Women in homelessness face extreme health- and social inequities. It could be postulated that during societal crises, they become even more vulnerable. Thus, the aim was to explore experiences related to the COVID-19 pandemic among women in homelessness.Ten interviews were conducted with women in homelessness, in Stockholm, Sweden, using researcher-driven photo elicitation. The data analysis was guided by the DEPICT model for collaborative data analysis and a qualitative content analysis was performed. A collaborative reference group of women with lived experience of homelessness contributed to the research process through designing the data collection, performing the data analysis, and providing feedback during report writing.adding insult to injury, as it significantly affected everyday life and permeated most aspects of existence, leading to diminished interactions with others and reduced societal support. Thus, in an already dire situation, the virus amplified health- and social issues to another level. The women strived to find their balance on the shifting sands of guidelines and restrictions due to the pandemic. Adhering to the new social distancing rules and guidelines in line with the rest of society, was simply impossible when experiencing homelessness. However, for some women the pandemic was nothing but a storm in a teacup. The harsh reality continued irrespectively, living one day at a time and prioritizing provision for basic human needs.For women in homelessness, the COVID-19 pandemic was The COVID-19 pandemic and homelessness can be viewed as two intersecting crises. However, the women’s aggregated experiences were greater than the sum of experiencing homelessness and meeting the threat of the virus. Gender, exposure to violence, poverty, social isolation, and substance use were additional factors that further marginalized the women during the pandemic. To rebuild a better and more sustainable post-pandemic future for all, global commitment to ending homelessness is crucial. In addition, addressing social determinants of health must be the number one health intervention.The online version contains supplementary material available at 10.1186/s12905-023-02157-x. Homelessness is increasing in almost all countries within the European Union , and conInclusion health is defined as a policy-, research- and service agenda focusing health efforts on people in extremely poor health due to marginalization, multi-morbidity, and poverty , 6. Peop‘with’ or ‘by’ members of the public rather than ‘to’, ‘about’ or ‘for’ them” . All content on the platform can be used freely for commercial and non-commercial use across print and digital media. The photos (n = 15) were subsequently used as stimuli to promote discussion during the interviews, i.e., a researcher-driven procedure .All participants were offered written and verbal information about the study, and written informed consent was given by all participants. No identifying personal information that could be connected to a specific woman was collected. Demographics such as age, current housing status and occupation were documented. All data were self-reported, and no medical files were accessed. Audio recordings and all written documentation of the research data were stored on a password protected server, only accessible to the research group. Documentation was consecutively organized in folders, each folder contained the audio file, the transcribed text, the written consent form for that interview, and a photo of the chosen photos.We were conscious of the fact that women who live/have lived in homelessness have difficult experiences of life, possibly characterized by abuse, trauma, and violence. Participating in interviews, as well as reading transcribed interviews, may trigger memories that cause significant distress for the interviewed women and the women attending Women Advisory Board workshops. Thus, attention and a concerted effort were focused on ensuring that the women had psychosocial support if needed in association with both the interviews and workshops.The COVID-19 pandemic: yet another dimension of the world’s predictable unpredictability for women in homelessness, represented by three sub-themes: Adding insult to injury, Shifting sands, and A storm in a teacup, see Table The analysis resulted in an overarching theme: Due to the COVID-19 pandemic women faced another dimension of the world’s predictable unpredictability. The women described that the on-going pandemic significantly affected everyday life and permeated most aspects of their existence. Living in homelessness comprises uncertainty and challenges to manage daily activities, these aspects were taken to another level during the pandemic. Adjustments and reorientation to a new reality dominated the women’s lives and they made efforts to be a small part of the pandemic society. However, there were also experiences that life was not changed because of the COVID-19 pandemic. The harsh reality continued irrespectively, with women living on the outskirts of society as per usual.The first sub-theme pertains to experiences that the ongoing pandemic significantly affected everyday life and permeated most aspects of their existence, leading to diminishing interactions with others, diminished opportunities with reduced societal support, and further accentuated loneliness in an already lonely life. The impact of the pandemic was described on several levels by women in homelessness, as individuals, in interactions with peers, and with societal services.“But it’s nice with the social bit, to be able to sit and talk. So that’s probably what I’ve noticed the most, that you’ve become even more lonely in loneliness, or whatever you call it. Peculiar.” (W1)According to the women, living in homelessness entailed having a lot of acquaintances but few friends. Alcohol and substance use were part of daily life, regardless of whether the women themselves used drugs or not. The importance of always being attentive, vigilant, and never trusting anyone was thus underscored. Yet, socializing with others in similar circumstances used to be an important part of life before the pandemic. With these opportunities being lost, a sense of connection in social communities was taken away. In line with adhering to social distancing guidelines, daily life and altered interactions accentuated experiences of loneliness even further.The importance of social connections and a chance to talk about other things, and another kind of life was highly valued, however, during the pandemic, this became much more challenging. Women described missing these types of interactions and personal contacts.In addition, some of the services for people experiencing homelessness were shut down and closed until further notice. This was often done at short notice and without offering any alternatives. Several natural meeting points just disappeared, seemingly overnight, resulting in a sense of loss and disconnect. The women also described that it was almost impossible to sleep over at the homes of acquaintances, as they often had done before the pandemic. Viewed as potentially contagious, they were not welcome anywhere. The only option left was living on the streets, often 24/7. Several women raised concerns over an increase of older women sleeping rough because of the pandemic. Spending so much time on the streets fundamentally affected the women’s lives negatively.“You noticed quite quickly that…, well, from March or April, it was all gone. And then we had to, at least in Stockholm, hmm… and then it turned up again, and got a little better after a month or so. And that month was like… Right, many of my friends started shooting instead because…, the ones who only smoked before started shooting up to get by, to avoid the worst withdrawal symptoms, and get it more concentrated.” (W3)The women elaborated on how dangerous rough sleeping was. To avoid being a victim of physical and/or sexual assault, the women needed to stay awake, sometimes for several days. This in turn, was not possible without using drugs, such as amphetamine. According to the women, heavy drugs such as heroin seemed to disappear from the streets during the pandemic. For women with severe substance use disorders, this was experienced as a critical problem as they feared forced abstinence. For these women, the outbreak of COVID-19 made a dire situation even worse.“…case management times get longer because it’s such long time. I’ve had to beg for food for… a year now, or half a year. Yeah, it’s rough.” (W8)The opportunities for personal contact in relation to health- and social care services also changed due to the guidelines for social distancing. Previously, the women had been able to sit face-to-face to discuss circumstances and potential interventions, but these meetings were either cancelled or conducted over the telephone.“So, I had to change case workers and never got to see her in person, because they accepted no visitors, and then it was all done over the phone. It became very impersonal somehow.” (W1)The loss of personal encounters was especially challenging when being assigned a new case worker.Having and managing to keep a mobile phone became a prerequisite to maintain contacts with health- and social care, as well as family and close friends, due to the pandemic. This in turn, added further to the women’s vulnerability as mobile phones were hard currency on the streets. The women described being robbed not only once, but several times. Worries of losing this lifeline, i.e., not being able to make telephone calls, as well as missed chances to establish personal connections and relationships, were described as heightening feelings of loneliness and isolation.The second sub-theme pertains to adjustments and reorientation to a new reality dominated by guidelines and restrictions during the ongoing pandemic. For women experiencing homelessness, who constantly face the world’s predictable unpredictability, the pandemic entailed yet another dimension of unpredictability that they had to adjust to and incorporate into their lives.“… Sure, you think about the two meters, and you don’t see that many people. I’ve tried wearing a face mask, but it gets so warm. But I do disinfect my hands and… and I’ve done that much more now after corona.” (W7)The women strived to balance on the shifting sands of guidelines and restrictions due to the pandemic. They were busy making sense of, and adhering to, the new social distancing rules and guidelines in line with the rest of society. There were multiple examples of reflecting on and assuming responsibility for following guidelines by wearing a face mask, washing hands, and avoiding social contacts.“Now that corona comes and is with us, you have to think… that you don’t sneeze in the same room. You go and wash your hands after sneezing. You have to manage your hygiene even better now, maybe like during the bird flu and stuff. Hmm, and you have to start taking care of yourself too.” (W4)There were also descriptions of ongoing monitoring and screening of one’s own body, including thoughts about when the experienced symptoms might be COVID-19, and when they were not. Women who participated in needle exchange programs, appreciated being tested for COVID-19 every three months. An increased awareness of the importance of self-care and how to best protect oneself, and others, from the virus were described by the women.“And then the fact that one shouldn’t be out in public transportation and stuff too much, well, you know, social services, they send you back and forth and sort of… so it’s actually… I don’t think I’ve ever used as much subway, buses and trains as in the past six months.” (W1)However, the women knew they were striving for the unattainable, as it is not possible to self-isolate, or to fully follow sanitation guidance as a person in homelessness. Nevertheless, the women did their best to adapt, and to fit in and be a part of a society in flux. They were aware of public health official's urgent admonishing to stay at home and to avoid non-essential travel. However, none of that was of much use for women who spend their nights either sleeping rough or in shared homelessness accommodation. Instead, they faced new dimensions of the harsh reality since the lockdown of society meant fewer beds in the shelters. Consequently, the women were forced to spend hours per day on public transportation systems to find a safe haven for one night at time.“…they may come coughing and stuff, and then they’re not admitted [to the shelter]: But if they have someone here at the hotel, they get in, and I don’t have any power to stop them…// And then that you invite people in from the street, so there’s faeces and garbage. People can sleep a little…in.. the elevators over there, and you throw your garbage, conduct your toileting and smoke, I mean… in elevators and stuff. Sometimes I see [drug] trading too…” (W2)Lack of beds in the shelters also impinged on women who were fortunate to have temporary accommodation. These became overcrowded when persons in homelessness, who were less fortunate, tried to find shelter from the streets. This resulted in feelings of insecurity and powerlessness among the women who lived there.“Me and my dad don’t care. Him and I meet anyway and what do you call it… have coffee in a place where we always have coffee. You keep your distance there. I mean, how they’ve place the chairs and tables, so that you’re not close to others. Maybe back to back but not… not more than that.” (W5)For women in homelessness, deviations from guidelines and restrictions related to the pandemic were inevitable, due to several reasons; sometimes simply to ease accentuated feelings of loneliness caused by social distancing. One woman stated that she meets her father, pandemic or not.“…right smack in the center [of the city]. There are lots… do you know how many people there are on Queen Street, I mean still? I don’t get it. I mean, it feels like they have no respect whatsoever.” (W5)In a life without the physical and psychological shelter of a home, the few bonds that still existed to family and close friends were very precious. In contrast to individuals with stable life situations, the interviewed women could not afford the "luxury" of opting out of relationships due to adherence to pandemic restrictions. Nevertheless, they were conscious of the stipulated guidelines and tried to do their very best to keep up with them. Thus, when guidelines were not followed by other people in society in general, they were surprised and upset as it, according to the women, signalized disrespect for others.The women tried coping with changes due to the pandemic, however, they were struggling with guidelines and restrictions created for insiders, or people integrated in society, not outsiders, like women experiencing homelessness.The third sub-theme pertains to the contradictory experiences that life was not changed due to the COVID-19 pandemic. The harsh reality for the women continued irrespectively. The women described living one day at the time, prioritizing provision for basic human needs, e.g., finding food, a safe place to sleep and last, but not least, escaping violence and abuse. For the women, the pandemic was nothing but a storm in a teacup.“I think the men, they seem to think this is all a hoax, the few… that this corona, it’s just some… they don’t believe in it. I’ve heard rumors that… They don’t care. They hug and shake hands and stuff like that.” (W1)There were rumors on the street, and in various situations, of people who did not believe in the coronavirus nor in the pandemic. Life went on as usual and some did not care, or perhaps had not even heard about guidelines and restrictions due to the pandemic.The struggle against the spread of the COVID-19 virus did not engage people in homelessness as they had their own battles to fight, the struggle for everyday survival.“But we who live there [temporary accommodation], we’ve lived as usual, I mean there’s no difference. I mean, if you get it, you get in, but I think that we users do pretty ok since we’ve lived rough, we are pretty resistant.” (W6)For women experiencing homelessness and problematic substance use, the pandemic represented unnecessary concern about an unimportant matter. Having lived rough on the streets for many years, and managing to stay alive was, according to them, a sign that they were true survivors. Thus, the women described not being afraid of catching a virus. They had been through much worse battles.“Yeah…, he has struck me so violently. I testified… it was probably … on his part last, it was two weeks ago now. I won’t do it again, let me tell you that, but I am a bit scared too…, well as long as he is locked up [I am safe]…” (W10)Women described they had other, more important, concerns and priorities in their daily lives than the virus. They underscored that their first and primary need was to obtain permanent housing. The longing for being able to close and lock a door of their own, to feel safe and secure was present in the women’s narratives. The one thing they wished for was getting out of their present life situation, including toxic relationships, that brought nothing other than misery.Violence and abuse were never far away for the women. Escaping abusive situations had often been contributing factors to homelessness and living in homelessness entailed becoming victims of violence again. Hence, the women found themselves in a never-ending vicious cycle of violence, which in turn was far more relevant than the pandemic caused by the COVID-19 virus.For women experiencing homelessness the outbreak of the COVID-19 pandemic represented a new dimension of the predictable unpredictability in society. The women had their own unique experiences of life during the pandemic, which we will discuss through the lens of inclusion health, intersectionality, and health literacy.No one is left behind, by reaching the furthest behind first, is a key feature in the discussions on the SDGs and represents a shift in thinking and subsequent confronting of global challenges [false sense of solidarity has been raised in literature [double disadvantage hypothesis [Based on our findings, COVID-19 and homelessness can be viewed as two intersecting crises. However, the women’s aggregated experiences were greater than the sum of homelessness and the virus. Gender, exposure to violence, poverty, social isolation, and substance use were additional factors that further marginalized the women during the pandemic. These factors can be labelled as social determinants of health, non-medical factors that influence health outcomes. The United Nations (UN) Sustainable Development Goals (SDGs) and the Agenda 2030, is a commitment to ensure a better and more sustainable future for all. allenges . In practerature . Thus, oterature , as theyterature . The phepothesis  and undepothesis . Nationapothesis , 6, i.e.The causes of increased risk of COVID-19 infection and related hospitalizations and mortality among people experiencing homelessness  are an iThe pandemic was described as having a devastating impact on the women with substance use disorders. Changes to substance supply routes led to an unpredictable supply, which in turn led to compulsive use as well as risk for withdrawal, at a time with reduced healthcare capacity. There are examples from other countries, where authorities tried to decrease the reliance on illicit, and often toxic, substances. In Canada, an emergency, provisional safe supply program provided pharmaceutical-grade medications and beverage-grade alcohol in COVID-19 isolation hotel shelters for people with substance use disorders . The prothe cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health [. The pandemic has indeed shown that dissemination of information regarding important public health issues needs to be adapted to persons with low health literacy [Some women in our study described that life went on as usual, regardless of the COVID-19 pandemic. A possible explanation for this finding is that people experiencing homelessness neglect health needs, since priorities related to basic human needs, e.g., food, shelter, and security, take precedence . Howeverd health . The panliteracy , which iliteracy . Furtherliteracy . To imprliteracy . The proliteracy . For theliteracy . To reacliteracy . Otherwiliteracy , as demoliteracy , 3.In line with inclusion health , a fieldDuring the COVID-19 pandemic, Sweden did not implement national lockdowns to mitigate viral spread . This coThe sample constitutes of 10 Swedish-speaking women who all lived in homelessness according to a definition widely used in Europe . The samWe used researcher-driven photo elicitation  to colleparticipatory coding by individuals, as two women had difficulties reading and writing in Swedish since they had other first languages. In addition, attention deficit challenges made it hard for the women to focus on long interview texts. Thus, one woman from the Women Advisory Board individually reviewed a subset of randomly chosen transcript, dynamic reading [The DEPICT model for collaborative data analysis  was a va reading , whereas reading  was a tiThe women (n = 8) and the researchers (n = 2) who attended the Women Advisory Board workshops (n = 11) appreciated the teamwork, but the collaboration also included challenges. Continuity of members of the Women Advisory Board was impossible to accomplish. The reason for this was that we had to meet the shelter’s requirements of security and confidentiality. Three women contributed to the study’s design (three workshops), whereas five other women contributed to the analysis and drafting of the manuscript (eight workshops). To summarize, eight women with lived experience of homelessness contributed to different parts of the research process by working 30 h together with two researchers (E.M. and A.K.). We acknowledge and value each woman’s unique contribution to different parts of the research process and argue that the collaboration strengthens the study’s trustworthiness.We interviewed women in homelessness about their experiences during the COVID-19 pandemic. Based on our findings, we can conclude that the women’s aggregated experiences were greater than the sum of homelessness and the virus. Gender, exposure to violence, poverty, social isolation, and substance use were additional factors that further marginalized the women during the pandemic. There are numerous examples that showed that the women in our study were left behind, including reduced access to vital societal services and fewer beds in shelters which meant no other options except living on the streets. The latter was devastating for the women with increased risk of exposure to violence and sexual abuse. Our findings provide a sad picture of structural inequity when crises intersect for women, that is, COVID-19 and homelessness. Even though we were all in the crisis together, the way the pandemic affected women in homelessness was profoundly different compared to other more privileged groups.To rebuild a better and more sustainable future for all after the pandemic, we need a global commitment to ending homelessness. In addition, addressing social determinants of health in close collaboration with inclusion health target populations must become the number one health intervention. This is imperative to ensure that people who are the most marginalized and underserved in society, the further behind, are reached first in the next, inevitable pandemic.Additional file 1. GRIPP2 short form.Additional file 2. Data collection method – Workshop 1-3 with the Women Advisory Board.


Gardening has the potential to improve health by providing access to nature, vegetables, and physical activity. However, scarce research exists on the health impacts of gardening on racial and ethnic minority urban populations in the United States. This study used qualitative interviews to examine the perceived physical and mental health effects of gardening in a primarily African American sample of 28 gardeners. Prominent physical health impacts attributed to gardening included providing an enjoyable source of activity, management of chronic diseases, and improved physical functioning. Participants also reported that gardening improved their mood, relieved stress, was an important part of their spirituality, contributed to their personal growth, and provided an opportunity for helping others. These findings suggest that gardening may improve physical and mental health among diverse groups. The vast majority of American adults do not meet physical activity or diet recommendations ,2, whichThe health benefits of gardening extend beyond physical health. Several studies have demonstrated that gardening is associated with reductions in stress and other elements of mental wellbeing ,20,21. OIn addition to the previously described quantitative studies, qualitative studies on gardening and health allow insights into the lived experiences of gardeners, and can unearth the perceived mental and physical health effects of urban gardening. These studies have found that gardeners commonly perceive that physical activity, diet, and mental wellbeing are promoted by gardening ,28,29,30This research was conducted in collaboration with Keep Growing Detroit (KGD), a non-profit organization serving gardeners in the cities of Detroit, Hamtramck, and Highland Park, Michigan. In 2021, Keep Growing Detroit supported approximately 24,088 Detroiters in 2020 gardens with their Garden Resource Program. In contrast to many other gardening organizations, Keep Growing Detroit does not manage or oversee their member’s gardens. Rather, they support gardens initiated by individuals or community organizations by providing material resources , technical support, and gardening education . Keep GrWhile many gardening organizations serve either home gardeners or community gardeners, Keep Growing Detroit serves any type of gardener located in their service area. Their member gardens are located throughout the city of Detroit , and incThis research used a community-based participatory research approach. A research committee comprised of Keep Growing Detroit staff, Garden Resource Program members, and academic researchers oversaw the project’s design and implementation. The committee chose semi-structured qualitative interviews as the mode of data collection to obtain in-depth accounts of participants’ experiences. The research committee chose topics to include in the interview guide, and the principal investigator designed open-ended questions based on these topics. The research committee provided feedback on the questions, and the principal investigator revised the interview guide to incorporate this feedback prior to data collection. The interview guide contained questions regarding the impact of gardening on mental and physical health and wellbeing see . The intThe interviews were conducted in 2015 by three research committee members: the principal investigator and two Garden Resource Program members. The principal investigator trained the interviewers in qualitative interview techniques prior to data collection. Twenty-eight Garden Resource Program members were interviewed, and participants were chosen through purposive sampling by the research committee to mirror GRP members in terms of their type of garden, age, race, and gender. Interviews were tape-recorded and transcribed, and the transcripts were checked for accuracy. Interviews were coded in Atlas.ti using a combined inductive–deductive thematic coding approach. An initial codebook was generated that included deductive codes based on the interview guide questions and inductive codes identified during transcript checking and from nine randomly chosen interviews. Next, two trained researchers each coded an additional nine interviews using this initial codebook. The two coders discussed coding differences, refined the codebook, and reached a consensus on coding. The first author coded the remaining interviews with this refined codebook. Data saturation was reached and was determined by the absence of new emergent themes found in the interviews. After the coding of all interviews was completed, codes were clustered into larger themes related to the primary research questions: physical health, physical activity, and mental wellbeing. For each of these themes, summary statements were written for each gardener and arranged in conceptually-clustered matrix displays . ConclusThe participant demographics are provided in Nearly half of the participants described gardening as physically demanding. Gardeners emphasized the physical work of gardening, either implicitly or explicitly stating that gardening was good exercise. For example, participant 5 said “Of course I’m not jogging, but I’m working. Swinging a hoe for several hours a day is no joke, or hands and knees weeding”.Similarly, several other participants mentioned specific gardening tasks that were especially physically strenuous, including hauling compost, carrying buckets of water, and digging. The wide variety of tasks needed to tend a garden, as well as the variety of types of movement , were described as working many parts of the body, with one gardener saying, “You use every muscle in your body. You’re using your back, your arms, your knees, your thighs, your calves, your ankles, your wrists, your elbows” (participant 12). Similar sentiments were shared by gardeners of all ages, and by gardeners with and without physical limitations. For example, one participant stated, “So I’d be riding my scooter up and down the lanes leaning out weeding… so that’s one thing you can say about gardening. It’s exercise” (participant 1). Further evidence for the intensity of physical activity during gardening came from participants who reported needing to stay in shape to be able to garden. This need encouraged some participants to exercise outside of the garden in ways that would improve their fitness for gardening. One participant also described a neighborhood walking group that had formed around the garden: “We walk in the neighborhood, check the garden out, watch out for the kids” (participant 11).Gardening was a primary source of physical activity for some participants. These participants engaged in little to no intentional exercise outside of the garden and they preferred gardening to more structured forms of exercise, such as going to the gym or running. As one gardener said, “Well, it gets me outside. And off my butt. I don’t like to exercise… so gardening is really my only exercise” (participant 15). Others also reported disliking other forms of exercise, indicating that gardening provided a source of physical activity for people who would not participate in much activity otherwise. In fact, other participants explained that they had been inactive before gardening and that the activity from gardening benefited their bodies. As one gardener said, “When I started gardening, it helped my body. Yeah, gardening makes you work. … for couple of years [before gardening] I was a couch potato” (participant 2). The importance of the activity from gardening was evident when participants compared their physical activity level during the gardening season with the winter. During the winter, gardeners mentioned that their activity levels were drastically lower and that they missed the physical activity from the garden. For example, one gardener said, “In the winter time I am lost because I don’t have that exercise that I get out of being in the garden” (participant 14).The physical activity from the garden was perceived to improve physical function, particularly for participants aged over 50 who had physical limitations or physical pain. These gardeners reported improvements in arthritis symptoms, increased flexibility, and regaining physical function after an accident. One gardener said, “My therapeutic gardening, I call it because the knee problems and the back problems and the arthritis, and all that, seems to be better because of my movement” (participant 14). Another gardener who had lost function in his hand after an accident credited gardening with regaining hand function. He said,The doctors told me that that’s all we can do for you. We can’t do anymore. I said well I know what to do. I will go back to gardening which is something that will work my body and work my hand and I have dug that garden across the street with my hands.Participants attributed a variety of other physical health improvements to gardening. Both improved dietary habits, such as eating more fruits and vegetables , and phTwo participants credited gardening with staying healthy while aging. As one participant said, “I don’t catch colds. And I haven’t had any type of problems, high blood pressure, nothing. I don’t take any pills, and I’m collecting social security now…I think working in the garden has a whole lot to do with” (participant 2). Gardeners also reported that spending more time outside, receiving vitamin D from the sun, and better sleep were health benefits of gardening.Stress relief and relaxation provided by gardening were prevalent themes related to mental wellbeing. Participants used words such as “peace”, “calm”, “grounded”, and “refreshed” to describe how gardening influenced their mental state. Several aspects of gardening were important for relieving stress and promoting relaxation. Some gardeners attributed stress relief to the physical act of gardening, tying the physical activity from the garden to this benefit. As participant 1 said, “It was just a true release of the stress ‘cause there was a lot of work to do [in the garden]… So it sort of like stimulate your brain and make it relaxed.” Interacting with nature by tending to the garden’s plants was another way in which the act of gardening contributed to stress relief: “… being able to interact and help cultivate the growth of such a plant and interact with life is a really different… is a very calm state when I am out in the garden” (participant 17). Participants also described the garden as a peaceful place. Some noted that just looking at the garden was relaxing, while others described a sense of peace or calm that they felt from just being in the garden: “I notice that in that little area where the garden is… it seems to be a peace…” (participant 10). The garden space contributed to stress relief by offering an opportunity to escape or being away from the stressors of daily life, with gardeners describing the garden as being separate from the outside world. This physical separation allowed gardeners to mentally disengage from the stress of their daily lives: “When I come home from work I will go straight to my garden and I don’t even think about my job anymore. It’s just–it’s another world” (participant 4). For another gardener, interacting with plants was closely tied to the garden being an escape: “What I enjoy is the life that it brings to each day…if I keep my focus on my relationship with the seeds and the plants, it’s almost like it’s a world that the world can’t invade…” (participant 13).Participants also explained that gardening improved their mood by making them happy or bringing them joy, as well as by reducing negative emotions, such as anger or sadness. Some of the same aspects of gardening that were linked to stress relief were important for improvements in mood: the garden being a happy place and the interaction with plants. Just as being in the garden was reported to relieve stress, gardeners also described how the physical garden space made them feel happy. As one gardener said, “I cannot tell you how great I feel when I am in the midst of that garden…” (participant 10). Another participant said, “Even just seeing my husband work it and the joy that he gets out of it is joy for me… just the presence of it is very comforting to me” (participant 16). Other gardeners reported that gardening provided an opportunity to help others, which is described in more detail below. Tending to or even just being with plants was another way that gardening made people happy or improved their mood. As gardener 8 said, “I always feel better, if I’m angry or upset, go be with the plants, talk to the plants, listen to the plants, I feel better”. Some also talked about how the garden helped them cope with difficulties in their lives, calling the garden “therapeutic”. After the death of her son, one gardener said,It woke me up. As I said, after my son passed away I was very depressed. I had to heal mentally and physically. [Gardening] was something I was able to do that I was able to do. It brought satisfaction to me, when I didn’t feel like eating, sleeping. So, that was something, a new day, that I can look forward. It’s therapy for me. It’s therapeutic in many ways… with the soul, the body (participant 3).Gardening was perceived to impact the participants beyond mental and physical health. Many gardeners described how gardening contributed to their personal growth through helping others and in other ways. For instance, some gardeners explained that they helped others by sharing their garden harvest or sharing gardening knowledge and inspiring others to start gardens. As participant 2 said, “I tend to want to help people more [since gardening], because people started coming to me, asking questions… three to four people have kicked off some really nice gardens”. Helping others also benefited the gardeners themselves: gardeners expressed feelings of happiness that came from helping others through the garden. For example, participant 4 said, “I have to do everything that I can to…share with others and give to others that don’t have…That’s very, very important to me”. Gardeners also described how gardening has contributed to their personal growth in ways beyond helping others. Several gardeners described how gardening made them grow by becoming more patient, tolerant, or laidback. Other gardeners experienced personal growth by learning lessons from observing the natural world and applying these lessons to their own lives. As one gardener said, “I gained, knowledge, I gained knowing how to live life… I learned how to just sit down and you know smell the flowers, look at the flowers, look at the sky, look at the birds” (participant 11). Another participant used examples of natural processes to metaphorically apply them to his life. This gardener said,I see how God is able to take and recycle a seed and take a broken, maybe wounded plant and… that plant just takes off and then the rest of it becomes beautiful all over again. Such as life. Take off that attitude, whether it be drinking, sex, gambling, or a mental attitude, and take it off and then you can begin to flourish… What can happen to a seed, it can happen to a human heart and a human life as well (participant 13).This quote is also an example of how gardening was related to spirituality or religion, which will be described in more detail in the next section.Most gardeners indicated that there was a relationship between gardening and their religion or spirituality. This relationship was present for participants who self-identified as being religious, as well as for participants who reported not being religious. For those that were religious, gardening reinforced or deepened their religious beliefs, such as by providing an opportunity to connect to God. As one gardener said, “Being in the garden just really quiets me down, puts me in contact with God, that’s right, that’s my prayer time really…I have learned to relate to God in a much different way and much more immediate [way]” (participant 15). Several other gardeners described the garden as God’s gift or creation.The exposure to nature in the garden was the most commonly cited factor that linked the garden to religion or spirituality. Several gardeners used terms such as being “in tune with nature” or “one with nature” in the garden to articulate this connection. The garden soil, birds, bees, and plants were all components of nature that were linked to spirituality and religion. An example of this was provided by participant 10: “Put your feet in that dirt and put your hand in that dirt, you will find Him, He’s right there in that soil”. Another participant said, “Well the spiritual dimension, it’s just amazing. The spiritual link between plants and humans and how the behavior of humans can impact the behavior of plants” (participant 7). Additionally, gardening was referred to as a part of “culture” or as a “tradition;” a way to connect people across generations. Some gardeners described gardening as a way to connect with their ancestors; as one gardener stated, “I mean [gardening is] so much a part of what my family has done. What is in African-Americans, from our traditions… it was just a part of the culture” (participant 16). Others talked about their desire to keep the next generation gardening: “So, we must keep this tradition alive. And continue it, and pass it on” (participant 3).This study qualitatively examined the perceived health and well-being impacts of urban gardening in a primarily African American sample of urban gardeners belonging to a gardener support program. Overall, our findings were highly consistent with previous research with less racially diverse participants conducted in Western countries. This study provides supporting evidence for the role of gardening in improving health in diverse populations.Several gardeners in our study described gardening as physically demanding and that it worked many parts of their bodies. In other qualitative studies, gardeners also described gardening as an all-around exercise, or that it worked the muscles by requiring a wide variety of activities ,27. SomeIn this study, the physical health improvements that participants attributed to gardening included improvements in physical function, such as increased flexibility or reductions in arthritis symptoms, and improvements in chronic diseases, including hypertension and diabetes. Similarly, other qualitative research has found that urban gardeners attribute a variety of physical health improvements to gardening, ranging from weight loss, maintaining health while aging, and feeling more fit ,27,30. TMental health benefits, such as stress relief, relaxation, and improved mood, were commonly mentioned in this study. Gardeners attributed these benefits to several aspects of gardening, including the act of gardening tasks and the garden itself as a peaceful place to be. Several other studies have similarly found that both the active and passive aspects of gardening were reported to be beneficial for mental wellbeing ,27,36. RThe key strengths of this work include the participatory planning process, qualitative design, and the diversity of the participants. Community-based participatory research can illuminate unique place-based circumstances that can impact research findings. Having Detroit gardeners co-write research questions, the interview guide, and conduct interviews facilitated trust and engagement among the research participants. Although the reported physical activity and physical health benefits of gardening were not objectively measured, the qualitative design allowed for the first-hand experiences and perceptions of the gardeners to directly identify the many ways in which gardening is perceived to influence physical and mental health. The qualitative design also allowed for in-depth investigation into which aspects of gardening are perceived to influence health. Additionally, this is one of the few studies on urban gardening and health in which the majority of participants are people of color. Hearing from diverse voices allows for a comprehensive representation of the range of meaning and experiences related to gardening and health, including the distinctive spiritual nature of gardening providing meaningful connections to their origin and ancestors.In conclusion, this study was one of few to examine the perceived health impacts of urban gardening in a racially diverse sample of participants in the United States. Participants commonly reported that gardening was beneficial to physical activity, physical health, and mental wellbeing, which is highly consistent with previous qualitative research conducted with mostly white participants in Western countries, but also shared their unique perspectives from their own cultures and communities. Our findings demonstrate that gardening has the potential to influence health in diverse groups of people, and thus may have the potential to address health disparities.


Reducing prolonged engagement in sedentary behavior is increasingly considered a viable pathway to older-adult health and continued functional ability. Community-based programs that aim to increase physical activity can improve programs’ acceptability by integrating older adults’ perspectives on sedentary behavior and healthy aging into their design. The purpose of this study was to better understand the perceptions of a diverse group of community-dwelling older adults regarding sedentary behavior and its influence on healthy aging. Six focus group discussions with forty-six participants took place across two senior centers in New York City. Self-report questionnaires about daily activity patterns, general health status, and typical sedentary behaviors were also completed by the participants and analyzed using descriptive statistics. The focus group discussions were audio-recorded, transcribed, and analyzed using inductive and deductive approaches and an ecological framework to identify salient themes. A qualitative analysis revealed that the participants were aware of the physical costs of engaging in prolonged sedentary behavior. However, many routine sedentary activities were perceived to be health-promoting and of psychological, cognitive, or social value. The insights gained can inform the development of senior-center programs and health-promotion messaging strategies that aim to reduce older adults’ sedentary behavior. Older adults are the least physically active ,2 and moPrevious qualitative studies ,23,24,25The published qualitative sedentary behavior studies designed to investigate sedentary behavior are largely limited to homogenous groups. It is unclear if these findings are consistent or relevant to more racially, ethnically, and socioeconomically heterogeneous groups. Our understanding of health behavior promotion among various populations is incomplete without adequate consideration of the socioeconomic and cultural dimensions of health ,27. TherA needs assessment was conducted to gain a better understanding of the beliefs held about sedentary behavior among a group of multi-ethnic/racial and socioeconomically diverse older adults. Focus groups allowed the researchers to explore in depth the personal, sociocultural, and environmental realities of the participants’ daily activity patterns. The researchers took the necessary step of gathering older adults’ perspectives and input in an effort to co-create an acceptable healthy aging program that would have value and meaning for the participants ,29. TheoThis needs assessment was conducted at two senior centers that had established academic-community partnerships through an academic program, located in New York City, that supported training (fieldwork) for occupational therapy students. One center is centrally located, within a large low-income public housing development in Queens, NY. The other is located on a commercial corridor in a middle- and upper-income neighborhood in Brooklyn, NY. Both centers are located in mixed  areas rich in neighborhood amenities .The sample consisted of older adults who attended one of the two aforementioned senior centers. Consistent with the inclusion criteria, participants were 60 years or older, showed a willingness to participate in a focus group interview, demonstrated an understanding of the aims and procedures of the study, and had sufficient ability to speak, write, and read English. Given the demographic and historical context of the neighborhoods in which the senior centers were situated, it was projected that the study participants would be racially, ethnically, and socioeconomically heterogeneous.Researchers implemented a proactive, face-to-face recruitment plan that sought to mitigate potential recruitment barriers to focus group participation . ParticiBefore going on-site to recruit, researchers met with the program directors to discuss the proposed study, conceptual framework, and anticipated outcomes. Once on-site, senior center staff and program directors facilitated introductions to potential participants, extending the circle of trust to the researchers. Additionally, senior-center personnel assisted with the posting of recruitment flyers and allowed the researchers to make recruitment announcements following the morning and lunch meetings. Recruitment flyers, consent forms, and an interpreter were available for Spanish-speaking participants.Six focus group interviews were conducted between January and March 2020. Focus group interviews lasted approximately 60 min and were moderated by the principal investigator in a semi-private area within each senior center shortly after lunchtime. At the beginning of each focus group interview, permission to audio-record was obtained verbally from all participants. After each focus group, participants completed a brief demographic questionnaire. As encouraged by Miles, Huberman, and Saldana (2014) , the priFocus Groups. A semi-structured discussion guide was developed based on interview questions and findings from previously published qualitative studies on older adult sedentary behavior ,23,24,25Descriptive Statistics. Socio-demographic , health- and activity-related, and center utilization variables were collected to describe study participants. Activity-related items were adapted from two validated sedentary behavior measures ,42 and tMicrosoft Excel was used to perform descriptive statistics on the socio-demographic and health- and activity-related variables. AI-powered transcription software  transcribed the audio-recorded focus group interviews, and the principal investigator verified the accuracy and corrected any transcription errors. ATLAS.ti  was used to store, organize, and manage the data retrieved from the interview transcripts.An ecological framework provided the conceptual foundation for this study and informed the analysis and interpretation of data through personal, social, and environmental/organizational themes. Thematic analysis of the transcripts and jottings was conducted using a framework method for health research . Specifin = 46) older adults participated in six focus groups across two senior centers. The sample characteristics of all participants obtained by the center are available in Forty-six  Avoiding sedentary behavior, enjoying seated activities; (2) multi-level influences on sedentary behavior; and (3) self-determining healthy aging. The themes, core categories, and sub-categories are presented in This theme revealed that the participants maintained a holistic view of sedentary behavior. On one hand, the participants attested to the adverse short-term health effects they felt as a result of sitting excessively, which included bodily aches, stiffness, and inadequate blood circulation. Other participants discussed their understanding of the long-term consequences sedentary behavior could have on their functional ability and health. For example, a participant stated, “...this sedentary life would destroy me because it weakens your bones and your muscles and you can’t get up”. In addition to physical symptoms, the participants also discussed feelings of guilt, depression, boredom, and idleness after extended periods of sedentary behavior. As one participant expressed, “I agree that the thing we all should do less of is sitting down watching TV for a long time … because when you’re watching TV, you’re really not doing anything”.Conversely, the participants shared positive attitudes toward sedentary time that afforded enjoyment, mental stimulation, and socialization. For example, one participant reported, “Doing the activities that I do—solving puzzles and at the same time talking to others at my table—helps me stay sharp”. The participants also perceived these sedentary activities as a form of rest and restoration, allowing them opportunities to relax, contemplate, and cope with environmental stressors. The participants also discussed how daily sedentary activities provided structure in their day after retirement. For example, one participant described how she began each day with sedentary time by stating: “Most of my sedentary time is listening to the radio in the morning—gospel music or some type of spiritual mediation, and then after a while, I’ll get up and move about”.The participants also discussed the personal, social, and environmental determinants of sedentary behavior within an aging context, as described below.The participants shared that chronic pain and mobility limitations acted as barriers to reducing sedentary time. As one participant explained, “I have difficulty walking since I had that stroke. I used to walk a lot. Now, I paint. I work at a computer. I write…”. The participants also considered how being sedentary impacted their functional ability and continued engagement in daily activities. Many discussed their need to modify their activity patterns because of health conditions and age-related physical decline. For example, a participant stated, “I started getting arthritis in my hips and knees and also COPD. So, that’s really slowed me down. I try to walk but not that far”.Retirement was also discussed as a key life transition that influenced current activity levels. Many saw retirement as an opportune time to engage in more of the leisurely activities that they enjoyed but did not have time for previously. As one participant revealed, “My life used to be a very routine life going to work, but now it changed because I retired. I started coming here [to the center] and began to socialize more, get to know more people, different things that I didn’t do before like exercise classes, computer classes…”. Some discussed how changes in activity level following retirement were a consequence of the type of work they performed previously. Those who held more physically demanding positions described an increase in sedentary time after retirement: “Yes, [I’ve become more sedentary] because before I worked in the field every day. So now, I don’t get up as much as I used to, and once I get up, I’m [sitting] at the TV”. Meanwhile, others, who worked more sedentary jobs, revealed how much more active they had become since retiring.Interpersonal relationships also influenced the amount of sedentary time the participants accumulated. For instance, a participant shared how her close relationships contributed to a reduction in the time she spent sitting: “I went from being very… active to being completely out of it, to now, I’m back and I have friends now that keep me busy”. Activities that provided enjoyment and social connection were valued by the participants, regardless of whether the activities were sedentary. Activities such as puzzles and watching TV were justified if they were performed as a group and provided a shared experience. For instance, a participant stated, “We have TV discussions here. Everybody comes in and we’re all [excited] about it. I just love it! and if I missed something, somebody else could tell me what I miss. It’s fun!” Conversely, conflict with peers at the center were discussed as a stressor that potentially impacted senior center attendance, increasing the likelihood of remaining at home and engaging in sedentary behaviors.The social climate at home or at the center was viewed as an integral part of healthy aging as it was perceived to shape the expectations of what was thought to be developmentally appropriate activities for older adults. Some participants described feeling compelled to perform certain activities seated because of prevailing social norms. The negative aging stereotypes encountered during interpersonal exchanges contributed to the participants feeling infantilized by family and friends, despite their best intentions. The participants strongly rejected the expectation that they should become more sedentary with age. As one participant remarked, “The biggest question is how to keep ourselves from getting shoved into that ‘you’re old now’; ‘it’s time to rest’; ‘you can’t’; ‘don’t push yourself too hard’ [category]”.Inclement weather and steep or uneven terrain were cited as factors that contributed to increases in sedentary time. The availability and affordability of transportation enabled them to venture out into their local neighborhood and beyond to engage in a variety of outdoor activities. As one participant remarked, “Being in New York, it’s much easier to get around. You don’t have to spend a whole lot of money to get someplace, and there’s so many things that are available for seniors here in New York City compared to elsewhere”. The availability of and proximity to leisure opportunities locally and at the center were identified as a significant influences in discouraging sedentary behavior. As one participant reported, “That’s one thing about this place. They have so many physical things to offer us, like the one I just went to yesterday, Stretching for Arthritis, really helped!” However, others noted the resource limitations of nearby senior centers, which limited the variety and quality of the programs offered.Neighborhood institutions, such as senior centers and places of worship, were emphasized for their critical role within the community, highlighting the importance of support and adequate funding for institutions that promote healthy aging. Therefore, the participants viewed their senior center as a key community resource that supported continued engagement in life activities and encouraged them to remain active and to flourish. The participants discussed broad societal factors as a backdrop against which healthy aging occurred by commenting on the ground-level impact of policy initiatives aimed at improving the health and wellbeing of older adults. Many acknowledged how municipal subsidies made low-cost meals and senior-center programming available. For example, one participant expressed gratitude by stating, “We have to thank the government, or the city, to have a center—a senior citizen center. They think about us having a meal, which is offered here. They offer exercise to keep us active, and I think it’s great”. Other participants thought policymakers should take greater action to ensure that older adults have the security they need to age well, as captured by a participant who observed, “If they don’t have enough food, they’ll be less healthy. They don’t have good health care, they’ll be less healthy. Well, to me, this is pretty obvious… if we need more food, then help with food stamps, and if we need better housing, then make laws that make housing more stable”.In considering other societal determinants, some participants bemoaned how technological advancements and modern-day conveniences in contemporary society encouraged more sedentary behavior. This was captured by a participant who stated, “…Most of the things we do every day do not involve movement [to any] extreme degree at all. We don’t walk great distances. Everything is automated to the point where it leaves you with your only options for exercise is something that’s structured exercise”.Many participants maintained a positive view of aging and held higher expectations of their aging self, asserting they had ultimate control over their health, and stating that personal accountability played an important role in healthy aging. As one participant expressed, “Some of us, as we age, we cause our own deterioration because we tell ourselves, ‘Oh, I can’t do this again because I’m a certain age…”. The participants strongly believed that one’s attitude towards aging was an important contributor to healthy aging. Meanwhile, the participants who did not identify as an ‘active person’ discussed how comforting their sedentary activities were and how much it was a part of their daily routine. For others, their own perceived mortality and the limited amount of time they had left was a significant motivation for seeking comforting activities, regardless of their sedentary nature, as exemplified by a participant who declared, “At this age, I want pleasure. So, I make my choices”. The identities and life roles that developed from the participants’personal beliefs and health habits also shaped how they viewed the interaction between sedentary behavior and healthy aging. Some participants, who embraced volunteering and caregiving as part of their identity, were resolute on remaining active as they age. As one participant expressed, “I have my dog that I walk, I help take care of [an older neighbor] in my building, and I help my mom. So, between [them], I’m running back and forth…”.These attitudes either motivated the participants to or prevented them from continuing to engage in activities despite health issues and age-related changes. Interestingly, some of the participants were critical of the term healthy aging altogether, as a participant stated, “I think [healthy aging] is a negative term in the first place. It’s like when you see the shirts, ‘Girls Can Do Anything’. Well, the only reason [they’re] wearing that is the same reason people used to wear ‘Black is Beautiful’ shirts. It’s because [they’re] trying to push back [against a prevailing norm]. ‘Healthy aging’ implies that aging is not healthy”. Despite this wrestling with terminology, the participants viewed healthy aging as being due to an accumulation of healthy habits and behaviors  that were developed over a lifetime. There was also a recognition that institutional and aging policies affected the resources available to them. Many of the participants felt strongly about the need to advocate and be included in local decision-making: “I think it’s very important that we have a voice in what’s going to happen at our local center, and that it does not happen from top down”.The major finding of this qualitative study among community-dwelling older adults from racially, ethnically, and socioeconomically heterogeneous backgrounds was that while the participants experienced the physical and emotional distress associated with prolonged sitting, the psychological, cognitive, social, and restorative benefits derived from daily sedentary activities were valued and viewed as part of their healthy aging routine. This has important implications for the development of future programs and messaging strategies to help older adults reduce their sedentary time. There is an increasing awareness in the literature ,45,46 ofIn the current study, the prevailing theme from early sedentary behavior messaging that excessive sitting is detrimental to health was consistently manifested in the focus group discussions. However, paradoxically, the participants also voiced a strong aversion to abandoning certain seated activities, as these were viewed as positive contributors to their overall health. This sample of older adults valued the enjoyable, mentally stimulating, and socially engaging seated activities in which they regularly participated. This finding adds context to the cross-sectional analysis of a national Canadian health survey conducted by O’Neill and Dogra , who fouThe participants with mobility limitations and gradual decline in physical function viewed seated activities, such as listening to audiobooks or socializing with peers, as positive coping strategies that they adopted to remain engaged in meaningful daily activities. This is in line with the results of a study by Chastin et al. , who alsWith regard to the social and physical context, the participants were determined not to be restricted by stigmatizing aging norms, the cultural expectation that they should sit, and the paternalistic attitudes of their family members. At the same time, however, the participants asserted it was their prerogative to sit, relax, and contemplate in their late age if they so desired. Similar to findings published in the qualitative study by Palmer et al. , the parLastly, we observed how the senior center played an essential role in helping this sample of older adults to maintain an independent lifestyle in the community. Recognized as vital community hubs where older adults can engage in healthy aging activities and avoid premature institutionalization , senior A primary strength of this study was the contextualized views on sedentary behavior and healthy aging gathered from a racially, ethnically, and socioeconomically diverse group of older adults. This research also emphasizes the importance of participant engagement when designing and implementing evidence-based programs to promote healthy aging. However, there are important limitations to consider. The use of a convenience sampling method, applied in a high-density urban location, limits the transferability to senior centers in other geographic regions and to other populations, including those that may be more sedentary or less mobile because of health issues. Moreover, the use of subjective measures to identify the activity patterns and sedentary behavior of the participants may have introduced social desirability bias. Furthermore, the sedentary behavior questionnaire used in this study combined two previously validated instruments but was not validated itself. Lastly, the study design did not include an in-depth analysis of the reported sedentary time to quantify a time point at which the participants perceived they were sitting for too long and sought to discontinue this behavior to avoid experiencing the symptoms associated with prolonged sitting. Future studies should consider engaging older adults in discussions surrounding such a sitting threshold and its influence on their health behavior.This study explored the perceptions of sedentary behavior and healthy aging among a heterogeneous group of community-dwelling older adults. Although the participants experienced the physical consequences of extended periods of sitting, value was placed on the psychological, cognitive, and social benefits of the routine sedentary activities in which they engaged. With a higher prevalence of sedentary behavior observed among women and minority populations, it is important to better understand prevailing perceptions to design more acceptable programs. In sharing their insights and recommendations for senior-center programs to reduce sedentary behavior, the participants in this study were able to exercise control and self-determination in their lives—key pillars of healthy aging.