Educators' Perspectives of the Feasibility, Acceptability, and Appropriateness of the Buddy Program for Secondary School Students Post‐Concussion

ABSTRACT

Background

Students want support from their peers to help them at school while they recover from concussion. Educators are responsible for implementing school‐based programs, including peer support. We explored educators' perspectives of implementing a novel peer support program “Buddy Program” for students post‐concussion.

Methods

We conducted a mixed‐methods feasibility case study to explore the feasibility, acceptability, and appropriateness of the Buddy Program.

Results

Thirty‐two educators at two independent secondary schools completed the survey and seven educators participated in a follow‐up interview. The Buddy Program was perceived to be feasible, appropriate, and acceptable to implement at school. Educators shared that access to social support and opportunities for student leadership, school culture and readiness, and considerations for adopting the Buddy Program affected program implementation.

Implications for School Health Policy, Practice, and Equity

The Buddy Program is a feasible avenue for providing social and academic support to students following a concussion. The implementation of the Buddy Program can be considered for schools as part of a holistic approach to concussion management.

Conclusions

The Buddy Program aligns with school values and may be an avenue to support students returning to school following a concussion.

1. Introduction

Mental health concerns are prevalent in adolescents; up to 20% of adolescents report a mental health disorder or languishing mental health [1]. Following concussion, adolescents are at an increased risk of reporting a mental health challenge [2, 3, 4]. The impact of mental health challenges may affect their school attendance and social participation [5]. Given adolescents spend most of their waking hours at school, efforts to foster mental wellness and prevent mental health problems in adolescents following concussion are needed.

Peer support is built on a platform of shared experience, empathy, and a sense of community [6]. Adolescents engage in peer support naturally through friendships and relationships [6]. Peer support may be a viable solution to assist adolescents recovering from concussion. A formalized peer support program was requested by adolescents who sustained a concussion [7]. Specifically, students requested a one‐on‐one peer support program (“Buddy Program”) whereby students with a concussion would be paired with a peer at school [8]. The one‐on‐one format facilitated a flexible style of support between peers and could include academic support, social support, advocacy support, or concussion education [8]. A school‐based peer support program may be an efficient and effective strategy to provide adolescents with support through existing friendships or new peer‐to‐peer relationships.

1.1. Objective

As the Buddy Program was developed to be implemented within secondary schools, understanding educators' perspectives of the Buddy Program and how feasible it is to implement the program within a secondary school setting for students post‐concussion is essential prior to widescale implementation. Given reported barriers to implementation of school‐based programs, including for concussion and mental well‐being [9, 10, 11], it is likely that without understanding the barriers and facilitators to implementing the Buddy Program, the intervention would not be successful. A better understanding of how to successfully implement the Buddy Program is not only essential for adoption, but also our process aligns with knowledge translation best practices. Thus, the purpose of this study was to describe educators' perspectives of the feasibility, acceptability, and appropriateness of the Buddy Program for secondary school students following a concussion.

2. Methods

2.1. Participants

We recruited an inclusive sample of secondary school educators from two co‐educational, independent schools located in Calgary, Canada to participate in this feasibility case study. This feasibility study is in follow‐up to the co‐design of the Buddy Program, which was done in partnership with the two schools (reported elsewhere). Educators included student support personnel, teachers, school nurses, and administrators who supported secondary school students (i.e., grades 10–12). All eligible staff members were invited to participate in the survey. Following completion of the survey, the educators could opt‐in to a follow‐up interview.

2.2. Evaluation Tools and Procedures

We administered an online survey (April to May 2024) to explore the feasibility, acceptability, and appropriateness of the Buddy Program [12], and then conducted interviews in person and via Zoom to further explore responses to survey questions (May 2024). Interviews lasted a median of 47 min (range 30–54 min). We analyzed the survey data descriptively (percentages) using Microsoft Excel (16.7). Following the analysis of the survey data, we conducted the qualitative interviews. Following completion of the interviews, qualitative data was transcribed using Rev.com AI [13] and then inductively coded using reflexive thematic analysis [14, 15]. We included quotations (with pseudonyms) to support the generated themes [14, 15]. The survey data and interview data were integrated to inform study findings.

All participants provided electronic consent for participation in the study. This study was approved by the University of Calgary Institutional Review Board (REB 23‐1112).

3. Results

Thirty‐two educators from two independent secondary schools in Calgary, Canada, including teachers, principals, athletic directors, school nurses, and student support personnel completed a survey. See Table 1. Of these, 27 educators taught at least one course and 16 had taught or were currently teaching more than one course (see Figure 1).

TABLE 1.

Participant demographics for educators who completed the survey.

Demographic variable	Number (%)
Age
Age	42 (26–63) a
Missing	4 (13%)
Gender
Woman	25 (78%)
Man	7 (22%)
Role
Administrator	3 (9%)
Athletic director	1 (3%)
Student support, school nurse, health care staff	5 (16%)
Teacher	23 (72%)
Grades currently teaching
10	20 (63%)
11	22 (69%)
12	22 (69%)
I do not currently teach	5 (16%)
Years
0–1	1 (3%)
2–5	7 (22%)
6–10	5 (15.5%)
11–15	5 (15.5%)
16–20	5 (15.5%)
21–30	5 (15.5%)
> 30	2 (6.5%)
Missing	2 (6.5%)

^a Median and range.

FIGURE 1.

Courses teaching.

We did not have full staff lists to identify the percentage of all possible responses from both schools. However, one educator reported all, or almost all, eligible educators at their school completed the survey. At the other school, an educator indicated that more than half of all eligible staff members completed the survey. Given survey responses were anonymous, it is likely the educators at each school made this assumption by survey completion rates.

Overall, educators felt the Buddy Program was feasible, acceptable, and appropriate. Although over 80% of educators believe the Buddy Program is feasible, meaning it is implementable, possible, and doable, less than 70% agreed that it seems easy to use at their school, which could affect adoption. However, over 80% of educators agreed or completely agreed the Buddy Program is acceptable, indicating the Buddy Program meets their approval, is appealing to them, they like it, and the program is welcomed. Further, over 80% of educators agreed or completely agreed the Buddy Program is appropriate as it seems fitting, suitable, applicable, and a good match given their school culture, values, and practices. See Figure 2.

FIGURE 2.

Perspectives of the acceptability, appropriateness, and feasibility of the Buddy Program. Measures from the acceptability of an intervention, intervention appropriateness measure, and feasibility of an intervention measure scales [12].

Seven educators participated in a one‐on‐one semi‐structured interview. The interviews described educators' perspectives of the Buddy Program, the relevance of the Buddy Program to their school, and factors related to implementation. We mixed the findings from the survey responses and the interview data to co‐create three main themes: (1) the Buddy Program provides access to social support and opportunities for student leadership; (2) school culture and readiness for the Buddy Program; and (3) considerations for adopting the Buddy Program. See Table 2 for additional supporting quotations.

TABLE 2.

Supporting quotations.

Theme	Subtheme	Supporting quotation
The Buddy Program Provides Access to Social Support and Opportunities for Student Leadership	Leadership and opportunities “to be involved and help others”	We have a lot of individuals doing a lot of things in leadership positions already I think that this option for them to be involved and help others would be a viable and a good option (Morgan).
School Culture and Readiness for the Buddy Program		I do also think that the staff here does care a lot about the kids. I think once you explain to people the benefits, everyone would be on board. Everyone's pretty on board pretty quickly as soon as they see that it can benefit kids. (Riley)
		Time and space are always the biggest [barriers]. So, making sure that the teachers have the time to be in charge of it and it's not just one more thing onto an already very full plate (Riley).
Considered for Adopting the Buddy Program	Buddy qualifications: “Some sort of training is good”	I think the one piece that we'll have to look at, which came through in the survey results was just about setting up those boundaries to making sure that it's not putting too much on the buddies (Sam).
	Buddy pairing: “Having a couple of common threads would be valuable” when pairing buddies, but “we have a lot of overcommitting kiddos”	I think specifically, let's say it was a hockey player and a hockey player, I think that would be huge or basketball or a non‐sport related. Then they just find those connections (Sam).
		The kids really overcommit, especially early in the year, then exams show up and then everyone just stops following through with the commitments the same way. So that would be something I'd be nervous about is if someone signed up, we paired people up. Maybe the concussion lasted a really long time, and their buddy stopped being supportive. This is probably one of my main concerns with it is if we're pairing them up right with a buddy and there's this consistent person and that someone's concussion lasts four months, what if their buddy's like ‘See ya’. (Cameron)
	Buddy meetings: Buddies should meet “at school” and should have the choice to “pull out”	In terms of accountability, there could be some kind of contract that you have to sign between the two of you saying that you might meet every week for this amount of time, and if it doesn't happen, these are the steps that you go to. (Alex)

3.1. The Buddy Program Provides Access to Social Support and Opportunities for Student Leadership

Educators believe the Buddy Program is acceptable and should be adopted. Benefits of the Buddy Program included different options for support, as well as access to social support (e.g., notetaking, social support, advocacy, education), peer modeling, and opportunities for student leadership and citizenship for both students with a concussion and the “buddies”. Importantly, the Buddy Program aligns with the schools' values and existing practices.

3.1.1. The Buddy Program Should Include Social Support: It Is Like “Having a Friend”

Educators discussed that adolescents may be more likely to disclose their concussion to a peer rather than an adult (e.g., teacher), and they may be more likely to seek social support from a peer, and in particular, from a peer with lived experience of concussion. Cameron explained how buddies can support their peers as their peers are more likely to speak to them about their concussion:

Sometimes in the high school, they're kind of dishonest about their symptoms. They want to get back to whatever they're doing. They're downplaying it, invalidating their symptoms… I feel like the kids are more likely to maybe tell their peers, and if their peers have training, they're like, ‘I'm going to advocate for you’ [or] ‘check in about this’.

This sentiment led educators to agree that the Buddy Program provides an opportunity for students with a concussion to disclose how they are feeling and to foster peer support, including social support.

Some educators believed access to social support should be the primary component of the Buddy Program as “they feel like someone hears them and knows what's going on” (Sam). Other educators believed the primary component should be academic support or to facilitate the student following through with school concussion protocols such as reporting a concussion or following a gradual return to school strategy. Ultimately, educators shared that social support, academic support, and other avenues of support are all valuable components of the Buddy Program.

3.1.2. Leadership and Opportunities “To Be Involved and Help Others”

The Buddy Program can provide opportunities for students to be engaged in leadership roles at school, which was valued by both participating schools. Educators discussed the importance of acknowledging buddies for their contributions to the Buddy Program. Examples of acknowledgments included writing letters of recommendation for school awards, writing reference letters for university applications or scholarship applications, or students receiving volunteer hours for their time.

The reality is, I think if you want it, then yeah, you're going to have to find a way to create some sort of extrinsic motivator for kids, and then maybe they'll end up enjoying it enough that it ends up becoming an intrinsic motivator for them (Jordan).

Both engaging in leadership opportunities and being recognized for leadership contributions through the Buddy Program were feasible, acceptable, and appropriate as they aligned with existing values and practices at both schools.

3.2. School Culture and Readiness for the Buddy Program

The Buddy Program aligns with school culture, but resource constraints and educator readiness for change could affect adoption. Facilitators to adoption included the focus on student health and wellness, which is “part of our [school] culture” (Taylor), the desire to eliminate stigma, the sense of community, and the alignment with school values. Barriers to adoption included educators' readiness to change and access to resources.

To support uptake, Riley suggested that schools could highlight that the Buddy Program was developed in response to the requests from adolescents to increase educator buy‐in.

I think the idea of the peer support and especially the fact that that's what the kids asked for. I think that's really cool. And if that's what they're asking for, then the opportunity for buy‐in is going to be even higher and even better.

Ways to increase educator buy‐in included stressing the importance of supporting students, of which the Buddy Program does, and to tailor these messages to different groups within the school community.

Educators within each school and between each school had different perspectives as to the availability of resources. For example, Alex discussed that the Buddy Program was not resource intensive to implement:

I don't really see it taking a ton of resources aside from the [education] modules, which is awesome. And just a teacher‐sponsor who was able to do it.

Whereas Jordan, employed at the same school as Alex, believed there were barriers to implementation:

I think you would need a space for the kids to meet. And yeah, we're kind of short on space around here if you haven't noticed…I think figuring out a space where they would be able to meet is probably pretty important.

Educators stated that access to personnel support and space were key factors to program implementation. With respect to personnel, a “educator‐sponsor” is needed to oversee the program, train the buddies, pair the buddies, meet with the buddies to review terms of the relationship, and be a point of contact if there are any concerns, which is resource‐intensive, even if supported by school culture. With respect to space, schools had access to spaces in the schools that could be used, but there was no dedicated space for students to meet. A dedicated space for the Buddy Program that allowed for confidentiality (e.g., study room in the library) and that could be supervised by the educator‐sponsor was desired.

3.3. Considerations for Adopting the Buddy Program

Educators expressed the need for clear parameters for implementation. Specifically, the qualifications needed to be a buddy, how buddies should be paired, when and where buddies would meet, and the parameters of the buddy relationship, and who would oversee the program.

3.3.1. Buddy Qualifications: “Some Sort of Training Is Good”

Overwhelmingly educators supported access to education and training for the buddy. It was recommended that education be provided only to the students interested in the program. Riley said,

I think having some sort of training education is good. I would recommend doing it just for the people who sort of sign up for the program. Because I found when we try and make something whole school and the whole school isn't interested, it actually diminishes from the people that are, because they kind of end up in an environment where everyone's blowing it off and it sends sort of the wrong message.

Some educators expressed concern with the potential burden of being a buddy. Educators wanted to ensure that social support did not become counseling, and that buddies do not become overburdened if providing social support to their peers with a concussion.

3.3.2. Buddy Pairing: “To Have a Couple of Common Threads Would Be Valuable” When Pairing Buddies, but “We Have a Lot of Overcommitting Kiddos”

I think it'd be nice for them to be in the same grade because then they're going to be going through similar classes and they know, it might be tricky for someone in grade 10 to be a buddy to someone in 11 or 12 (Sam).

Most educators believed the buddy should demonstrate leadership skills and be up to date with schoolwork. Educators shared that buddies who paired naturally and had common interests would likely be better suited to providing support than educator‐sponsor‐matched buddies. This is because buddies who already know each other would have an established level of trust in the relationship. Barriers to buddy pairings included students not signing up to participate as buddies and students overcommitting and not able to fulfill their commitment to the Buddy Program. Cameron said, “getting students to sign up for it I think is a barrier for sure” and Alex expanded,

Maybe they just don't want to do it, and that's okay too. Maybe they had a bad concussion experience, and they don't want to relive it with another person.

3.3.3. Buddy Meetings: Buddies Should Meet “at School” and Should Have the Choice to “Pull Out”

Educators discussed that the buddy meetings would occur at school, but outside of class time. The frequency of meetings between buddies and the length of the buddy relationship would be determined at the onset of the pairing, with a Term of Reference or contract signed between buddies, all of which would be overseen by the educator‐sponsor. One suggestion was to create the relationship for a specified period for all buddies (e.g., 4 weeks), with a caveat that the pairing would be re‐evaluated at this time and any adjustments would be made based on each individual within the program. The relationship could end earlier if the student with a concussion had recovered and no longer needed support. Also, there should be an option for either student to withdraw from the program at any time.

I think there always has to be an optional exit. If their person is not willing to do or able to do what they set out to do, then they have to have the choice to say, ‘You know what? I need to pull out at this point in time, and I can't help you anymore, but I've done what I'm able to do’ (Morgan).

4. Discussion

This two‐school case study aimed to understand educators' perspectives of the feasibility, acceptability, and appropriateness of adopting the Buddy Program in a secondary school setting. The findings of this study revealed the Buddy Program is feasible, acceptable, and appropriate for secondary schools to implement to support students following concussion. Notably, peer support aligns with the educators' values and practices, and thus, the Buddy Program is an appropriate program to adopt. Schools need to consider if they have the resources to implement the Buddy Program, such as an educator‐sponsor to oversee the program, spaces for students to meet, training of student “buddies,” and a Term of Reference in place to protect both the student with concussion and their buddy.

We found that the Buddy Program aligns with existing school values of leadership and peer‐based support. This is unsurprising given peer‐based programs are not uncommon in secondary schools [16, 17, 18, 19, 20, 21, 22]. Moreover, the Buddy Program is well‐positioned to support adolescents following concussion as our participants highlighted that adolescents may be more likely to disclose information to their peers than to an adult. This is echoed in the literature, whereby adolescents may view their peers as more credible and have a better understanding of their lived experiences than adult mentors [18].

The uniqueness of the Buddy Program—the flexible nature of support as students with a concussion may want different types of support throughout their recovery—requires schools to consider resources and parameters for the program prior to implementation [8]. Educators in our study highlighted how a Term of Reference between buddy pairings is an essential component to protect both the student with a concussion and the buddy. The biggest operational concern for the Buddy Program was the potential for a buddy to provide social support to a peer that could veer into a peer counseling role [23]. Secondary students' lack of qualifications to provide counseling and doing so could harm one or both students. To mitigate the concern for buddies to encroach on a peer counseling role, it was recommended that the educator‐sponsor ensure both the student with the concussion and the buddy have completed a mandatory Training Module prior to the buddy pairing.

The Buddy Program's operational costs are low [8]; however, limited educator availability and limited space could affect its adoption. Resource limitations are not a new phenomenon in schools [24, 25, 26, 27]. In Canada, many schools have seen cuts to funding for educational assistants and teachers, as well as reductions in school‐based extra‐curricular activities [28, 29, 30, 31, 32, 33]. Our participants highlighted that their focus of supporting students holistically drove them to find solutions to address resource barriers; however, they acknowledged this may not be feasible for other schools. A solution could be to employ the expertise of school resource officers to identify ways to leverage existing resources at schools to facilitate students' return to school following concussion. For example, the resource officer may be able to identify spaces for buddies to meet (e.g., library, cafeteria) and the educator‐sponsor role may align with the point‐person who already oversees students with concussion. Ultimately, our participants discussed that they were willing to make concessions to put the student first; this mindset may be critical to ensuring the adoption and successful implementation of the Buddy Program in secondary schools.

The purpose of this study was to explore educators' perspectives of adopting the Buddy Program at schools. Given schools need administrative support to operate school‐based programs, understanding educators' perspectives of the program was the first step in program operation. As we have determined that the Buddy Program is feasible, acceptable, and appropriate, future research will explore the effectiveness of the Buddy Program to support students returning to school with a concussion.

4.1. Implications for School Health Policy, Practice, and Equity

Adolescents spend much of their waking hours at school. Facilitating access to peer support at school via the Buddy Program may be a practical and feasible approach to providing academic and social support to students following a concussion. The flexible nature of the Buddy Program enables students to seek out and receive support tailored to them and supports the development of leadership skills, social skills, and empathy. School personnel, including student support staff, guidance counselors, school nurses, or school counselors, may be well‐positioned to lead the Buddy Program at schools given their expertise within the school environment, as well as understanding of mental health in adolescents.

Schools that are interested in implementing the Buddy Program should be mindful of including mandatory education for staff on the nature of the program, as well as to students with concussion and the “buddy” who will support them. Furthermore, it is essential that schools conduct an environmental scan of their resources, personnel, space, as well as their educators' perceptions on concussion prior to program adoption. It is likely that the Buddy Program will need to be tailored to each school, accounting for school resources. As the Buddy Program is adaptable, this is unlikely to be a problem if the environmental scan is considered prior to implementation. It is recommended that should schools be interested in adopting the Buddy Program for their school context, they survey the educators to understand school culture and readiness, as well as perceptions of student malingering following concussion. Following this, we recommend schools start with a small number of students and pilot the Buddy Program in their school prior to widescale implementation. We believe the Buddy Program is well‐positioned to be part of a comprehensive approach to return to school following concussion for secondary students.

4.2. Strengths and Limitations

The strengths include that this is the first study to explore the feasibility of a Buddy Program to support students with concussion within a secondary school setting. Additionally, an explanatory sequential mixed methods design enabled us to gain deeper insights into educators' survey responses and to tailor questions to address survey responses. Study limitations include the sample size. We conducted this study in two co‐educational, independent secondary schools in Calgary, Canada, which may have access to different resources than public schools and/or schools outside this jurisdiction, limiting the generalizability of our findings.

5. Conclusions

The Buddy Program as a peer support program for students following concussion is feasible for schools to implement and aligns with school values. The Buddy Program provides an avenue for peer support, including social support, for adolescents. Buddies should be acknowledged for their time and not be overburdened by supporting one of their peers. Resource constraints may affect the adoption of the Buddy Program, so personnel support and a space for buddies to meet need to be considered for program adoption. Further research to evaluate the effectiveness of the Buddy Program in secondary schools is warranted.

Funding

This study is part of a larger program of research, Surveillance in High School and Community Sports to Reduce Concussions and Their Consequences (SHRed Concussions) study. This research was investigator‐initiated as part of a grant competition funded by the NFL/Football Research Inc.; funding decisions were made by an independent Scientific Advisory Board.

Ethics Statement

The study was approved by the University of Calgary Conjoint Health Research Ethics Board (REB 23‐1112).

Conflicts of Interest

The authors declare no conflicts of interest.

Shepherd H. A., Bobye‐Magnusson H., Cavanagh R., et al., “Educators' Perspectives of the Feasibility, Acceptability, and Appropriateness of the Buddy Program for Secondary School Students Post‐Concussion,” Journal of School Health 96, no. 3 (2026): e70119, 10.1111/josh.70119.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.