Factors shaping bricolage tactics

Introduction

This chapter is the second of two which explores in more depth the influences shaping bricolage tactics that we outlined in the previous chapter. Based primarily on interviews with residents and the household survey we identify six key factors which shaped bricolage behaviours. These are set out below. In doing so, we also seek to highlight the usefulness of bricolage as a tool to understand the ways that individuals enact resources across neighbourhoods and transnational boundaries. The first relates to socio-demographic factors which shaped access to resources. A second set of factors were more migration-related, including being a migrant or the descendant of migrants, the importance of language for communication with providers and the ability to understand local provision. Discrimination and entitlements to healthcare were also raised as important influences. A third set of influences related to health literacy and cultural health capital to secure knowledge and information and to negotiate and access different systems to secure and blend resources. Trust was identified as a fourth factor shaping individuals' choices and behaviours, with loss of trust in a particular health professional or an entire system a key element of individuals’ bricolage stories. Agency is presented as a fifth key factor which also influenced bricolage behaviours. Not all individuals with the desire to bricolage ox- access to wide-ranging resources engaged in bricolage, but those who were able to express their demands appeared to be able to undertake ‘within system’ and ‘added- to-system bricolage’. Finally, through a neighbourhood-level analysis, we also illustrate how deprivation at a local level may also shape bricolage behaviours, and with ‘within system’ bricolage being more prevalent in deprived neighbourhoods.

Socio-demographic factors and bricolage

The first key factor which shaped bricolage tactics and behaviour related to sociodemographic characteristics. The diversification of diversity is a key characteristic of superdiversity and implies the need to focus on the intersection between multiple variables including migration status, gender, age, class, employment status, education level and so on (Vertovec, 2007). Associated with such diversification, it is important to identify the difference, or combination of differences, which shape people’s access to healthcare (Berg & Sigona, 2013) and to understand which social, economic and demographic determinants shape bricolage behaviours. The association between type of bricolage and sociodemographic determinants is presented in Table 7.1.

Estimates in Table 7.1 that are higher than one (1) indicate an increased likelihood to engage in certain types of bricolage whereas estimates smaller than one mean a reduced probability compared to the reference categories (i.e. the 18-29 age group; women; low education; low income; working for pay). Since the coefficients are difficult to interpret as there are many reference categories, descriptive statistics to this analysis can be found in Table A1 in the appendix.

In summary, the household survey data indicates that men were less likely to bricolage in general (witness the figures of less than one across all of the bricolage 'types’ in Table 7.1), while women were more likely to engage in within-system bricolage and to add to the system. Survey findings around women engaging in higher levels of within-system bricolage were unsurprising given the predominance of women in our semi-structured intex-views reporting the important work they undertook attempting to make public health systems work for them and their families. Indeed, in Bradby et al. (2019) we describe the significant practical, administrative and emotional efforts that women make in order to access appropriate care for their parent or offspring as well as for themselves.

In addition, whilst the results presented in Table 7.1 do not necessarily highlight any immediate trends in respect to the relationship between age and bricolage practices, this is due to a number of employment categories (e.g. those who are a pupil, student or who are in further training, as well as those who are in retirement) being strongly related to age. In contrast, when employment status is discounted, there is a much stronger association between age and bricolage practices, with those over 60 less likely to engage in bricolage (see the descriptive analysis presented in Table Al in the appendix; also see Phillimore, Brand, et al., 2019). Nevertheless, many of the elderly people interviewed talked about their reliance on others to both understand and access the public healthcare system. For example, MSantos from Lisbon explained her reliance on a civil society organisation called "More Proximity, Better Life”, which enabled her to engage in both added to the system and within the system bricolage.

They keep me company, enlighten me about a lot of things I did not know, even when it is about paperwork for example when my landlord wanted to increase the rent, the woman explained me that the landlord couldn't increase more than a certain amount. And this is very good because we are in a blind world, here. Here you do not see anything, do not know anything. There are two ladies who volunteer and will probably stop by today, very kind and they talk to me a lot. When it was for supplement of my pension it was also the woman who told me to give the documents and took care of it. ... If I need them to give me assistance in going to the doctor I just call and they sent me a person to accompany me. Because I have a lot of imbalance on the street. On the street and at home. As I have almost no strength in the legs, having a person next to me makes me feel safer, this is a disease that affects you psychologically, when a person does not have the strength.

Table 7.1 Types of brieolage

Types ofbricolage

No bhcolage (base outcome)

Within-system bricolage

Added-to-system

bhcolage

Alternative

Age groups (ref. 18-29)

30-44 year's

1

1.16 [0.57,2.37]

1.05 [0.49,2.25]

0.48 [0.17,1.37]

45-59 years

1

1.13 [0.56,2.26]

0.94 [0.44,2.01]

0.85 [0.31,2.33]

60-97 years

1

0.79 [0.38,1.67]

0.59 [0.26,1.37]

0.88 [0.28,2.76]

Gender (ref. women)

Men

1

0.73 [0.54,1.01]

0.45*** [0.32,0.64]

0.72 [0.42,1.22]

Education (ref. low)

Medium

1

2.12** [1.29,3.49]

1.98* [1.11,3.51]

6.49*** [2.58,16.3]

High

1

2.10** [1.31,3.36]

2.74*** [1.57,4.78]

6.74*** [2.62,17.3]

Income (ref. low)

Rather low

1

1.38 [0.89,2.14]

1.10 [0.68,1.78]

1.19 [0.56,2.53]

Rather high

1

1.39 [0.75,2.58]

0.81 [0.42,1.57]

1.62 [0.61.4.27]

High

1

1.51 [0.80,2.84]

1.27 [0.64,2.53]

1.71 [0.64.4.59]

Employment status (ref. working for pay

Unemployed

1

1.20 [0.66,2.16]

0.84 [0.43,1.64]

1.37 [0.46,4.06]

Pupil, student, further training

1

2.11 [0.78,5.72]

1.59 [0.55,4.56]

4.58* [1.36,15.4]

In retirement

1

1.12 [0.67,1.86]

0.82 [0.46,1.47]

0.54 [0.22,1.31]

Permanently sick/disabled

1

1.25 [0.52,3.00]

1.78 [0.67,4.70]

Fulfilling domestic tasks

1

0.84 [0.38,1.87]

0.89 [0.39,2.01]

0.94 [0.29,3.12]

Other

1

1.03 [0.23,4.54]

2.47 [0.40.15.4]

3.62 [0.45,28.9]

N

1749

Note: Coefficients are relative risk ratios, 95% confidence intervals in parentheses, results ate adjusted for survey country. 5 no estrmates due to small numbers * p<0.05, ** p<0.01, *** pcd.OOl

The survey data presented in Table 7.1 also highlights how income or employment status did not generally shape bricolage behaviour (there are a variety of patterns present) but individuals with intermediate or higher education qualifications were more likely (had an increased probability) of adding to the system or engaging in alternative bricolage and completely bypassing the public healthcare system. For example, while only 23% of the residents with lower- level educational qualifications were engaged in added-to-system bricolage, the proportion was 40% for those with a higher-level qualification (see Table Al). Being a student also increased the likelihood of individuals only using alternative resources.

 
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