By Dea Ellen Epley Birtwistle, LISW, SSWS
The Rationale: Why Now?
Why would a recently retired social worker who practiced school social work in Iowa for 38 years, including during the pandemic, write an article about COVID-19 vaccine confidence given that the public health emergency ended in May 2023? I was selected as an NASW Connect to End COVID-19 Ambassador in order to enhance confidence and information about the COVID-19 vaccinations. Being a caretaker for my 97-year-old father who contracted COVID-19 three times from health facilities in the past three years sparks my passion for prevention. In addition, my spouse was diagnosed with T-Cell Non-Hodgkin’s lymphoma during the COVID-19 Pandemic resulting in him receiving chemotherapy, an unexpected pulmonary embolism, and a stem-cell transplant. The transplant wiped out his immune system necessitating him to repeat all his childhood and adult vaccines over the course of two years. My husband’s yet incomplete road to recovery adds to my sense of urgency to promote vaccine uptake. Although the COVID-19 public health emergency ended on May 11, millions of unvaccinated Americans are still at risk of severe illness and death. As school social workers, we have an opportunity to play a role in promoting accurate information about the safety and effectiveness of the vaccines, and in supporting informed decision making by individuals and families.
While my husband recovered from his transplant, I continued to provide social work services to young children in four rural districts in Iowa, a population at that time which was entirely without vaccine options because vaccines had not yet been approved for preschoolers. Even with current vaccines available for young children, many obstacles persist to parents getting vaccines for themselves and their family members. Under 70% of the population in the United States are fully vaccinated, and of this, fewer than 18% of those who are fully vaccinated have received the updated booster that was approved in September 2022. In Iowa, as of April 2023, only 60% of the population are fully vaccinated, which is below the national average. Twenty per cent of those who have been fully vaccinated have received the booster. (COVID Data Tracker, 2023) Young people with children, pregnant people and families in rural areas often face barriers to vaccination including access to transportation, sufficient medical providers and misinformation about vaccines and pregnancy. Misinformation conveyed to parents including parents who are teachers, paraprofessionals and school support staff heightens the urgency for school social workers to advocate for more understanding about the safety and efficacy profile of COVID-19 vaccines. Currently, no evidence exists that the COVID-19 vaccines cause fertility problems in women or men. In fact, people who are pregnant are at great risk of severe illness, hospitalization and death from COVID-19. (Prevention, Centers for Disease Control and, 2022a) A rigorous scientific process, clinical outcomes and outcome data for millions of people demonstrates that the COVID-19 vaccines are safe, effective and efficacious for people aged six months and over.
The Connect to End COVID-19 Initiative
The Connect to End COVID-19 initiative is being undertaken by the National Association of Social Workers (NASW) and the University of Texas at Austin Steve Hicks School of Social Work. It is funded by the Centers for Disease Control and Prevention.
The initiative launched in the Fall of 2021 and has included NASW chapter-hosted trainings in numerous states on how to deploy motivation interviewing (MI) and Screening, Brief Intervention and Referral for Treatment (S-BIRT) modalities in supporting clients in vaccine decision making. Objectives of the initiative include providing information about vaccine uptake, boosting vaccine confidence and helping clients to make informed decisions about becoming vaccinated. The role of social workers is not to tell clients to become vaccinated, but to meet them wherever they are and provide an opportunity to process this health decision, armed with accurate information. The decision is ultimately up to the client, consistent with the social work value of self-determination. (NASW, n.d.)
COVID and Vaccination Information
A sense of complacency resulting from the fatigue of dealing with this epidemic has enveloped professionals, families and communities. As the country transitions, however, from an emergency state, people are still getting severely ill and dying from COVID-19 despite the availability of safe and effective vaccines. Up to 30% of people who have had COVID-19 are developing Long COVID. During January 2023 over 2,000 people nationwide died from COVID-19. (Prevention, Centers for Disease Control and, 2023) For the school age population, 0-17 years, 1,583 children have died from COVID-19 in the past three years from 2020 through April 12, 2023. (Centers for Disease Control and Prevention and National Center for Health Statistics, 2023)
School social workers conduct their practice with groups that include vulnerable, marginalized and special populations, some of whom may be vaccine hesitant. In Iowa for school social workers, this primarily includes students with disabilities. Other special populations highlighted by the initiative due to the barriers they face to COVID-19 vaccination include people experiencing homelessness, incarcerated or detained individuals, and immigrants as well as minority populations who may distrust the medical system. Also, in high-risk groups are LGBTQ youth, people with certain pre-existing conditions, including mental health conditions. COVID-19 infection even when mild can exacerbate mental health conditions.
Studies on risk factors suggest that people from certain racial and ethnic groups are dying from COVID-19 at younger ages and are younger when they develop chronic health concerns or possibly develop more than one condition. The CDC adds, “Race and ethnicity are risk markers for other underlying conditions that affect health, including socioeconomic status, access to health care, and exposure to the virus related to occupation, e.g., frontline, essential, and critical infrastructure workers” (2023c,para,1). Consequently, they are more likely to develop health conditions that predispose them to severe illness from COVID-19.
School social workers are trusted messengers who conduct their practice at the intersections of the school, the home, and the community and are committed to the well-being of all people. Most school social workers interact with some of the individuals from the above-name special populations during the school year. School social work may dovetail with special populations indirectly through consultation with other professionals about students’ interventions. As a group, school social workers may underestimate the impact of their consultation with school administrators, school nurses, teachers, school counselors, paraprofessionals, and support staff including but not limited to speech and language pathologists and occupational therapists, and educational consultants and early childhood providers. Social workers, also, have an ethical responsibility to protect themselves, the students and families with whom they work and their colleagues and loved ones.
Disability Groups and Risks
The Centers for Disease Control and Prevention (CDC) reports, “People with disabilities are more likely than those without disabilities to have chronic health conditions, live in shared group (also call ‘congregate’) settings, and face more barriers in accessing health care” (Centers for Disease Control and Prevention and National Center for Immunization and Respiratory Diseases (NCIRD), 2023b,para 2). The CDC adds that people with certain disabilities are more likely to get COVID-19 and have worse outcomes. Persons with disabilities as a group have increased risks while conducting their daily routines.
Students with limited mobility cannot consistently avoid meeting with others who may be infected such as members of their family or their service providers.
Students with disabilities may also have trouble with understanding information about social distancing or directions for sanitation procedures such as handwashing.
Students with disabilities may not be able to communicate symptoms of illness. (Prevention, Centers for Disease Control and National Center on Birth Defects and Developmental Disabilities, 2022)
How can school social workers protect themselves and the people they work with in the community when a high or moderate COVID-19 transmission rate is present?
Check with your employer for any specific policy and procedures and use everyday prevention measures.
Keep at least six feet of distance between yourself and others in the home or community setting.
Wear a mask in confined and crowded settings.
Encourage others, if possible, to wear a mask. Increased risk of virus spread occurs when ventilation is poor. Wearing a mask may be difficult for children with sensory, behavior, and cognitive issues. Masks are not recommended for children under two or those who struggle to breath or who cannot remove a mask without assistance.
Clean and disinfect frequently touched objects, surfaces and equipment.
Help team members to update care plans or an emergency notebook. This information helps the student, family, or support worker who provide consistent care if the usual school providers are not available. All direct providers need a copy including the student if appropriate.
Help families and the school discuss at least two forms of communication with each other if there is an emergency (e.g., landline, cell phone, text messages, email. (National Center on Birth Defects and Developmental Disabilities and Centers for Disease and Prevention, 2021)
How Do School Social Workers Talk with Families about COVID-19 Vaccination?
School social workers are trusted and are valued as change agents in their community. Although they are not medical providers, they can be a source to provide accurate information including referrals to health and mental health professionals.
Motivational interviewing (MI) is an evidence-based modality that can be deployed in talking with clients about COVID-19 vaccinations. Motivational interviewing honors the social work value of self-determination. The goal is to help people manage ambivalent feelings and move to behavioral change that is consistent with their values and needs. The conversation can occur in one to five minutes with students or their families and involves four steps.
Embrace an attitude of empathy and collaboration. Be curious about why the student or family feels the way they do and be sensitive to culture, family dynamics, and circumstances that influences how they perceive vaccines. Taking a strong stance or debating can erode trust.
Ask permission to discuss vaccines. Say something like, “If it is okay with you, I would like to spend a few minutes discussing vaccines.” If the student or family member says no, respect that. For example, comment, “I respect that and because I care about your health, maybe we can talk about the vaccines at a future time.” These conversations may take time and multiple meetings.
Conduct MI. Ask a scaled question: "On a scale of 1-10, how likely are you to get a COVID-19 vaccine?" If someone responds with a four, ask, “Okay, why not a lower number?” Possibly, ask the following question, “How could you move to a six?” Encourage them to talk aloud as this assists them to process choices. Ask them to express benefits aloud. Listen to their mixed feelings and use reflective listening. It is important to support their values.
Respond to questions about vaccines or mental health. Consider your qualifications, scope of practice, and agency procedures. If you feel qualified, respond to questions with empathy and scientific information. If the question is out of your expertise, refer the student or family member. Recommend they speak with a medical and/or mental health provided. (Skillings et al., 2021)
School social workers use both art and science daily to support students. School social workers have strengths in the skills of navigating multiple, complex systems and in knowing resources. The additional resources and information CDC provides as well as the techniques of MI can be added to the toolbox to challenge COVID-19 fatigue and to enhance safety for children, families and educators. The Connect To End COVID-19 NASW website also shares fact sheets, videos, and complimentary webinars for addressing the barriers to vaccine uptake.
School social workers collaborate with many social workers in a variety of positions throughout the school year and can join the initiative and encourage others to join as well. The Connect to End COVID-19 initiative is intended to support all social workers regardless of what population they serve and what challenges they are encountering to help clients make sound decision making around vaccines.
Centers for Disease Control and Prevention and National Center for Immunization and Respiratory Diseases. (2021, November 3). How to address COVID-19 misinformation. https://www.cdc.gov/vaccines/covid-19/health-departments/addressing-vaccine-misinformation.html
National Association of Social Workers. (n.d.). Connect to end COVID-19. https://bit.ly/3kkJTAa
Centers for Disease Control and Prevention. (2023, January). National forecast incidents.https://www.cdc.gov/coronavirus/2019-ncov/images/science/forecasting/deaths/2023january/National-Forecast-Incident-Cumulative-Deaths-2023-01-02.jpg
Centers for Disease Control and Prevention. (2023, April 15). COVID data tracker. https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-fully-percent-total
Centers for Disease Control and Prevention and National Center on Birth Defects and Developmental Disabilities. (2022, July 20). People with disabilities. https://www.cdc.gov/ncbddd/humandevelopment/covid-19/people-with-disabilities.html
Centers for Disease Control and Prevention and National Center for Health Statistics. (2023, April 12). Provisional death counts for coronavirus disease 2019 (COVID-19). https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm
Centers for Disease Control and Prevention and National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. (2022, July 14a). What you need to know about COVID-19 vaccine and fertility. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/planning-for-pregnancy.html
Centers for Disease Control and Prevention and National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. (2023, February 10b). People with certain medical conditions: Overview. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html
Centers for Disease Control and Prevention and National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. (2023, April 7c). Risk for COVID-19 infection, hospitalization, and death by race/ethnicity. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
National Association of Social Workers, (n.d.). COVID-19 vaccine confidence. https://www.socialworkers.org/Practice/Infectious-Diseases/COVID-19-Vaccine-Confidencehttps://www.socialworkers.org/Practice/Infectious-Diseases/COVID-19-Vaccine-Confidence
National Center on Birth Defects and Developmental Disabilities and Centers for Disease Control and Prevention. (2021, September 13). Guidance for direct service providers. https://www.cdc.gov/ncbddd/humandevelopment/covid-19/guidance-for-direct-service-providers.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fneed-extra-precautions%2Fdirect-service-providers.html
Skillings, J., PhD, ABPP; Swedish, E., PhD; McLeod, R., PhD; Prinstein, M., PhD, ABPP; and Gillaspy, S., PhD and Centers for Disease Control and Prevention and National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases and the American Psychological Association. (2021, Nov. 3). Talking with patients about COVID-19 vaccination. https://www.cdc.gov/vaccines/covid-19/hcp/engaging-patients.html
Dea Ellen Epley Birtwistle is a member of the Iowa School Social Worker’s Association and a 2004 recipient of the Iowa School Social Worker of the Year Award and the Midwest School Social Worker of the Year Award. She is also a member of the National Association of Social Workers School Specialty Practice Section (SPS) and a member of the School Social Work Association of America (SSWAA).