Spanish residents’ experiences of care during the first wave of the COVID-19 syndemic: a photo-elicitation study

ABSTRACT Purpose The main aim of this research was to explore experiences of care during the lockdown of the first wave of COVID-19 syndemic in Spain Methods This is a qualitative and explorative study using self-photo-elicitation as a data collection method. Fifteen participants (Twelve women and three men) shared 25 photographs and one video between the June 18 and August, 2020. Participants’ photographs and texts were collected online. Data were analysed based on Thematic Analysis. Results Three emerging categories were constructed: 1) the deconstruction of care: self-care 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
Research and sociopolitical debates around the impact of the COVID-19 pandemic have mostly focused on morbidity and mortality. However, the COVID-19 pandemic has also forced us to critically look into our systems' health and the determinants of health (Harish, 2021). Some academics are already focusing their work on understanding how systemic social and political structures are connected to the COVID-19 pandemic (Chatzisakis et al., 2020;MacLeavy, 2020;Malherbe, 2020). Social health inequities in the context of the COVID-19 pandemic are already well-documented (Fisher et al., 2020;Jacques-Aviñó et al., 2020), suggesting the need for social medicine (Ashton, 2006;Trout et al., 2018) and other social sciences to respond to what can be considered a social disease (Trout & Kleinman, 2020). Also, some authors are already referring to the COVID-19 pandemic as a syndemic (Harish, 2021;Horton, 2020), a concept introduced by medical anthropologists to conceptualize ill-health in complex pandemics by understanding the intersection between socio-environmental and biological factors (Singer et al., 2020). This is the term that will be used throughout this paper, to acknowledge and consider socio-environmental that are linked to the development and consequences of COVID19. Also, as we understand the need to include social, structural and environmental factors in COVID-19 policies.
The current COVID-19 syndemic has been established as a crisis of care (Chatzisakis et al., 2020), which inevitably links back to the crisis of care previously theorized as the result of neoliberal politics (Fraser, 2016;Pérez Orozco, 2006). This political model implies the prioritization of monetized economic powers and markets, considering people as mere tools to sustain systemic structures (Pérez Orozco, 2006). The crisis of care refers to the challenges that neoliberal societies face to ensure social reproduction, a term that encompasses self-care and care for others (childcare, eldercare and healthcare) while maintaining physical spaces and organizing required resources (cleaning, shopping, repairing), and human reproduction (having and raising children) (Arruzza, 2016;Hester, 2018). It is both a political and ethical crisis (Malherbe, 2020) that comes with the peril of deepening intersecting oppressions towards social agents (mostly women) (Cohen & van der Meulen Rodgers, 2021) who are made socially and politically responsible for ensuring social reproduction to sustain the monetized spheres of our economies (European Commission, 2021). Studies conducted during the COVID-19 syndemic have shown that this work overload has had impacts on mental health, both in terms of work-life balance and the "mental burden" of caregiving responsibility (Fisher et al., 2020;Jacques-Aviñó et al., 2020, 2022Matulevicius et al., 2021). Thus, we cannot afford to neglect it if we want to ensure individual and collective survival. Especially, if we understand the experiences of care (referring to the physical or symbolic elements that allow people to survive in society) as a framework for understanding how to act in a crisis, as it encompasses all the heterogeneous practices that constitute the maintenance and repair of something (Anigstein et al., 2021).
Therefore, the crisis of care has led to a destabilization of the previous redistributions of social and monetized 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 opportunities, digital work and work-from-home policies (MacLeavy, 2020). These new realities may have a higher negative impact on women, explained by the feminization of paid and unpaid care, higher unemployment and employment insecurity, and the pay associated with a gender-segregated workforce (MacLeavy, 2020). According to research carried out with heterosexual couples during 2021, women reported having fewer physical and temporal space limits to manage productive and reproductive work time than men. While men reported doing care work once they have finished their productive tasks (Chauhan, 2022). This can be partly explained by women's web of culturally-assigned responsibilities and role both in non-monetized and monetized activities. In fact, the closure of school and daycare centres has had particularly affected impacted female carers (Alon et al., 2020). In addition, other research has shown that some women would feel extraordinarily vulnerable if they were faced with closed schools in the future, knowing that the need to reduce productive working hours to care for dependents would be an aggravating factor for them (Soubelet-Fagoaga et al., 2021).
Thus, we are living an unprecedented situation for today's society and so we need to understand how the population conceptualizes and experiences care in the context of the current syndemic (Chatzisakis et al., 2020). The current study was initiated to respond to the need to focus on "care" as a central element in the analysis of the impact of the COVID-19 syndemic in Spain. Especially considering the strict lockdown that occurred in Spain during the first wave of COVID-19 and the existing (gendered) crisis of care in our context prior to the syndemic (Río Lozano M et al., 2021). Throughout this research we intend to initiate, or rather continue, the conversation on the need to place care at the centre of the public and private response to the COVID-19 syndemic. Also, to our knowledge, there is a gap qualitative studies conducted during this period, especially from non-verbal technique. Therefore, our main aim was to explore experiences of care during the lockdown of the first wave of the COVID-19 syndemic in Spain. This aim was formulated to address the following research questions: How do the images represent the experiences of care in lockdown during the first wave of COVID-19 in Spain? What relationship do people make between the image and the text about their experiences of care during the first COVID-19 lockdown? This study is part of a larger mixed-methods project that aims at evaluating the psychosocial impact of COVID-19 syndemic in Spain, taking a gender-based approach (Jacques-Aviñó et al., 2020).

Methods
The work presented in this article is an exploratory qualitative study using photo-elicitation (Collier, 1957;Harper, 2002) as a method for data collection. Our study has been conducted using a gender-based perspective and a critical paradigm. The choice of photoelicitation was justified by the possibility of capturing expressions of experience that could not be apprehended in any other way. Using photographs could be an advantage to evoke "deeper elements of human consciousness" (Harper, 2002), compared to the analysis of words or narratives. The use of photo-elicitation has also been reported to enrich the research process. This is especially relevant when combined with narrative data. Also, when participants are able to take photographs themselves, they can metaphorically represent what is most important to them and thus guide researchers on what to focus on. Photo-elicitation is helpful to promote rapport and enable researchers to understand participants' perspectives and narratives through their own lens (Berenguera et al., 2017). This was useful as data were collected under strict lockdown and all research data had to be collected virtually. Besides, photo-elicitation could allow the emergence of unexpected topics, which we considered highly relevant given the lack of evidence on the impact of COVID-19 syndemic at the time of data collection, and the need to conduct exploratory research on this topic. Photo-elicitation could also aid data analysis and interpretation by including participants' own photographs and narratives (Collier, 1957;Harper, 2002;Meo, 2010). This method was also deemed appropriate given that conducting face-to-face research was not possible due to the COVID-19 public health measures at the time of data collection.
The quality and rigour of our study was assessed by using the Guba & Lincoln's criteria, ensuring the credibility, transferability, dependability and confirmability of the research (Guba & Lincoln, 1994). We used the Standards for Reporting Qualitative Research (SRQR) tool to ensure reporting standards for qualitative studies (O'brien et al., 2014).

Participants and recruitment strategy
Participants were adults (>18 years old) who self-identified as "carers" and resided in Spain during the first wave of the COVID-19 syndemic. Although the researchers planned a selective and purposive sampling, convenience sampling was followed due to limitations during recruitment. Participants were recruited based on their participation in a previous survey-based study (Jacques-Aviñó et al., 2020) on the psychosocial impact of the COVID-19 syndemic in Spain. Those participants who had identified themselves as "caregivers for others" (minors and other dependent people) in the survey were invited by email to take part in the photo-elicitation study. The invitation email was sent three times to 392 people in total. Fifteen participants, 12 women and three men aged 22-68, took part in the study (see Table 1 for participants' socio-demographic data). The team considered sufficiency and saturation criteria to determine the sample size. A few potential participants declined taking part as they preferred not to share "personal" images or did not have time to engage in the study.

Data collection
Data were collected through photo-elicitation methods (Collier, 1957;Harper, 2002). We specifically used a method called photo-self-elicitation method (Harper, 2002) or participant photography (Miller & Happell, 2006) which consisted in asking participants to share a photograph based on the following instruction: "Take a photograph that represents your experience caring for others (children or adolescents, people with disabilities, or other people) during lockdown". Besides, participants were asked to give meaning to their photograph by choosing a title for the photograph and including a short text explaining what the photograph represented for them.
Participants shared 25 photographs and 1 video overall. This was because three participants sent more than one photo; one of them also included a video. Data were collected by email from 18 June 2020 to 7 August 2020.

Data analysis
Data were analysed based on Thematic Analysis (Berenguera et al., 2017;Braun & Clarke, 2006). Although there are no particularly prescribed methods for analysing and interpreting photo elicitation research, Thematic Analysis (Braun & Clarke, 2006) is one of the commonly applied methods to ensure rigour in data analysis in photo elicitation studies (Murray & Nash, 2017). In this study all five authors participated in the analysis process. First, the researchers independently described and analysed all photographs and identified themes in photographs' titles and descriptions provided the participants. Visual and narrative elements for each participant were combined, so that themes and sub-themes could be identified for each case. This was an inductive and reflexive process that was later shared throughout several team meetings. These discussions were useful to triangulate the analysis and to identify initial pre-analytic ideas and for the first author to construct an initial thematic framework, based on the independent analysis conducted by the researchers. Thus, themes and sub-themes were identified across participants' data. A final joint analysis and discussion session was organized with all researchers to discuss final thematic framework. Individual and collective reflexivity was an important tool used by the research team throughout the study, and especially during data analysis. For instance, analysis meetings included discussions around how the researchers understood "care", what their perspective was on what might be considered a rural context, or the researchers' deconstructions on anthropological privileges and the focus on animalism. These discussions were highly valuable in situating the researchers' perspective on the research and the collected data. Hence, these collective insights were part of the analytical process.

Ethical considerations
All participants were given information about the photo-elicitation study and were requested to give their written consent prior to their participation. Although parental/legal guardian consent was solicited when photographs included minors or people with disabilities, identifiable photographs will not be included in this article for ethical reasons. Photographs of those participants who refused to make their photographs public will not be disseminated either. This study was granted ethical approval by the Institut de Recerca en Atenció Primària Jordi Gol i Gurina (IDIAPJGol) Ethical Committee on 4th of April 2020 (reference 20/ 063-PCV).

Results
Three themes were identified: (1) The deconstruction of care: self-care and collective care; (2) The crisis of care and gendered care; and (3) Beyond anthropocentrism: animalism and ecology.

The deconstruction of care: self-care and collective care
Although the researchers explicitly asked participants to share their experiences of caring for others, some of them discussed experiences of self-care and collective care. In some cases, having more time for oneself during lockdown had become an opportunity to reflect on (and question) one's life and to be grateful for the new insights that this period of life was bringing.
"But I had time to cook, look at the scenery, listen to and feed the birds that came to my terrace. Knowing that the previous life, was not a life" (P3) Caring for others was often framed as a form of selfcare, representing self-care through fulfilling one's needs for social interaction, love and belonging, and freedom ( Figure 1). However, self-care often seemed to be relegated to other people's needs, especially among participants who were main carers for children or cared for someone with a disability. Besides, some participants mentioned situations in which they had the opportunity to interact and establish relationships of care with other people, situations that were rather unusual or non-existent prior to the syndemic. It seems then that, despite the isolation, the syndemic had brought unexpected opportunities to connect with and care for other people. Somehow, care seemed to turn into being more collective. Receiving care appeared to be more valued at critical times, compared to before the COVID-19 syndemic.
Seven in the evening in the emergency room after nine hours of sweat, running around, two gowns, two gloves, two glasses without being able to touch our face and my supervisor arrives with cold drinks that, one of many organizations that expressed solidarity during lockdown, has donated to us. I would have never thought that I would cry over a cold Coke; cry out of thirst, cry of feeling so much neediness, cry of emotion after the surprise that someone cares for me (P12) "Family moments together, reinventing activities with neighbours, who we barely knew until that time" (P15) On the other hand, some participants explained how they had experienced a deep lack of care during lockdown. They shared moments of despair and helplessness when trying to seek medical assistance, being isolated and/or left without a support system to ensure social reproduction. Their needs were represented in the spaces and objects photographed.
"I am sending the image of the portrait called The Scream of Munch. It represents the anguish because of the loneliness. There was no one on the other side. The doctors did not respond" (P11) "I am sending a few photos of the hard lockdown, trying to entertain my grandchildren, while my daughters worked at the Pharmacy. It was really very difficult … " (13) Related to the previous point, one participant explained that new mutual support networks were created during lockdown. The aim of these networks was to provide assistance to those who could not otherwise obtain it (eg. Elderly or chronically ill people or those living with a chronic health condition). This participant called for the need of collective care, suggesting that institutions were not able to respond to some people's needs during COVID-19 first lockdown measures ( Figure 2).
In the photograph I was delivering medicines to vulnerable people who could not leave their houses. I participate in a mutual support network that has been created in my town with the objective that the people help the people during lockdown (P5) Participants expressed fear, pain, and hardship, but also of resilience and joy. Some people shared their relief and joy of being reunited with loved ones, and their optimism towards life itself. Thus, despite the adversity of syndemic some participants decided to focus on what they were grateful for, rather than on experiences of grief, sorrow or dread. This could be interpreted in different ways. It could be that participants had not personally and/or consciously experienced emotional distress. Another explanation could be that, at the time of data collection (when lockdown measures were significantly lessened), "positive" feelings of appreciation of day-to-day and social relationships became more powerful.

The crisis of care and gendered care
Care networks were abruptly destabilized once educational centres closed down and some carers (e.g., grandparents) were not available for being considered high-risk populations, mobility restrictions or other responsibilities. Participants shared their experiences of adapting to their new realities, which were sometimes perceived as "chaotic" (P1, P9) but also as opportunities for growth (P4, P7) and connection (P7, P10, P14). The narratives were often a mix between the perceived hardship of the situation and the resistance to change and the need to adjust to living in uncertainty. This chaos that some participants referred to was in some cases represented in the images shared. Some photographs also presented spaces that could be interpreted as signs that participants were living in a situation of social and economic deprivation (e.g., based on furniture in bad condition or the size and light of photographed spaces), (Figure 3). "This image represents for me the context in which I have lived more than two months locked in with two children who are 7 and 3 years old. It represents the idea that took hold of me regarding the suitability of not trying to tidy up the space permanently, because this was untidy after five minutes by the children. The result consisted of living in a state of permanent untidiness, but at least it did not mean a Sisyphustype effort … " (P9) Participants expressed a sense of (inescapable) responsibility, stoicism and "emotional duty" towards caring. Although caring was sometimes framed as an act of self-care, as discussed above, this could also relate to this stoicism and the powerlessness experienced during the syndemic. This duty to care went   sometimes beyond caring for other individuals, and extended to a sense of responsibility to comply with COVID-19 political measures to control the impact of the syndemic.
"The photograph represents the brief time there was sun in the morning that illuminated the house's balcony in which we studied or just enjoyed the moment, and the responsibility of contributing for everything to go well. Also the acknowledgement of those who, in my opinion, have been the only ones that have complied with lockdown measures with rigour and determination" (P6) It's worth noting that most participants were women (N = 12) and most images and experiences shared were related to social reproduction. Interestingly, it seemed that male carers were more focused on the impact that caring had on them during lockdown (internal focus), while female carers' photographs and narratives appeared to be rather centred in the experiences of the people they cared for (external focus). Men in our study (N = 3) disclosed more frustration while women expressed their tiredness, loneliness and perceived lack of support. While they cared for others they often felt (un)cared for. For one female participant, the closure of borders meant that she was left alone caring for their two children and having to reorganize her day-to-day in order to ensure social reproduction. Although she was sharing her house with other people, she received no help with care responsibilities. Even if we do not know the reasons of this lack of support, it is interesting to consider that physical proximity does not ensure a supportive environment ( Figure 4). "My husband got stranded in Senegal, he is from there and there was no'real' possibility of coming back and I was alone all the time (…) I share a flat with 2 people but they were inexistent, pretty much" (P1)

Beyond anthropocentrism: animalism and ecology
Some participants expressed the need for a deeper connection with nature and other beings, especially 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 came to my terrace (…)" (P3). This connection was seen as a way to cope with isolation and was symbolically associated with freedom. Being more in contact with nature and non-human animals was also a way to connect and share time with loved ones. Green and open spaces, even through a window, were photographed in several occasions ( Figure 5).
"I was lucky enough to be with my family during lockdown in the countryside where we live and this photo is just of one of the moments when we walked at sunset (…) To me this photo means the start of a new routine that lasted the months we were in lockdown for COVID-19 and that now we maintained once in a while, the walks in nature together, the importance of dedicate some time to share time together and be aware of that" (P14) "It was helpful to my son to think he had a cat's life during lockdown: not going outside, but enjoying the 'terrace' and the landscape" (P7) Emotional support and care were not only perceived as to be directed to (and received from) other humans, but also other animals such as dogs and cats with whom the participants shared living spaces with during lockdown. There was a feeling of mutual care and gratitude towards animals. Caring for an animal had even created opportunities to meet, get and offer support to others ( Figure 6). "We were also lucky to have our cat! He has been his [participant' son] best friend, playground buddy and partner these weeks and a great help to make sense of the new routines" (P7) "Sharing my life with a dog during COVID-19 has meant I have had more emotional support and more structure thanks to my dog Hanna (…) it has also meant I have become friend of several dog-lovers homeless people who live under the building next to my home and that suddenly became visible in the deserted city" (P8) One participant (P8) also perceived dogs as vulnerable to COVID-19 and the effects of the crisis, and expressed anger at the increased abandonment of animals during the beginning of the pandemic due to people's fear of dogs as vectors of infection. This lack of care, emotional and physical abandonment was seen by her as a symbol of fear and the crisis of care in today's society. Also, she was worried that violence towards non-human animals might increase, given the impact of the syndemic on people's emotional health (Figure 7). "Taking care of a rescued dog during COVID-19 has meant I have worried about the other thousand dogs that have been and are abused everyday-and particularly when people are frustrated and under stress" (P8) The same participant expressed her frustration regarding public's disregard for the intersection between planetary and human health "I have felt defeated and I am really struggling to believe the COVID-19 pandemic will make us understand that human health depends on our environment" (P8).

Discussion
This study contributed to research on social reproduction in the context of the COVID-19 syndemic. Participants' accounts focused on the need to reorganize their day-today lives to ensure social reproduction, and the struggles and impact of doing so after care networks had collapsed. This inevitably links to the crisis of care previously introduced (Chatzisakis et al., 2020;Fraser, 2016;Pérez Orozco, 2006), in which monetized reproduction is prioritized over social reproduction. The COVID-19 syndemic has meant a institutionalization of social reproduction (e.g., through closures of schools and day care centres) (Alon et al., 2020). While social reproduction was previously (at least partly) institutionalized in Spain, it has turned into a merely private matter since the start of the COVID-19 syndemic. Public health and austerity measures due to global financial strains appear to have led to the loss of institutionalized care networks (Bergmann & Wagner, 2021), mostly affecting those who previously shared caring responsibilities and balanced care with paid labour. Based on participants' narratives, this reorganization of social reproduction has led to a reconceptualization and restructuring of relationships within home units and was associated with emotional struggles. This lack of institutional care was also visible through the challenges that a few participants experienced to access the healthcare system during lockdown (Núñez et al., 2021) and receiving care (Bergmann & Wagner, 2021).
Another important discussion is around the profound impact of the crisis of care on women. Previous research has already indicated the lack of attention to women's unpaid labour and the costs of fulfilling care roles (Folbre, 2006a), as well as women's increased vulnerability in the context of health crises, especially among the racialized or migrant populations (Azcona et al., 2020;Cohen & van der Meulen Rodgers, 2021;Doyal, 1996;Jacques-Aviñó et al., Harman, 2016;Jacques-Aviñó et al., 2020, 2022Sherman, 2020;Smith et al., 2021;Wenham et al., 2020). However, a generalized lack of gendered political and economic responses to the COVID-19 syndemic prevails (Smith et al., 2021). In our research, it appeared that women may feel more responsible for caregiving and the wellbeing of those who they cared for. In contrast, in our study, men's focus was rather on their own experiences of caring for others, and how caring had an impact on themselves. This suggests that women continue to feel compelled to social reproduction while their own experiences and needs are neglected. Men's more internal focus could be explained  by the lessened social pressures to provide care, and not being as used to balance paid and unpaid labour as women (Jacques-Aviñó et al., 2020). As Smith et al. (2021) argue "not only is COVID-19 a global health crisis, it is also a global gender equity crisis transcending differences in scale, response, and political-economic systems". Thus, gender and feminist approaches need to be prioritized and incorporated in public health strategies (Kuhlmann, 2009;Smith et al., 2021) so that the value of reproductive care can be socially and economically reassessed. Despite the gender differences identified in our research are supported by evidence and gender-based theory, our findings need to be interpreted with caution given the small number of men included in the study.
In our research highlights the need to acknowledge self-care and collective care. Participants referred to a lack of self-care associated with having to provide care. At the same time other participants shared how being able to dedicate more time to themselves during lockdown was an opportunity to draw their attention inwards and practice self-care. In both scenarios, the importance of self-care during periods of lockdown and, overall, throughout the COVID-19 syndemic needs to be discussed. An increasing amount of evidence on the impact of COVID-19 on mental and emotional health has been published (Jacques-Aviñó et al., 2022;Gloster et al., 2020). Academics worldwide have made a call to prioritize mental health science and public health actions directed to protecting and promoting mental health and its determinants (Holmes et al., 2020). Given that self-care is an important factor to protect and promote health, including mental health (Lucock et al., 2011), we believe it becomes crucial that conceptualizations of care in social, political and research spheres broaden their stance to include self-care. Moreover, research on the associations between selfcare and positive health outcomes should be further encouraged (Pilkington & Wieland, 2020). Furthermore, the impact of social reproduction on mental and physical health among informal carers needs to be acknowledged and investigated (Gérain & Zech, 2019).
Housing is a major determinant of health (Bonnefoy, 2007;Krieger, 2001;Vásquez-Vera et al., 2019) and health equity (Swope & Hernández, 2019). Based on participants' photographs, we could observe structural differences in housing conditions (size, furniture, etc.). Their narratives included housing conditions in terms of the "chaos" and "untidiness" that lockdown and caring responsibilities had brought. It should also be considered that social life in Spain is mostly carried out outdoors and outside one's home, due to good-weather conditions and culture (Bru-Ronda & Lázaro-Fernández, 2016). Issues associated with suboptimal housing may not have been perceived to be as serious prior to lockdown as they became during lockdown. This could have led participants to share more insights into their living spaces, related to self-care and emotional experience. Considering that social reproduction encompasses the maintenance of physical living spaces (Arruzza, 2016;Hester, 2018), it is relevant to ensure affordable housing, housing quality, residential stability and neighbour opportunity (context) to promote and protect the population's health (Thomson et al., 2013) and social reproduction. Housing security should encompass tackling energy poverty (Vásquez-Vera et al., 2019), which especially affected vulnerable populations in Spain during the COVID-19 syndemic (Guiteras, 2020) while energy costs continue to rise (FACUA, 2021).
Our research also includes the experience of a young man who was involved in collective care networks. Experiences of collective care through the participation in community-based care networks created during the COVID-19 syndemic are also particularly relevant. Accounting for informal collective care networks can be useful for policy making. It can lead to direct actions towards strengthening, not only healthcare systems, but also community networks (Drury et al., 2019). Reicher and Bauld (2021) have argued how the context of COVID-19 has led to the development of collective resilience, as the syndemic has accentuated a sense of shared identity and collective thinking. Encouraging to rethink the relationship between the institutions and the public, and acknowledging the latter's power of self-organization and the role of social capital can be key (Wong & Kohler, 2020). However, institutions need to provide enough resources and training to develop and sustain social capital that guarantees social reproduction (Reicher & Bauld, 2021).
Interestingly, some participants shared experiences of caring for non-human animals during lockdown. Sharing life with a non-human animal was framed as a form of social support and as a protective factor to endure lockdown and to create social networks. Attachment and relationships with non-human animals have actually been found to protect and promote mental health (Brooks et al., 2018), even during COVID-19 (Gasteiger et al., 2021;McDonald et al., 2021;Ratschen et al., 2020). Participants also referred to their need to be in contact with nature as a way to alleviate the psychological impact of lockdown, and as a form of self-and social care. This collates with evidence on the positive link between the exposure to nature and mental health outcomes before (Dillman-Hasso, 2021;White et al., 2021) and during the COVID-19 syndemic (Ribeiro et al., 2021). Besides, the need to promote planetary health was mentioned by one participant, as the COVID-19 syndemic was thought to be an outcome of planetary dysbiosis (Hinchliffe et al., 2021).
Framing care from an ecological perspective, including non-human animals, contact with nature and planetary health, might be crucial to develop effective public health strategies that also secure universal care (Hinchliffe et al., 2021). The current planetary crisis will require a change in human productive and consumerist practices, as well as socio-economic policies that prioritize sustainable and ecological actions (Guzmán et al., 2021).
This research has limitations. First, we need to acknowledge the potential impact of the digital divide. Despite the team's effort to reach populations that may have limited access to computers and the Internet, participation may not have been possible for some people. Besides, not being able to contact participants through non-digital tools may have hindered building enough rapport to encourage participation. Despite the researchers' efforts to motivate more men to participate in the study, only three men participated in our research. This may have limited our gender analysis and interpretation. Another limitation is that even if the use of photo-self-elicitation methods was useful to ensure participation and provides unique and valuable information, data access has been limited to photographs and brief texts sent by participants. However, we had the opportunity to explore innovative research methods such as self-photo-elicitation techniques while still maintaining rigour (Centre for Critical Qualitative Health Research, 2020;Jowett, 2020). It is also important to consider that data collection took place just after the first COVID-19 lockdown in Spain and participants were quite relieved and expressed more positive experiences.

Conclusions
This research contributes to the visibility of the care crisis in the COVID-19 syndemic in Spain. Based on participants' experiences of care during the lockdown of the first wave of COVID-19, we promote the need to ensure universal care. This is our capacity and practice to ensure the political, social, material and emotional conditions that allow human and nonhuman life to prosper. Care needs to be conceptualized in terms of social reproduction, including not only caregiving towards other humans, but also selfcare, collective care and care towards (and from) nonhuman animals. Planetary health and the human need to be in contact with nature should also be considered to ensure social reproduction and promote health. Furthermore, this study is a representation of the resilience of the population to cope with a health and social crisis that required the reorganization of social reproduction. Gender and feminist-based policy strategies need to place social reproduction at the centre and as a determinant of the public's health, in order to alleviate the crisis of care that the COVID-19 syndemic has deepened. Future research should focus on conducting broader gender analyses of how social reproduction can be ensured during health and social crises, alongside ensuring social equity. Methodological issues, such as equitable gender representation, should be addressed. This should not only include people who identify within a gender binary (i.e., woman/man) but represent a diverse range of gender identities. We believe that this research could support policymaking to ensure social reproduction. Also, to promote human health from a one-health perspective.

Acknowledgments
We thank all the people who have participated in the photo elicitation process.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
The project received a research grant from the Carlos III Institute of Health, Ministry of Economy and Competitiveness (Spain), awarded on the call for the creation of Health Outcomes-Oriented Cooperative Research Networks (RICOR), with reference RD21/0016/xxxx, cofunded with European Union -NextGenerationEU funds. Constanza Jacques-Aviñó, has a degree in Psychology, a Master in Public Health and PhD in Medical Anthropology (University Rovira i Virgili). She is a social sciences and public health researcher at the Institut Universitari d'Investigació en Atenció Primària (IDIAPJGol). She also exercises postgraduate teaching activities, is a qualitative research professor 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 Autonomy de Barcelona and in the Bachelor's Degree in Psychology at the Open University of Catalonia, where she teaches Community Psychology and has collaborated in the development of various teaching materials. She is a member of the working group on social determinants of health of the Spanish Society of Epidemiology (SEE), in the immigration initiative. Her research focuses on social inequities of health from a gender and intercultural perspective, social participation and sexual health. She is currently leading a project on the social and psychological impact in Spain and Latin America. She currently has several publications in journals with an impact factor and extensive experience in health and social interventions.

Notes on contributors
Tomàs López-Jiménez has a degree in Statistics and a Master's in Public Health. He is currently a PhD student. From 2004-2015 he worked as a researcher and statistician at the IMIM Foundation (GRECMC unit), and during the years 2011-1015 he also worked as an associate professor in the Medicine degree UAB-UPF (Barcelona). Since 2015 he works as a statistician and researcher at the IDIAPJGol foundation, and has tutored final degree projects for nursery students at the Gimbernat University (UAB) and is currently tutoring a final master's degree project in public health. He is an expert in statistical analysis in the SPSS, SAS, Stata and R programs. He participate in projects related to cancer, health surveys, menstrual health, mental health, environmental pollutants, diabetes, hypertension, drugs and general medicine. Within the different projects he has worked, among others, aspects related to gender, agingageing, social class, occupation, education and obesity. He has published more than 40 scientific articles in international journals.
Catuxa Máiz-Mazuela has a degree in Medicine and a Master's in Public Health in Pompeu Fabra University. She is currently a PhD student in Open University of Catalonia. She has experience in qualitative and mixed methodology research in the fields of Public Health. She has participated in projects on topics such as mental health, gender, care, COVID-19 syndemic and long-term care.
Anna Berenguera Ossó has a degree in Psychology and a Master's in Social Sciences from the University of Surrey (United Kingdom). In 2011, she obtained the title of Doctor in Public Health from the University of Barcelona. Currently, she works as a social science researcher and coordinator of the Transversal Research Unit at the Institut Universitari d'Investigació en Atenció Primària (IDIAPJGoL). Since 2017, he has been part of the internal scientific committee of IDIAP Jordi Go. She also exercises postgraduate teaching activities, is a qualitative research professor in the master's degree in public health at the Pompeu Fabra University, a master's degree in health promotion at the University of Girona and the University of Lleida. She has experience in quantitative, qualitative and mixed methodology research in the fields of Public Health, Primary and Community Care. Its main lines of research are: health promotion, community health, complex interventions, Long Covid and citizen participation in research. She currently has more than 50 publications in impact factor journals and more than 1400 citations, accumulating an H index of 18. She is also the principal investigator of different projects in competitive calls.