Negotiated Compliance at the Street Level: Personalizing Immunization in England, Israel and Sweden

"Personalization allows health practitioners to make new kinds of appeals to parents, in recognition that recourse to arguments about public duty and public health may be losing ground..."

Public noncompliance with childhood immunisation poses a significant challenge for government. The current literature tends to employ a "top-down" perspective on the formal instruments implemented by government in response to noncompliance. To explore what compliance efforts entail on the ground, this study focuses on "street-level bureaucrats", who are the first governmental tier to encounter public noncompliance. Specifically, the study explores how frontline nurses encounter and respond to parents' hesitance with childhood immunisation, and how they exercise their discretion in order to minimise noncompliance.

The article begins by reviewing the literature on public noncompliance, highlighting street-level compliance efforts as a neglected aspect of existing scholarship. It goes on to discuss childhood immunisation in the context of noncompliance and to set out the research design and methodology. Namely, the analysis compares 3 countries that have all experienced periodic spikes in noncompliance but that differ in the direct-delivery arrangements of vaccination provision. (In all 3 countries, a standardised protocol of childhood immunisation is implemented, in which vaccinations against measles, mumps, and rubella are predominantly given as a combined MMR vaccine. Yet, the countries differ in terms of the organisation of the healthcare and immunisation systems, the previous history of child vaccination (with Sweden starting its national programme earlier), and the level of trust of citizens in public institutions - a factor that is known to affect compliance.) Between 2012 and 2016, the researchers conducted 48 semi-structured interviews with frontline nurses and regional/national public health officials in England (N=15), Sweden (N=17), and Israel (N=16).

The analysis indicates that all informants, both nurses and officials in the 3 countries, mentioned encountering parents' concerns with immunisation, which mainly reflect general worries of potential harm or specific worries such as overloading a child's immune system at a preschool age. In response, nurses talked of exercising their discretion in an attempt to accommodate parental concerns and steer them away from noncompliance, which implies that immunisation is not merely a deployment of a standardised provision protocol. Rather, frontline nurses' compliance efforts emerged as getting engaged in a joint decision-making process with the parent, during which the necessity and safety of vaccination as well as non-vaccination consequences are discussed, possibilities are weighed, and current delivery arrangements are negotiated. This joint decision-making process is termed here "street-level negotiation".

In all 3 countries, street-level negotiation emerged as a similar 3-phase process:

1. A trigger that starts the negotiation as parents introduce doubts whether or not to comply with the immunisation protocol; parental concerns are almost always portrayed by interviewees as legitimate. Specifically, informants emphasised that the response to parental concerns should not be disregarding or critical. Rather, parents' point of view should be respected and listened to with an attentive ear, and the dialogue with them should focus on encouragement. Moreover, street-level implementation actions should avoid making parents feel like they have been forced to agree to their child having the vaccine against their will.
2. Reciprocal discussion, which entails an exchange of perceptions, attitudes, and professional information between parents and nurses. Nurses indicated that they tried to listen actively to the parents and emphasised that they made an effort to develop tailored communication practices and personal appeals. Often, the discussion started by giving facts and providing information; however, when they encountered persistent resistance, nurses often diverted parents' attention to the dangers of the diseases that were covered by the vaccine. This was seen to be important because people no longer have the fear of these diseases that older generations would have had.
3. A negotiated outcome, in which street-level discretion is exercised to adjust the rather strict delivery protocol to a more personalised immunisation provision (e.g., delaying the shots), which diverges from the rather strict delivery protocol. Parents were often portrayed as "equal" in making the decision of whether to immunise their child, either by referring to the role distribution between the parents and the professionals or by explicitly arguing that the parents are those who are responsible for their child. (Practising street-level negotiation to secure compliance may be a result of the unavailability of vaccine-related sanctions in all 3 countries.)

Three differences emerged between the countries, which are shaped by the institutional options available to nurses in their compliance efforts. For example, in Sweden, nurses spoke of the scope to develop a personal rapport over the long term, as parents and the nurse meet regularly in the child's first year in that country. In contrast, common across the English and Israeli data was the finding that nurses attempted to use the one-off interaction with parents as an opportunity to build a rapid rapport. This led some nurses, to, for instance, share their own family experience, which was presented as having a significant impact on parents and also demonstrates a non-paternalistic approach to parents.

The conclusion section of the article examines the advantages of a focus on street-level negotiation, where frontline workers experience noncompliance as an evolving decision-making process of discussing possibilities and weighing implications through face-to-face communication, rather than the typical top-down approach to public noncompliance. One benefit is that street-level negotiation highlights the need to provide frontline workers with the communication skills and resources to enhance citizens' compliance during direct-delivery interactions.