Medical and dental student knowledge about COVID-19 and influenza vaccines impact opinions about vaccine advocacy and future practice.

Introduction: The World Health Organization has identified vaccine hesitancy as a global public health challenge. Healthcare providers are among the most influential and trusted figures for vaccine counseling. This article focuses on COVID-19 and influenza personal immunization behaviors, vaccine knowledge and opinions, and vaccine counseling confidence among future healthcare providers - dental and medical students. Methods: A cross-sectional anonymous online survey was conducted at four dental schools and one allopathic medical school in the United States. Items included personal vaccination status for the COVID-19 and influenza vaccines and vaccine-specific items developed based on past research to assess knowledge, opinions, and behaviors. Results: Two hundred and thirty-two medical and 221 dental students completed the survey. 68 and 55% scored average/above-average knowledge on COVID-19 and influenza vaccine items, respectively. There were significant differences between those with average/above-average and below-average knowledge scores regarding learning about, recommending, and advocating for vaccines and counseling vaccine-hesitant patients for both vaccines (p < 0.0001). Although higher-knowledge students had higher vaccination rates (p < 0.0001), many had insufficient knowledge about vaccines. Discussion: Healthcare providers play a crucial role in vaccine advocacy. The identified knowledge gaps are significant as they impact quality of patient care. And opinions about future vaccination practice such as recommending, providing, and counseling about vaccines. Equipping students with knowledge and communication skills will enable them to be strong vaccine advocates to improve overall public health.

Beyond COVID-19: the impact of recent pandemics on medical students and their education: a scoping review.

INTRODUCTION: Over the past two years, coronavirus disease (COVID-19) has greatly altered medical student education as well as daily life. Medical schools across the world were disrupted and had to immediately adapt the educational experience to the online environment in order to continue the delivery of quality medical education. However, COVID-19 was not the only recent pandemic. This posed the question, were similar disruptions and adaptations also seen in recent past pandemics such as Severe Acute Respiratory Syndrome (SARS) or Middle East Respiratory Syndrome (MERS) that could have prepared medical educators for COVID-19? This scoping review investigated the educational and personal impact of recent pandemics on medical students. METHODS: This review followed the PRISMA-ScR guidelines for scoping reviews. Nine databases including PubMed, ERIC, and EMBASE were systematically searched using keywords and subject headings related to medical students and SARS, H1N1, MERS, Ebola, Zika, and COVID-19. Studies were limited to research studies published between 2000 and 2020 and in English. Based on exclusion and inclusion criteria, all studies were independently screened by two reviewers first by the title/abstract and then via full text. Data were extracted from the included studies and analyzed qualitatively using thematic analysis. RESULTS: A total of 174 studies fit the criteria. Seven major themes emerged from those studies: educational adaptations and online modifications, knowledge and attitudes of students, mental wellness of students, student involvement and use of telehealth, student vaccination, physical wellness of students, and stigma. CONCLUSION: This review provided insights into how medical students were affected by recent pandemics and their perceptions of pivoting to online education, mental health, and knowledge of the diseases. Additionally, this review showcases the various educational adaptations that emerged uniquely during the COVID-19 pandemic, such as telehealth services or video conferencing tools, that can be utilized in a post-pandemic environment.

COVID-19 Vaccination Concerns and Reasons for Acceptance Among US Health Care Personnel.

OBJECTIVES: Because health care personnel (HCP) are potentially at increased risk of contracting COVID-19, high vaccination rates in this population are essential. The objective of this study was to assess vaccination status, barriers to vaccination, reasons for vaccine acceptance, and concerns about COVID-19 vaccination among HCP. METHODS: We conducted an anonymous online survey at a large US health care system from April 9 through May 4, 2021, to assess COVID-19 vaccination status and endorsement of reasons for acceptance and concerns related to vaccination (based on selections from a provided list). RESULTS: A total of 4603 HCP (12.2% response rate) completed the survey, 3947 (85.7%) had received at least 1 dose of a COVID-19 vaccine at the time of the survey, and 550 (11.9%) reported no plans to receive the vaccine. Unvaccinated HCP were 30 times more likely than vaccinated HCP to endorse religious or personal beliefs as a vaccine concern (odds ratio = 30.95; 95% CI, 21.06-45.48) and 15 times more likely to believe that personal vaccination is not needed if enough others are vaccinated (odds ratio = 14.99; 95% CI, 10.84-20.72). The more reasons endorsed for vaccination (ß = 0.60; P < .001), the higher the likelihood of having received the vaccine. However, the number of concerns about COVID-19 vaccine was not related to vaccination status (ß = 1.01; P = .64). CONCLUSIONS: Our findings suggest that reasons for vaccination acceptance and concerns about vaccination need to be considered to better understand behavioral choices related to COVID-19 vaccination among HCP, because these beliefs may affect vaccination advocacy, responses to vaccine mandates, and promotion of COVID-19 vaccine boosters.

A health education outreach partnership between an academic medical library and public library: lessons learned before and during a pandemic.

Background: Public libraries serve as community centers for accessing free, trustworthy health information. As such, they provide an ideal setting to teach the local community about health and health literacy, particularly during public health crises like the COVID-19 pandemic. Since 2018, an outreach partnership between an academic medical library and public library has developed, delivered, and continuously evaluated a health education program targeting public library users. Case Presentation: Health education activities were integrated into three existing public library programs: adult workshops, child and family programming, and circulating family activity kits. Prior to COVID-19, events were held at the public library, which then pivoted online during the pandemic. An interprofessional team approach combined the expertise of academic medical and public librarians, medical school faculty and staff, and medical students in developing the educational programs. Twelve in-person and five virtual programs were offered, and five circulating health education family kits were launched. Activities were assessed using program evaluation surveys of the adult and children's programs and circulation statistics of the kits. Conclusions: This case report showcases the lessons learned from implementing a longitudinal outreach partnership between an academic medical library and public library before and during the COVID-19 pandemic. The interprofessional team approach and flexibility in program design and delivery in both the in-person and virtual environments proved critical to the success of the partnership. This partnership could serve as a model for other libraries interested in pursuing interprofessional collaborations in educating local communities on healthy behavior and health information-seeking practices.

COVID-19 Vaccine Hesitancy Among Healthcare Personnel Who Generally Accept Vaccines.

To identify psychological antecedents of COVID-19 vaccine hesitancy among healthcare personnel (HCP). We surveyed 4603 HCP to assess psychological antecedents of their vaccination decisions (the '5 Cs') for vaccines in general and for COVID-19 vaccines. Most HCP accept vaccines, but many expressed hesitancy about COVID-19 vaccines for the psychological antecedents of vaccination: confidence (vaccines are effective), complacency (vaccines are unnecessary), constraints (difficult to access), calculation (risks/benefits), collective responsibility (need for vaccination when others vaccinate). HCP who were hesitant only about COVID-19 vaccines differed from HCP who were consistently hesitant: those with lower confidence were more likely to be younger and women, higher constraints were more likely to have clinical positions, higher complacency were more likely to have recently cared for COVID-19 patients, and lesser collective responsibility were more likely to be non-white. These results can inform interventions to encourage uptake of COVID-19 vaccines in HCP.

Evaluating Effectiveness of Faculty and Near-Peer Delivered Teaching and Communication Skills Training.

Medical students who are given opportunities to teach and communicate complex information in an understandable manner will be more effective in educating patients in the future. We provided faculty and near-peer training to medical student facilitators of a community outreach program for middle school students to assess which type of training resulted in better teaching preparedness and confidence. Near-peer-trained students were more confident in their teaching compared to faculty trained counterparts; therefore, there may be some added benefit to peer-delivered/faculty-supervised training for community outreach programs.

COVID-19 vaccine acceptance and hesitancy among dental and medical students.

BACKGROUND: Dental students (DS) and medical students (MS) are exposed to COVID-19. It is important to achieve high COVID-19 vaccination coverage rates in both of these groups. The authors developed a survey to assess COVID-19 vaccine hesitancy among MS and DS. METHODS: The authors conducted the study at 3 US dental schools and 1 US medical school using an online survey that assessed previous immunization behavior, attitudes about and perceptions of COVID-19 vaccines, and personal experience with COVID-19. RESULTS: A total of 248 DS and 167 MS completed the survey. Forty-five percent of DS and 23% of MS were hesitant about receiving the COVID-19 vaccine. Results of bivariate analyses found that MS were 2.7 times more likely than DS to receive the vaccine (odds ratio, 2.74; 95% CI, 1.76 to 4.31; P = .0001). Although DS were more likely than MS (P < .05) to have had COVID-19 and to personally know someone who had COVID-19, MS were more likely to agree with mandates and trust information about the vaccines. In multivariable analyses, after controlling for demographic variables, experience with COVID-19, and personal vaccination behaviors, being a MS or DS was no longer predictive of willingness to get the vaccine. CONCLUSIONS: These results highlight the need for profession-specific curricula designed to enhance student knowledge about the vaccines and vaccine counseling skills. PRACTICAL IMPLICATIONS: The American Dental Association supports dentists administering vaccines, including the COVID-19 vaccines. Dentists and DS should be willing to receive the vaccines themselves. Education about the vaccines is needed to improve uptake.

Dental students' attitudes and hesitancy toward COVID-19 vaccine.

BACKGROUND: Dentists are a group of providers who have been identified by CDC at high risk of exposure to COVID-19 through their contact with patients. This would apply to dental students as well. Thus, it is important to achieve high COVID-19 vaccination rates in this group. Further, as healthcare providers, they are entrusted with providing health recommendations and advocating for their patients, community, and profession, including vaccinations. METHODS: Using ualtricsXM an online platform, in 2020, a survey was administered anonymously to dental students at three dental schools to assess the attitudes of dental students to the novel COVID-19 vaccine. Factors and reasons associated with vaccine hesitancy and acceptance toward the COVID-19 vaccine and likelihood of recommending and giving the vaccination to patients were assessed. RESULTS: Nearly, all participants had positive attitudes toward vaccines in general, agreed they would likely be exposed to COVID-19, and personally knew someone who had COVID-19; however, only 56% are willing to take a COVID-19 vaccine as soon as an FDA-approved vaccine was available. Of those unwilling to take the vaccine, 63% reported they would take it if mandated by the health systems/dental school; however, 16.3% of the overall respondents would not take the COVID-19 vaccine even if mandated. Several factors are associated with vaccine acceptance and the likelihood of recommending the vaccination, such as trusting public health experts, concerns about side effects, and agreeing with vaccine mandates. CONCLUSION: Our results highlight the need for an educational curriculum about the safety and effectiveness to promote the uptake of COVID-19 vaccine.

COVID-19 vaccine hesitancy among medical students.

BACKGROUND: Medical students are among the group of frontline healthcare providers likely to be exposed to COVID-19 patients. It is important to achieve high COVID-19 vaccination coverage rates in this group as soon as a vaccine is available. As future healthcare providers, they will be entrusted with providing vaccine recommendations and counseling vaccine-hesitant patients. METHODS: This project used self-report to assess vaccine hesitancy and acceptance among medical students towards the novel COVID-19 vaccine. RESULTS: Nearly all participants had positive attitudes towards vaccines and agreed they would likely be exposed to COVID-19; however, only 53% indicated they would participate in a COVID-19 vaccine trial and 23% were unwilling to take a COVID-19 vaccine immediately upon FDA approval. Students willing to immediately take the vaccine were more likely to trust public health experts, have fewer concerns about side effects and agree with vaccine mandates (P < 0.05). Concern for serious side effects was independently predictive of lower odds of intent to participate in a COVID-19 vaccine trial (AOR = 0.41, P = 0.01). CONCLUSION: This is the first study to evaluate COVID-19 vaccine hesitancy among US medical students and highlights the need for an educational curriculum about the safety and effectiveness to promote uptake of the COVID-19 vaccine.

Will they lead by example? Assessment of vaccination rates and attitudes to human papilloma virus in millennial medical students.

BACKGROUND: Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. It is also well established that HPV viruses are responsible for a variety of cancers. Little is known about the prevailing knowledge and attitudes toward the HPV vaccine in our future healthcare providers, a majority of whom were among the first in the target age group to receive the vaccine; the same vaccine that they will in turn be expected to recommend to their patients. The aims of this pilot study were to examine the HPV vaccination rate among medical students and determine their knowledge about HPV and attitudes toward vaccination. METHODS: To aid in the development of an HPV educational intervention, a needs assessment survey was administered to discover medical students' knowledge and attitudes toward the HPV vaccine. All medical students at a Midwestern US medical school were invited to complete the survey. RESULTS: Two hundred fourteen of 390 medical students completed the survey with 44% having been previously vaccinated. Although 82% of all respondents believed they would recommend the vaccine to family and friends, only 40% felt knowledgeable about the vaccine and 40% felt comfortable counseling patients. More positive attitudes and better knowledge scores were found in fully vaccinated students compared to non-vaccinated students. Provider recommendation was strongly associated with HPV vaccination status. CONCLUSIONS: This study revealed the unique perspectives of U.S. millennial medical students as the first group of future healthcare providers to have personally encountered the HPV vaccine. Overall, students' knowledge as well as their comfort level in counseling patients was lacking. This assessment has guided the development of targeted educational interventions to address knowledge gaps and prepare students to appropriately discuss the vaccine with patients and parents and help protect young people from life threatening cancers.

An Assessment of Needs of Church Coordinators Providing Meals to a Homeless Shelter.

Charitable meal services are crucial in sustaining the homeless, but few use nutritional professionals to create a balanced diet or make adjustments for those with specific dietary needs. A needs assessment was conducted among church coordinators responsible for providing meals to clients at a multi-service shelter in Detroit, Michigan. A survey and focus group were used to assess the processes involved in planning, preparing, and providing meals, which provided critical information and insight concerning nutrition and factors influencing meal-planning. According to the survey, a majority of faith organizations responding tried to meet food group requirements every meal. A predominant theme from the focus group was the desire to satisfy clients resulting in a variety and abundance of food enabling poor choices. The provision of healthy options was constrained by efforts to ease meal preparation, desire to provide comfort foods, and having difficulties accommodating diets related to health problems.

Physician as teacher: promoting health and wellness among elementary school students.

BACKGROUND: Every day, physicians engage in teaching during their patient encounters. It may be that medical students who are introduced to the principles of teaching and learning are more likely to become good communicators and learners. Service-learning may be an effective way for medical students to practice skills in teaching and communication in a real-world setting, while also filling a need within the community. The purpose of this study was to identify common themes within medical students' reflections on what they learned through participating in a teaching exercise with local elementary school children. METHODS: As a required component of a longitudinal prevention and public health course that spans the first and second years of undergraduate medical education, second year students at the Oakland University William Beaumont School of Medicine, in Detroit, Michigan, in the USA completed a service-learning activity, which included teaching a standardized curricular module to local elementary school children. Students were required to complete a reflection assignment based on their teaching experience. Medical students' responses to assignment's three guided questions were qualitatively coded to identify common themes among the responses related to the teaching activity. RESULTS: Qualitative analysis of students' reflections revealed several themes regarding what the students learned and viewed as the benefits of the activity: The importance of early education and parental involvement; the importance of understanding your audience when teaching; the importance of simplifying complex concepts to the audience's level; and the importance of preparation for teaching. Medical students identified the difficulties of communicating at an audience appropriate level and providing patient education outside the confines of a controlled classroom setting. DISCUSSION: This activity provided medical students with hands-on experience presenting to an audience age-appropriate, health-related topics. Presenting in an elementary school environment helped students better understand what health information various age groups knew about and the importance of clarifying information when communicating with a younger audience.

Comparison of lymphedema in patients with axillary lymph node dissections to those with sentinel lymph node biopsy followed by immediate and delayed ALND.

PURPOSE: The purpose of the study was to show that delayed axillary lymph node dissection (ALND) has higher rates of lymphedema compared with immediate ALND, using data from NSABP-B32 at Beaumont Hospital. METHOD: NSABP B-32 at Beaumont had 207 patients with follow-up data on 199 patients, randomizing clinically negative axilla to sentinel lymph node biopsy (SLNB)+ALND (GrA N=98), and SLNB+cytology±ALND (GrB N=101). All patients had preoperative volumetric arm measurements and only node negatives had routine postoperative measurements assessing lymphedema for 36 months. We contacted node-positive patients for postoperative measurements for this study. Twenty-four and 15 cytology-positive patients had SLNB+ALND in GrA and GrB, respectively (SubGrA1 N=24; SubGrB1 N=15). Fourteen hematoxylin and eosin-positive patients had delayed ALND (SubGrB2a N=14). RESULTS: Lymphedema rate for node-positive SLNB+ALND was 10.3% [SubGrA1 (3/24)+SubGrB1 (1/15)=4/39] and node-negative SLNB+ALND was 6.8% (SubGrA2=5/74). Lymphedema was 14.3% for delayed ALND in SubGrB2a (2 of 14) and 0% for 72 SLNBs in SubGrB2b. Our study comparing immediate and delayed ALND lymphedema was not statistically significant (10.3% vs. 14.3%, P=0.65). Comparing node-negative ALND (SubGrA2= 5/74=6.8%) to node-positive ALND (A1+B1+B2a=6/53=11.3%) was not statistically significant (P=0.52). Comparing lymphedema for node-negative ALND (SubGrA2) to SLNB (SubGrB2b) only approached significance (6.8% vs. 0%, P=0.058). CONCLUSIONS: The rate of lymphedema was higher in delayed ALND but not statistically significant. Comparison, however, is difficult, given the limited sample size. We urge the other centers of NSABP-B32 to validate this, by contacting the node-positive patients for measurements. The lymphedema rate for SLNB alone was 0% and approached statistical significance when compared with node-negative ALND.

Sex differences in the pathway from low birth weight to inattention/hyperactivity.

Inattention/hyperactivity is a childhood outcome of low birth weight. However, the mechanisms by which low birth weight leads to inattention/hyperactivity are unclear. This study examined arousal, activation, motor speed, and motor coordination as possible mechanisms, attending to sex differences. 823 children (400 males) from Detroit and surrounding suburbs were assessed with the Child Behavior Checklist and the Teacher Report Form and completed experimental tasks to assess vigilance and activation (Continuous Performance Test signal detection parameters) and motor output speed and control (Grooved Pegboard) at 6 years of age. The relationship between birth weight and inattention/hyperactivity was slightly, but not significantly, stronger for boys than for girls. Arousal, motor speed, and motor coordination significantly partially mediated the relationship between birth weight and inattention/hyperactivity for boys and girls. Moderated mediation was found for the pathway between motor coordination and inattention/hyperactivity such that this relationship was stronger for boys than for girls. Sex differences in the associated features of attention symptoms may reflect partially distinct etiological pathways.

Intelligence and other predisposing factors in exposure to trauma and posttraumatic stress disorder: a follow-up study at age 17 years.

CONTEXT: Prospective data on standardized measures of early predispositions would allow a strong test of hypotheses about suspected risk factors of posttraumatic stress disorder (PTSD) and exposure to traumatic events. OBJECTIVE: To prospectively examine the extent to which intelligence, anxiety disorders, and conduct problems in childhood influence the risk for PTSD and for exposure to traumatic events. DESIGN: A longitudinal study of a randomly selected sample assessed at age 6 years and followed up to age 17 years. SETTING: Samples were randomly selected from the 1983-1985 newborn discharge lists of 2 major hospitals in southeast Michigan (N=823). PARTICIPANTS: Cohort members with follow-up data at age 17 years (n=713; 86.6% of the initial sample). MAIN OUTCOME MEASURES: Cumulative exposure up to age 17 years of qualifying traumatic events; DSM-IV PTSD among participants who have experienced 1 or more traumatic events. RESULTS: Youth with teacher ratings of externalizing problems above the normal range at age 6 years were at increased risk for exposure to assaultive violence (adjusted odds ratio, 2.6; 95% confidence interval, 1.4-4.9). Youth aged 6 years with an IQ greater than 115 had decreased risk for exposure to traumatic events (adjusted odds ratio for assaultive violence, 0.3; 95% confidence interval, 0.2-0.7); a decreased risk for nonassaultive trauma (adjusted odds ratio, 0.6; 95% confidence interval, 0.3-0.9); and a decreased conditional risk for PTSD (adjusted odds ratio, 0.2; 95% confidence interval, 0.1-0.9). The conditional risk for PTSD was increased for youth with anxiety disorders and teacher ratings of externalizing problems above the normal range at 6 years of age. CONCLUSIONS: The results of this prospective community study highlight the role of intelligence in avoidance of exposure to traumatic experiences and their PTSD effects. They underscore the need for investigating cognitive processes in persons' responses to traumatic experiences and the involvement of general intelligence in these processes.

Reports of birthweight by adolescents and their mothers: comparing accuracy and identifying correlates.

Birthweight is associated with health outcomes throughout the lifespan. Official birthweight records are not always available, and researchers must rely on self-reports for birthweight information. This study evaluates the accuracy of adolescent self-reports of birthweight, using medical records as a standard, and compares it with maternal reports. It also examines potential correlates of accuracy. Respondents are 17-year-old adolescents and their mothers, who participated in a follow-up study of randomly selected samples from newborn discharge lists (1983-85) of two major hospitals in south-east Michigan. Nearly one-quarter of the adolescents stated that they did not know their own birthweight, with males twice as likely as females to respond 'don't know'. In addition, self-reports of birthweight among the remaining adolescents were inaccurate, and accuracy was inversely related to birthweight. While maternal reports of offspring's birthweight are highly accurate across diverse subgroups of the population, adolescent self-reports of birthweight are unlikely to be useful in medical research.

Family cohesion and children's behavior problems: a longitudinal investigation.

We examine the association of family cohesion and conflict with childhood behavior problems. A stratified random sample of 823 children was evaluated at ages 6 and 11 years. Mothers rated the family environment at age 6 using the Family Environment Scale. Mothers and teachers rated children's behavior problems at ages 6 and 11, using the Child Behavior Checklist and the Teacher Report Form, respectively. Multiple regression analysis, applying generalized estimating equations, was used. Although results varied between mothers' and teachers' data, they converged in identifying family cohesion as a factor in children's mental health. Family cohesion, as rated by mothers, had a beneficial effect on children's internalizing and attention problems, as rated by both mothers and teachers, that was stable over time. The study highlights an important relationship between family cohesion and children's internalizing and attention problems.

Maternal smoking during pregnancy and offspring IQ.

BACKGROUND: Maternal smoking in pregnancy lowers birthweight. It is unclear, however, whether smoking during pregnancy lowers offspring IQ, and, if it does, whether it is through the smoking effect on fetal growth. METHOD: Representative samples of low birthweight (<2500 g) and normal birthweight children born in 1983-85 from inner-city and suburban communities in southeast Michigan, USA were assessed at ages 6, 11, and 17, using Wechsler intelligence tests. Smoking during pregnancy was ascertained from mothers at the first assessment; and smoking at any time was ascertained at the first and second assessment. Generalized estimating equation models were used, with children's IQ at all three assessments as outcomes (n = 798). RESULTS: Without adjustment, offspring of mothers who smoked during pregnancy scored 6.8 IQ points lower than offspring of mothers who never smoked, on average. Low birthweight children scored 5.4 IQ points lower than normal birthweight children, on average. The statistical association of maternal smoking with offspring IQ was confounded by maternal characteristics, chiefly, maternal cognitive ability as measured by IQ and education; adjustment for these factors eliminated the association. By contrast, adjustment for maternal IQ and education as well as smoking during pregnancy had a negligible effect on the low birthweight-related IQ deficit. Low birthweight did not mediate the association of smoking and lowered IQ in offspring. CONCLUSION: Maternal smoking during pregnancy is a proxy for a matrix of vulnerabilities for adverse child cognitive development and has no direct causal effect on child's IQ. The relationship of low birthweight and IQ is independent of maternal smoking and maternal cognitive abilities.

Trauma exposure and posttraumatic stress disorder: a study of youths in urban America.

We estimate the cumulative occurrence of traumatic events and posttraumatic stress disorder (PTSD), using Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria, in a high-risk sample of young people in urban United States. The epidemiological sample (n = 2,311) was recruited in 1985-1986 at entry into first grade of a public school system of a large mid-Atlantic city. Participants were interviewed about history of trauma and PTSD in 2000-2002 when their mean age was 21 years (n = 1,698). We found that the lifetime occurrence of assaultive violence was 62.6% in males and 33.7% in females. The risk of assaultive violence in males (but not females) varied by childhood area of residence within the city; the occurrence of other traumas did not vary by area of childhood residence. Females had a higher risk of PTSD than males following assaultive violence (odds ratio = 4.0, 95% confidence interval 2.0-8.3), but not following other traumas. A comparison of the results from this largely inner-city sample with the results from a recent study of a largely suburban sample in another region of the United States in which the same criteria and measures of trauma and PTSD were used suggested the possibility that males' risk for assaultive violence and females' risk for PTSD following exposure to assaultive violence might vary by characteristics of the social environment.