgments to motivate more men to participate in the study, We thank all the people who have participated in the photo only three men participated in our research. This elicitation process. may have limited our gender analysis and interpre­ tation. Another limitation is that even if the use of Disclosure statement photo-self-elicitation methods was useful to ensure participation and provides unique and valuable No potential conflict of interest was reported by the information, data access has been limited to photo­ authors. graphs and brief texts sent by participants. However, we had the opportunity to explore inno­ Funding vative research methods such as self-photo-elicita­ tion techniques while still maintaining rigour The project received a research grant from the Carlos III (Centre for Critical Qualitative Health Research, Institute of Health, Ministry of Economy and Competitiveness (Spain), awarded on the call for the crea­ 2020; Jowett, 2020). It is also important to consider tion of Health Outcomes-Oriented Cooperative Research that data collection took place just after the first Networks (RICOR), with reference RD21/0016/xxxx, co- COVID-19 lockdown in Spain and participants were funded with European Union – NextGenerationEU funds. quite relieved and expressed more positive experiences. Notes on contributors Laura Medina-Perucha (MSc, PhD) is a health psychologist Conclusions and social sciences researcher in health. Her research inter­ ests and experience are on women’s health and social This research contributes to the visibility of the care inequities of health. Dr Medina-Perucha’s PhD research at crisis in the COVID-19 syndemic in Spain. Based on the University of Bath (UK) [Sexual health and social inequi­ participants’ experiences of care during the lockdown ties in women on opioid substitution treatment: what are the opportunities for community pharmacy?] focused on sexual of the first wave of COVID-19, we promote the need health and social inequities in women who use drugs. to ensure universal care. This is our capacity and During her PhD she worked as a research assistant at the practice to ensure the political, social, material and University of Bath (UK) from 2015 until 2018. Since March emotional conditions that allow human and non- 2019, Dr Medina-Perucha has worked as a postdoctoral human life to prosper. Care needs to be conceptua­ researcher at the Institut Universitari d’Investigació en lized in terms of social reproduction, including not Atenció Primària Jordi Gol i Gurina (IDIAPJGoL) in Barcelona (Spain). Among other projects, she is the principal only caregiving towards other humans, but also self- investigator of the “Equity and Menstrual Health in Spain”, care, collective care and care towards (and from) non- funded by the European Society of Contraception and human animals. Planetary health and the human need Reproductive Health. She has been awarded a Sara Borrell to be in contact with nature should also be consid­ postdoctoral grant in 2021. She is also teaching qualitative ered to ensure social reproduction and promote research methods in the MSc Public Health (Universitat Pompeu Fabra) and Social Psychology (Universitat Oberta health. Furthermore, this study is a representation of de Catalunya). the resilience of the population to cope with a health and social crisis that required the reorganization of Constanza Jacques-Aviñó, has a degree in Psychology, a social reproduction. Gender and feminist-based policy Master in Public Health and PhD in Medical Anthropology (University Rovira i Virgili). She is a social sciences and public 12 L. MEDINA-PERUCHA ET AL. health researcher at the Institut Universitari d’Investigació 18. She is also the principal investigator of different projects en Atenció Primària (IDIAPJGol). She also exercises post­ in competitive calls. graduate teaching activities, is a qualitative research profes­ sor in the master’s degree in public health at the Pompeu Fabra University, a master’s degree in Master in International Health and Cooperation at the University ORCID Autonomy de Barcelona and in the Bachelor’s Degree in Constanza Jacques-Aviñó http://orcid.org/0000-0001- Psychology at the Open University of Catalonia, where she 8506-780X teaches Community Psychology and has collaborated in the development of various teaching materials. 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