Delivering concussion education to pre-service teachers through the SCHOOLFirst website: Evaluating usability and satisfaction

Abstract

BACKGROUND:

Return-to-school processes indicate ‘when’ to initiate activities and ‘what’ activities should be accomplished, but are missing ‘how’ to implement the process. The SCHOOLFirst website provides the ‘how’ through building concussion knowledge, creating a supportive culture, and defining roles. Due to the involvement of pre-service teachers in schools during training and imminent transition to becoming teachers, it is important that pre-service teachers are trained in concussion and can optimally support current and future students.

OBJECTIVE:

To determine: 1) pre-service teachers’ knowledge and confidence surrounding the return-to-school process before and after using the SCHOOLFirst website; 2) the usability, intended use and satisfaction of the SCHOOLFirst website from the perspective of pre-service teachers.

METHODS:

Thirty pre-service teachers completed the demographic survey, knowledge and confidence survey, System Usability Scale, and satisfaction and intended use survey after participating in a workshop.

RESULTS:

Significant increases in concussion knowledge (Z = –4.093, p < 0.001) and confidence in helping students return-to-school (Z = –4.620, p < 0.001) were measured after using the SCHOOLFirst website. Participants were satisfied with the SCHOOLFirst website (93.4%) and intend to use it in the future when supporting a student post-concussion (96.4%).

CONCLUSION:

The SCHOOLFirst website is a valuable tool for pre-service teachers to support students’ return-to-school post-concussion.

Keywords

Educators teachers concussion school students return-to-school return-to-learn

1 Introduction

A traumatic brain injury (TBI) may negatively impact children and youth’s school performance (Centers for Disease Control and Prevention, 2018). Nearly 20% of all youth across North America will experience a mild TBI, or concussion, in their lifetime (Ilie et al., 2013; Veliz et al., 2017). Concussion has been declared a public health concern in children and youth in Canada (Tator, 2013). A concussion is caused by an impact to the head, neck, or body that transmits force to the head (McCrory et al., 2017). Concussions can occur in different ways and contexts such as sports, recreation, falls, and motor vehicle accidents. Concussions may result in an array of physical (e.g., headaches), emotional (e.g., feeling sad), and cognitive (e.g., difficulty concentrating) symptoms, in addition to sleep/wake disturbances (e.g., drowsiness) (McCrory et al., 2017). Concussion symptoms in children and youth typically resolve within four weeks, but symptoms may continue to persist for 30% of children and youth (Zemek et al., 2016) for months and even years after injury (Centers for Disease Control and Prevention (U.S.), 2009; Zafonte, 2011). Protracted recovery from concussion may impact a youth’s ability to participate in activities.

School is a youth’s main occupation, establishing return-to-school as a main priority during concussion recovery. However, post-concussion symptoms may affect a youth’s school attendance leading to anxiety about missed work and a decrease in school performance (Arbogast et al., 2013; Ransom et al., 2015; Russell et al., 2019). For example, 64% of youth reported having problems at school during their concussion recovery, with 30% of these same youth reporting continued problems at school after concussion symptom resolution, demonstrating the potential long term impact of concussion on youth (DeMatteo et al., 2019).

In the United States between 2009 and 2014, all 50 states and the District of Columbia passed youth sport concussion legislation (Thompson et al., 2016). As of 2018, 12 states include language regarding participation in academic environments after a head injury in their state laws. Requirements vary and may include education about the effects of concussion on academics and step-by-step protocols for returning to school (Potteiger et al., 2018). Training opportunities exist for teachers and school personnel, such as multi-module online TBI training programs like In the Classroom After Concussion: Best Practices for Student Success (Glang et al., 2019). In Canada, Ontario has established concussion legislation for schools whereby school boards must establish a concussion policy with return-to-school guidelines and provide training and education to relevant school staff (Policy/Program Memorandum 158, 2019; Ontario Ministry of Education, 2019; Parachute, 2022).

In addition to a healthcare team, a multidisciplinary return-to-school team has been recommended, which may include teachers, school administrators, principals, guidance counselors, coaches, etc. (Bradley-Klug et al., 2015; Broglio et al., 2014; Gioia, 2015; Halstead et al., 2013; Sady et al., 2011). It is important for all team members to understand their roles and responsibilities in concussion management and the return-to-school process.

Particularly, teachers are critical stakeholders in the return-to-school process (Lyons et al., 2017; Romm et al., 2018) as they are uniquely positioned to monitor a student’s daily progress. However, research has shown that teachers often do not feel confident in recognizing symptoms and report that they do not have sufficient knowledge about concussions or classroom management for students with concussion (Dreer et al., 2016). Surveys of professionals working with students have shown average TBI knowledge scores of 55% (Ettel et al., 2016) and average self-efficacy (or confidence in taking action) of 68% (McCart et al., 2020). Furthermore, teachers and school administrators have reported barriers to supporting students with concussion, including lack of knowledge and training, resources available to assist students, and perceived importance by some school personnel regarding concussions (Romm et al., 2018). Procedural implementation limitations have also been identified, such as an absence of placement options, time required to implement return-to-school protocols, and balancing this process with their other students (Romm et al., 2018).

Teachers believe that concussions are serious (Kasamatsu et al., 2017; Romm et al., 2018) and that they have a role in implementing return-to-school protocols for students with a concussion (Kasamatsu et al., 2017). However, as previously mentioned, teachers often have limited knowledge or do not feel confident in their knowledge of concussion (Dreer et al., 2016; Ettel et al., 2016; Farmer & Johnson-Gerard, 1997; Linden et al., 2013; McCart et al., 2020; Romm et al., 2018), indicating a significant gap in care for youth recovering from a concussion. Specifically, 82% of teachers indicated that they require more information about concussions and how to manage students with a concussion in the classroom (Dreer et al., 2016). Further, as return-to-school processes must meet the particular needs of a student with a concussion, no singular set of strategies exist, leaving school personnel to make important individualized decisions regarding a student’s recovery process. Previous studies reported that teachers with a formal concussion education were more familiar with academic adjustments and were more likely to recommend them for a student with concussion (Kasamatsu et al., 2017; Purcell et al., 2019).

Pre-service teachers are post-secondary or graduate education program students training to enter the teaching profession (UNESCO Institute for Statistics, 2022). Canadian pre-service teaching programs include both course work and practicums, in which pre-service teachers are placed in school environments and receive mentorship from an experienced teacher (Gambhir et al., 2008). During practicum, pre-service teachers develop skills through observing their mentor, creating lesson plans, teaching lessons, and learning about classroom/student management (Allen & Wright, 2014). However, despite the present and future influence that pre-service teachers have on students, pre-service teachers have been an under-explored stakeholder to date in research and education efforts specific to concussions in school settings (Davies et al., 2013).

Currently, return-to-school protocols mandated by school boards focus on when stages of student activity should be initiated in the return-to-school process as well as what activities should be accomplished in each stage. The most important component of how to implement the return-to-school process is missing for key stakeholders with little to no training in concussion management. Improper or lacking academic arrangements may worsen or prolong concussion symptoms.

To address this gap of how to facilitate the return-to-school process, the SCHOOLFirst website supports school personnel, such as teachers, principals, school administrators, coaches, guidance counselors, etc., to take up their role as a Concussion Champion (C. Provvidenza et al., 2018). The goal of a Concussion Champion is to ensure the best possible outcome for a student as they recover from a concussion, including re-integrating them into school activities successfully and safely. SCHOOLFirst provides tangible strategies and plans for teachers to use to support and provide accommodations for students in their return-to-school after concussion.

With the overall goal to disseminate SCHOOLFirst as widely as possible, the website first needed to be pilot tested to ensure it met the needs of end users. The objectives of the study were to determine: 1) the knowledge and confidence surrounding the return-to-school process of pre-service teachers before and after using the SCHOOLFirst website; and, 2) the usability, intended use and satisfaction of the SCHOOLFirst website from the perspective of pre-service teachers. In practice, the findings from this study informed improvements to the SCHOOLFirst website for broader consumption and use by stakeholders in the school setting, including pre-service teachers.

2 Methods

A descriptive survey-based study was conducted to evaluate the SCHOOLFirst website from the perspective of Canadian pre-service teachers. This study was approved in concordance with the Research Ethics Board of the University of Toronto in Toronto, Canada (RIS Protocol Number 38380, 17Jan2020) and the University of New Brunswick in Fredericton, Canada (38380, 23Jan2020). All participants provided informed consent to act as participants in this study and to have their data used to meet the objectives of this study.

2.1 SCHOOLFirst

SCHOOLFirst aims to help school personnel understand their role as a Concussion Champion through three core concepts: 1) Build your concussion knowledge; 2) Create a supportive and concussion aware school culture; and, 3) Know your role in facilitating and enabling successful return-to-school for students after a concussion. SCHOOLFirst provides strategies to support students with a concussion in the classroom; links to helpful websites, videos and tools to expand their concussion knowledge; and, a planning tool for student accommodations. In its first iteration, SCHOOLFirst was a bilingual (English and French), interactive PDF that was freely available for download (Provvidenza et al., 2018). With the success of the first iteration, the SCHOOLFirst concussion resource was updated as a bilingual website (https://schoolfirstconcussion.ca/) containing new content, and optimized formatting and design features (Provvidenza et al., 2022). The development of both iterations of SCHOOLFirst employed an integrated knowledge translation (iKT) approach, defined as a co-production of knowledge through a relationship between researchers and decision makers, to inform their creation (Gagliardi et al., 2015). Experts and key stakeholders, including healthcare professionals, researchers, knowledge translation experts, and teachers with experience in concussion and the return-to-school process, were engaged in the website’s development. In line with the iKT approach and knowledge-to-action cycle (Graham et al., 2006), end users were leveraged to review the website to ensure high quality with respect to the website’s content, organization and format to align with end user needs (Provvidenza et al., 2022).

2.2 Procedure

Study activities were conducted within a two-hour in-person concussion education workshop for pre-service teachers at a Canadian university. During the workshop, participants received general concussion education, learned the purpose of the SCHOOLFirst website, and had the opportunity to explore the resources and functionality of the SCHOOLFirst website. The main goal of the workshop was to educate end users about concussion and the SCHOOLFirst website, with the research study to evaluate the website as the secondary goal.

Paper copies of the Survey Package were administered to workshop attendees upon completion of the workshop. Workshop attendees were invited to participate in the study, although it was not mandatory in order to attend the concussion education workshop.

2.3 Participants

Participants were pre-service teachers from the Bachelors of Education program at a Canadian university who attended the SCHOOLFirst education workshop. To be included in the study, participants were required to provide informed consent, be a pre-service teacher, and be able to read and write in English.

Thirty-five individuals (pre-service teachers, n = 33; in-service teachers, n = 2) attended the education workshop. Of the attendees, 32 participants completed the Survey Package for a survey completion rate of 91.4%; two surveys were excluded as they did not meet the inclusion criteria of being a pre-service teacher, leaving 30 surveys completed by pre-service teachers for analysis. Participant demographics can be found in Table 1.

Table 1
Participant characteristics

Demographic Variables No. Frequency,

Responses n (%)

Grades eligible to teach 30

Elementary^a 10 (33.3)

Intermediate/Secondary^b 17 (56.7)

Both 3 (10.0)

Subjects taught^c 13

Physical education 7 (53.8)

Science 7 (53.8)

French/French immersion 2 (15.4)

English 2 (15.4)

Math 1 (7.7)

Music 1 (7.7)

Social studies 1 (7.7)

Years of experience in education 30

0–5 years 28 (93.3)

5–10 years 2 (6.7)

Experience supporting a student with a concussion 30

Yes 7 (23.3)

No 16 (53.3)

Unsure 7 (23.3)

Demographic Variables	No.	Frequency,
Grades eligible to teach	30
Elementary^a		10 (33.3)
Intermediate/Secondary^b		17 (56.7)
Both		3 (10.0)
Subjects taught^c	13
Physical education		7 (53.8)
Science		7 (53.8)
French/French immersion		2 (15.4)
English		2 (15.4)
Math		1 (7.7)
Music		1 (7.7)
Social studies		1 (7.7)
Years of experience in education	30
0–5 years		28 (93.3)
5–10 years		2 (6.7)
Experience supporting a student with a concussion	30
Yes		7 (23.3)
No		16 (53.3)
Unsure		7 (23.3)

a. Elementary school = Kindergarten to Grade 5; b. Intermediate/High school = Grades 6 to 12; c. Some respondents indicated more than one subject so frequencies do not sum to 100%.

2.4 Outcome measures

Data was collected from all participants using a Survey Package that included four parts:

Demographics Survey: This seven-item survey was purposefully developed by the research team to gather basic information about the study participants, including their professional role, subjects and grades eligible to teach, years in the education field, and experience supporting students with concussion. Check boxes and free text were utilized.

Concussion Knowledge and Confidence Survey: This survey was purposefully developed by the research team and evaluated one’s self-reported level of concussion knowledge and confidence in supporting the return-to-school process before and after using the SCHOOLFirst website. The survey was developed with input from the research and clinician team, and pilot tested with clinicians, KT specialists, evaluation experts, and researchers before use. A five-point Likert scale (1 = no knowledge/not confident at all to 5 = completely knowledgeable/extremely confident) was employed to answer closed-ended questions pertaining to a participant’s overall concussion knowledge, knowledge of concussion resources, classroom accommodations, their role in the return-to-school process, and their confidence in managing the return-to-school process. The survey was administered after use of the SCHOOLFirst website; pre-levels of knowledge and confidence were reported retrospectively by participants.

The System Usability Scale (SUS; Brooke, 1986): The SUS is a validated 10-item survey where participants rate their level of agreement on the usability (8 items) and learnability (2 items) of web-based applications on a five-point Likert scale (1 = Strongly disagree to 5 = Strongly agree) (Brooke, 1986). Item scores are processed to calculate a total score out of 100 (Brooke, 1986). A SUS score of 68 out of 100 is average. The SUS has strong reliability scores (α= 0.91) and validity (Bangor et al., 2008). The SUS has also been previously used by researchers to evaluate telehealth applications and other healthcare platforms (Harrati et al., 2016). To meet the needs of this study, the survey questions were adapted by modifying ‘system’ to ‘website.’

Satisfaction and Intended Use Survey: This 13-item survey was purposefully developed by the research team and used to evaluate initial satisfaction of the SCHOOLFirst website through open and closed-ended questions. The survey consisted of questions regarding initial impressions of the website, satisfaction using and navigating the website, and recommendations for modifications to the website. The survey also asked participants whether they intend to use the website to support the return-to-school of students post-concussion, as well as recommendations for supports that would encourage use of the website.

2.5 Data analysis

Descriptive statistics (i.e., frequencies, medians) were used to analyze closed-ended questions from the Demographic Survey, Knowledge and Confidence Survey, SUS, and Satisfaction and Intended Use Survey. Open-ended questions were analyzed by conceptual content analysis to determine the occurrence of common terms within the data. Wilcoxon signed-rank tests were conducted to detect changes in self-reported concussion knowledge and confidence before and after using the SCHOOLFirst website.

3 Results

3.1 Concussion knowledge and confidence

An overall increase in concussion knowledge after using the SCHOOLFirst website was reported by participants, with significant positive shifts in knowledge observed for all items (Table 2). At the individual level, in almost all cases, no participants reported having no knowledge of a concussion-related topic after using the SCHOOLFirst website. For both knowledge of ‘the specific stages of return-to-school’ and ‘the role of others in supporting a students’ return-to-school,’ one participant reported still having no knowledge after using the website.

Table 2
Concussion knowledge before and after using the SCHOOLFirst website

Knowledge of . . . N Frequencies, % (n) Median Wilcoxon

Signed-Rank

Test

1 –No 2 –Slightly 3 –Somewhat 4 –Moderately 5 –Completely

knowledge knowledgeable knowledgeable knowledgeable knowledgeable

Overall concussion knowledge (e.g., causes, symptoms) Pre 30 0.0 (0) 20.0 (6) 46.7 (14) 23.3 (7) 10.0 (3) 3 Z = –4.093

Post 29 0.0 (0) 0.0 (0) 10.3 (3) 69.0 (20) 20.7 (6) 4 p < 0.001^*

The impact of concussion on RTS^a Pre 29 24.1 (7) 34.5 (10) 31.0 (9) 6.9 (2) 3.4 (1) 2 Z = –4.527

Post 29 0.0 (0) 3.45 (1) 6.9 (2) 75.9 (22) 13.8 (4) 4 p < 0.001^*

Specific classroom accommodations Pre 30 33.3 (10) 33.3 (10) 30.0 (9) 3.3 (10) 0.0 (0) 2 Z = –4.554

Post 30 0.0 (0) 13.3 (4) 33.3 (10) 43.3 (13) 10.0 (3) 4 p < 0.001^*

Tools and resources available to support students’ RTS Pre 30 46.7 (14) 36.7 (11) 13.3 (4) 3.3 (1) 0.0 (0) 2 Z = –4.684

Post 30 0.0 (0) 3.3 (1) 26.7 (8) 63.3 (19) 6.7 (2) 4 p < 0.001^*

The specific stages of RTS Pre 30 50.0 (15) 23.3 (7) 20.0 (6) 3.3 (1) 3.3 (1) 2 Z = –4.520

Post 29 3.4 (1) 3.4 (1) 31.0 (9) 55.2 (16) 6.9 (2) 4 p < 0.001^*

Your role in supporting a students’ RTS Pre 30 36.7 (11) 36.7 (11) 16.7 (5) 6.7 (2) 3.3 (1) 2 Z = –4.695

Post 30 0.0 (0) 13.3 (4) 20.0 (6) 50.0 (15) 16.7 (5) 4 p < 0.001^*

Others’ role in supporting a students’ RTS Pre 30 43.3 (13) 30.0 (9) 23.3 (7) 0.0 (0) 3.3 (1) 2 Z = –4.367

Post 30 3.3 (1) 3.3 (1) 46.7 (14) 40.0 (12) 6.7 (2) 3 p < 0.001^*

Knowledge of . . .		N	Frequencies, % (n)	Median	Wilcoxon
Overall concussion knowledge (e.g., causes, symptoms)	Pre	30	0.0 (0)	20.0 (6)	46.7 (14)	23.3 (7)	10.0 (3)	3	Z = –4.093
	Post	29	0.0 (0)	0.0 (0)	10.3 (3)	69.0 (20)	20.7 (6)	4	p < 0.001^*
The impact of concussion on RTS^a	Pre	29	24.1 (7)	34.5 (10)	31.0 (9)	6.9 (2)	3.4 (1)	2	Z = –4.527
	Post	29	0.0 (0)	3.45 (1)	6.9 (2)	75.9 (22)	13.8 (4)	4	p < 0.001^*
Specific classroom accommodations	Pre	30	33.3 (10)	33.3 (10)	30.0 (9)	3.3 (10)	0.0 (0)	2	Z = –4.554
	Post	30	0.0 (0)	13.3 (4)	33.3 (10)	43.3 (13)	10.0 (3)	4	p < 0.001^*
Tools and resources available to support students’ RTS	Pre	30	46.7 (14)	36.7 (11)	13.3 (4)	3.3 (1)	0.0 (0)	2	Z = –4.684
	Post	30	0.0 (0)	3.3 (1)	26.7 (8)	63.3 (19)	6.7 (2)	4	p < 0.001^*
The specific stages of RTS	Pre	30	50.0 (15)	23.3 (7)	20.0 (6)	3.3 (1)	3.3 (1)	2	Z = –4.520
	Post	29	3.4 (1)	3.4 (1)	31.0 (9)	55.2 (16)	6.9 (2)	4	p < 0.001^*
Your role in supporting a students’ RTS	Pre	30	36.7 (11)	36.7 (11)	16.7 (5)	6.7 (2)	3.3 (1)	2	Z = –4.695
	Post	30	0.0 (0)	13.3 (4)	20.0 (6)	50.0 (15)	16.7 (5)	4	p < 0.001^*
Others’ role in supporting a students’ RTS	Pre	30	43.3 (13)	30.0 (9)	23.3 (7)	0.0 (0)	3.3 (1)	2	Z = –4.367
	Post	30	3.3 (1)	3.3 (1)	46.7 (14)	40.0 (12)	6.7 (2)	3	p < 0.001^*

a. RTS = return-to-school; ^*Statistically significant at p < 0.05

An overall positive shift was also observed in participants’ confidence in the return-to-school process, and implementing strategies and accommodations for students returning to school post-concussion (Table 3). A significant increase in self-reported confidence after using the SCHOOLFirst website was measured for all items. At the individual level, after using the website, all participants reported having some level of confidence (i.e., at least slightly confident).

Table 3

Confidence in the return-to-school process before and after using the SCHOOLFirst website

Confidence in . . .		N	Frequencies, % (n)					Median	Wilcoxon
									Signed-Rank
									Test
			1 –Not confident	2 –Slightly	3 –Somewhat	4 –Moderately	5 –Extremely
			at all	confident	confident	confident	confident
Helping students’ RTS^a post-concussion	Pre	30	33.3 (10)	26.7 (8)	30.0 (9)	6.7 (2)	3.3 (1)	2	Z = –4.620
	Post	30	0.0 (0)	3.3 (1)	30.0 (9)	53.3 (16)	13.3 (4)	4	p < 0.001^*
Implementing specific classroom accommodations	Pre	30	33.3 (10)	33.3 (10)	26.7 (8)	3.3 (1)	3.3 (1)	2	Z = –4.657
	Post	30	0.0 (0)	13.3 (4)	20.0 (6)	50.0 (15)	16.7 (5)	4	p < 0.001^*
Using the tools and resources available to support a students’ RTS	Pre	30	36.7 (11)	43.3 (13)	16.7 (5)	0.0 (0)	3.3 (1)	2	Z = –4.763
	Pre	30	0.0 (0)	3.3 (1)	16.7 (5)	63.3 (19)	16.7 (5)	4	p < 0.001^*
Implementing the specific stages of RTS	Pre	30	53.3 (16)	20.0 (6)	16.7 (5)	0.0 (0)	3.3 (1)	1	Z = –4.523
	Post	30	0.0 (0)	10.0 (3)	30.0 (9)	46.7 (14)	13.3 (4)	4	p < 0.001^*
Your role in supporting a students’ RTS	Pre	30	30.0 (9)	33.3 (10)	26.7 (8)	6.7 (2)	3.3 (1)	2	Z = –4.517
	Post	30	0.0 (0)	3.3 (1)	16.7 (5)	60.0 (18)	20.0 (6)	4	p < 0.001^*

a. RTS = return-to-school; ^*Statistically significant at p < 0.05

3.2 Usability of the SCHOOLFirst website

The mean SUS score for all participants was 80.7 (range = 62.5–97.5), which is above average and achieves an A- on the Suaro-Lewis curve grading scale (Lewis & Sauro, 2018). A detailed scoring breakdown is presented in Table 4. Over 60% (n = 19) of participants agreed/strongly agreed that they would like to use this website frequently and over 90% (n = 28) of participants agreed/strongly agreed that they felt confident using the website. Participants reported that the website was easy to use (n = 25, 89.3%), not complex (n = 27, 90.0%), consistently designed (n = 29, 96.7%), and that its functions were well integrated (n = 27, 90.0%).

Table 4
Usability of the SCHOOLFirst website

SUS Questionnaire N = 30 Frequencies, % (n)

1 –Strongly 2 –Disagree 3 –Neither agree 4 –Agree 5 –Strongly

disagree nor disagree agree

I think I would use this website frequently. 0.0 (0) 3.3 (1) 33.3 (10) 53.3 (16) 10.0 (3)

I found this website unnecessarily complex. 43.3 (13) 46.7 (14) 6.7 (2) 3.3 (1) 0.0 (0)

I thought this website was easy to use. 0.0 (0) 0.0 (0) 10.7 (3) 60.7 (17) 28.6 (8)

I think I would need assistance to be able to use this website. 60.0 (18) 36.7 (11) 3.3 (1) 0.0 (0) 0.0 (0)

I found various functions in this website were well integrated. 0.0 (0) 0.0 (0) 10.0 (3) 66.7 (20) 23.3 (7)

I thought there was too much inconsistency in the website. 60.0 (18) 36.7 (11) 3.3 (1) 0.0 (0) 0.0 (0)

I would imagine that most people would learn to use this website very quickly. 0.0 (0) 0.0 (0) 6.7 (2) 63.3 (19) 30.0 (9)

I found the website very cumbersome to use. 40.0 (12) 50.0 (15) 6.7 (2) 3.3 (1) 0.0 (0)

I feel confident using the website. 0.0 (0) 0.0 (0) 6.7 (2) 66.7 (20) 26.7 (8)

I need to learn a lot of things before I could use this website. 43.3 (13) 46.7 (14) 10.0 (3) 0.0 (0) 0.0 (0)

SUS Questionnaire N = 30	Frequencies, % (n)
I think I would use this website frequently.	0.0 (0)	3.3 (1)	33.3 (10)	53.3 (16)	10.0 (3)
I found this website unnecessarily complex.	43.3 (13)	46.7 (14)	6.7 (2)	3.3 (1)	0.0 (0)
I thought this website was easy to use.	0.0 (0)	0.0 (0)	10.7 (3)	60.7 (17)	28.6 (8)
I think I would need assistance to be able to use this website.	60.0 (18)	36.7 (11)	3.3 (1)	0.0 (0)	0.0 (0)
I found various functions in this website were well integrated.	0.0 (0)	0.0 (0)	10.0 (3)	66.7 (20)	23.3 (7)
I thought there was too much inconsistency in the website.	60.0 (18)	36.7 (11)	3.3 (1)	0.0 (0)	0.0 (0)
I would imagine that most people would learn to use this website very quickly.	0.0 (0)	0.0 (0)	6.7 (2)	63.3 (19)	30.0 (9)
I found the website very cumbersome to use.	40.0 (12)	50.0 (15)	6.7 (2)	3.3 (1)	0.0 (0)
I feel confident using the website.	0.0 (0)	0.0 (0)	6.7 (2)	66.7 (20)	26.7 (8)
I need to learn a lot of things before I could use this website.	43.3 (13)	46.7 (14)	10.0 (3)	0.0 (0)	0.0 (0)

3.3 Satisfaction and intended use of the SCHOOLFirst website

Twenty-seven of 28 respondents (96.4%) indicated that they intended to use the SCHOOLFirst website to support students’ return-to-school after a concussion. Participants intending to use the SCHOOLFirst website said the website would be helpful in the future to support a student’s return-to-school as they can, “ . . . turn to this website for readily available information” and, “By providing tools, strategies, and resources in a user-friendly manner.” Another participant said the website would aid teachers in, “Understanding what [the students] are going through and how to help them.” Eighty percent (n = 24) of participants said the website contained the right amount of information.

Table 5 presents closed-ended satisfaction ratings. Over 90% of the participants agreed/strongly agreed that the website was satisfactory, the interface was appealing, and that the information on the website would be helpful. As well, 96.9% (n = 29) of participants indicated that they would recommend the SCHOOLFirst website to other teachers.

Table 5
Satisfaction with the SCHOOLFirst website

Satisfaction Survey N Frequencies, % (n)

1 –Strongly 2 –Disagree 3 –Neither agree 4 –Agree 5 –Strongly

disagree nor disagree agree

I am satisfied with the website. 30 0.0 (0) 0.0 (0) 6.6 (2) 56.7 (17) 36.7 (11)

The interface is very appealing. 30 0.0 (0) 0.0 (0) 10.0 (3) 43.3 (13) 46.7 (14)

I would recommend this website to other teachers. 30 0.0 (0) 0.0 (0) 3.3 (1) 36.7 (11) 60.0 (18)

This website has information that will assist me in helping return my students to the classroom and engage in school-based activity post-concussion. 29 0.0 (0) 0.0 (0) 3.4 (1) 41.4 (12) 55.2 (16)

Satisfaction Survey	N
I am satisfied with the website.	30	6.6 (2)	56.7 (17)	36.7 (11)
The interface is very appealing.	30	10.0 (3)	43.3 (13)	46.7 (14)
I would recommend this website to other teachers.	30	3.3 (1)	36.7 (11)	60.0 (18)
This website has information that will assist me in helping return my students to the classroom and engage in school-based activity post-concussion.	29	3.4 (1)	41.4 (12)	55.2 (16)

Participants noted both helpful parts of the website as well as suggestions for improvement through open-ended responses. Conceptual content analysis results are presented in Table 6. In summary, participants appreciated the content of the web pages and methods in which they were shared. Contrarily, participants suggested ways to improve website navigation, such as search tools and ways to find what they are looking for quicker.

Table 6

Frequency results of conceptual content analysis on open-ended responses of most helpful part of the SCHHOLFirst website and suggestions for improvement to the SCHOOLFirst website

Category	% of	Example
	Respondents (n)
Helpful parts of SCHOOLFirst website
Quality of resources	60.9 (14)	“I liked how there were multiple resources available on the site as well as lots of links to other sites.”
		“The pdf/downloadable resources are a helpful and practical resource.”
Videos	21.7 (5)	“ . . . .liked the mix of instructional videos and testimonials.”
Links to resources and guidelines	26.1 (6)	“The multiple links to resources is very helpful.”
Content on roles of professionals	8.7 (2)	“For me, the information about our roles as professionals was best helpful for me.”
Concussion education and knowledge sections	8.7 (2)	“Build your knowledge” section
Creation of a supportive culture around concussion sections	4.3 (1)	“Create a supportive culture. This has a link to ‘provide education for teachers.”’
Suggestions to improve SCHOOLFirst website
Resources	47.1 (8)	“Under helpful website section, maybe highlight which website helps with specific questions.”
		“Lesson plans possibly...”
		“Case specific example stories.”
		“Maybe some more cool animations for the kids.”
		“A forum for people to come together to speak about their experiences.”
Ease of use	22.8 (4)	“A general overview with steps for teachers that do not have time to research right away but need to deal with a concussion.”
		“Quick tips”
Website function	23.5 (4)	“I think a search tool would be beneficial in order to narrow searches.”
		“Maybe do a drop down menu to break up info and easier to find what
		you need.”
Accessibility	11.8 (2)	“Possibly too academic looking to some (but I know it is all research based).”
		“Games/quizzes”

While the SCHOOLFirst website is targeted to school personnel, participants reported that the website and its resources would also benefit parents (n = 17), coaches (n = 11), athletes (n = 2), healthcare professionals (n = 2), employers (n = 1), bus drivers (n = 1), and after school program/extracurricular leaders (n = 2). These individuals are all widely involved in the day-to-day lives of students and may need to provide support and implement accommodations for students recovering from concussion.

4 Discussion

Evaluation of the SCHOOLFirst website indicated that the website was satisfactory and that participants intend to use the website in the future. Participants identified increased knowledge and confidence regarding concussion and the return-to-school process after using the website. The SCHOOLFirst website appears to successfully fill the need to support how to implement the concussion return-to-school processes and support students with a concussion.

The engagement of pre-service teachers was an important aspect of this study as the engagement of pre-service teachers in concussion education will enable a new generation of teachers to create positive culture around concussion in schools by raising awareness and initiating supportive and concussion aware schools as Concussion Champions. Studies acknowledge a gap in teacher concussion knowledge that impacts the success of students returning to school (Davies et al., 2013; Dreer et al., 2016), reinforcing that educators would benefit from concussion resource like SCHOOLFirst as part of the teacher training curriculum. Currently the Ontario College of Teachers accreditation criteria (Ontario College of Teachers, 2017) covers ‘Mental Health, Addictions and Well-Being’ with no mention of concussion, although it is also a serious public health concern (Tator, 2013). Sharing the SCHOOLFirst website will aid future students with concussion as survey responses indicated that pre-service teachers intend to use and share the SCHOOLFirst website and its resources.

Gioia (2016) states six themes to consider to best support students with concussion: 1) a formal education and training of school personnel; 2) a clear definition of the roles of school personnel, family, and student; 3) preparation of the school environment; 4) the use of standardized forms or materials; 5) development and active use of individualized plans; and, 6) regular, ongoing communication between necessary stakeholders (Gioia, 2016). Furthermore, common barriers to returning to school reported by youth with lived concussion experience include: 1) inadequate support from teachers due to a lack of concussion education (Fetta et al., 2021; Wildgoose et al., 2022); 2) a lack of a supportive concussion environment for students post-concussion (Stevens et al., 2021); and, 3) insufficient communication between key stakeholders due a lack of role definition within the student’s concussion recovery team (Fetta et al., 2021; Wildgoose et al., 2022). Considering these points across previous research and youth with lived experience, we point out how the core themes of SCHOOLFirst (i.e., three main pages of the SCHOOLFirst website) meet Gioia’s recommended themes, address barriers reported by youth with lived experience, and provide supports for school personnel to become facilitators, rather than barriers, to a successful return-to-school for students with a concussion.

First, the ‘Build Your Knowledge’ page on the SCHOOLFirst website provides a formal education about concussion signs and symptoms, recovery, and student assessments through various media types (e.g., text, video, infographics, helpful links) as recommended by Mallory et al. (2022) in a recent scoping review. This page is important as a 2019 survey study by Janson et al. (2019) reported that 40% of principals did not think academic accommodations were necessary for students with a concussion (Fetta et al., 2021), which can lead to poor outcomes for students returning to school due to lack of educator knowledge of concussion (Romm et al., 2018). Additionally, in the broader TBI literature, online concussion education training has been shown to be effective in improving knowledge and self-efficacy (or confidence to take action), and that importantly, these gains were found to be maintained over time (Glang et al., 2019). After using the SCHOOLFirst website, participants of the current study indicated a significant increase in knowledge about concussions in general, as well as specific classroom accommodations. These findings suggest that the SCHOOLFirst website provides educators with the missing knowledge to enable positive health outcomes for their students post-concussion.

Second, the ‘Create a Supportive Culture’ page on the SCHOOLFirst website recommends how to build and prepare a concussion aware and supportive school environment. Students require a supportive environment for a successful return-to-school (Jimenez et al., 2019; Linden et al., 2013; Stevens et al., 2021), and schools with a supportive concussion culture where both staff and students prioritize students with concussion act as a facilitator to a student’s return-to-school. Students with lived concussion experience indicated that a lack of understanding and awareness about concussion (Wildgoose et al., 2022), and therefore a lack of social support from friends (Kita et al., 2020) was a barrier to their return-to-school after a concussion. With that, a participant indicated that the SCHOOLFirst website helped them better understand the experiences of students with a concussion and the impact concussion has on return-to-school. The SCHOOLFirst website may illicit a more empathic response from teachers towards their support of students returning to school post-concussion.

Finally, a lack of role definition in a multi-disciplinary concussion management team leading to miscommunication between supports is a barrier to returning to school for students with a concussion (Fetta et al., 2021; Wildgoose et al., 2022). Study findings indicated that the SCHOOLFirst website fills this gap as significant increases in knowledge of and confidence in one’s role in supporting a student’s return-to-school, in addition to an increase in knowledge of others’ roles were observed. The ‘Know Your Role’ page on the SCHOOLFirst website outlines a clear definition of each person’s role within a multidisciplinary return-to-school team. As a whole, the SCHOOLFirst website provides the necessary information to establish a positive experience for students to return-to-school and provide support to educators on how to facilitate the return to school process.

The success of the SCHOOLFirst website is evident from significant increases in self-reported knowledge and confidence. The website was said to be an excellent resource for learning as well as that it was expected to be an important resource for supporting students with concussion. Now that the website has been reviewed and deemed satisfactory and usable, the question becomes, “How do we ensure the long-term success and use of the SCHOOLFirst website?” In-person workshops, while valuable, may not be the most efficient method of educating end users of the SCHOOLFirst website and resource. Approximately half of respondents indicated that online training workshops would be helpful in supporting them to use this website, specifically with the creation of “YouTube video[s] (explaining how to use/navigate the website).” With this in mind, a strong dissemination plan targeting end users at both national and international levels is paramount to raise awareness of the SCHOOLFirst website and how to use it. Sharing the SCHOOLFirst website with key stakeholders (e.g., school personnel, medical professionals, coaches, parents, after-school leaders) will provide them with the knowledge (e.g., What is a concussion?) and strategies (e.g., website orientation video) they need to be a Concussion Champion and support students with a concussion.

This study builds on the findings of Glang et al. (2019) indicating the need to develop evidence-based, cost-effective approaches to transfer TBI knowledge to educators and teachers, such as In the Classroom after Concussion training (Glang et al., 2019, 2019). Particularly, SCHOOLFirst answers the call of researchers and educational management to deliver training for educators by providing an accessible, bilingual website that goes further than providing concussion education to the educators. The SCHOOLFirst website will support educators to appropriately and confidently take actional steps towards promoting positive health outcomes for students returning to school post-concussion.

4.1 Limitations

While the objectives of the study were met, limitations exist. While educating pre-service teachers about concussion and their role in supporting students’ return-to-school post-concussion is important, their experience in education is minimal which limits their perspectives on the topic. Additionally, immediate shifts in knowledge and confidence were measured, with the pre-levels of knowledge and confidence measured retrospectively. This may enter bias into the knowledge and confidence scores. Additionally, this approach to measuring changes in concussion knowledge did not account for maintenance of knowledge (e.g., Does this knowledge remain over longer periods of time?), nor if the SCHOOFirst website was in fact used to support students and if that use was impactful. Future studies to further evaluate the impact of the SCHOOLFirst website can include additional time points for data collection throughout a school year to generate longitudinal data and to explore actual use of the website when supporting students with a concussion.

5 Conclusions

Changes in self-reported concussion knowledge and confidence in supporting the return-to-school process after using the SCHOOLFirst website, along with the usability, satisfaction and intended use of the SCHOOLFirst website, were evaluated within a sample of pre-service teachers. Overall, the participating pre-service teachers were satisfied with the SCHOOLFirst website and intend to use it in the future when supporting a student during the return-to-school process post-concussion. Participants provided valuable feedback to enhance the website to ensure user needs are satisfied using an integrated knowledge translation approach. In the future, broad dissemination of the SCHOOLFirst website to Canadian and international audiences will occur to drive access to essential resources that can help school personnel support students with concussion in returning to their primary occupation, school. Further research evaluation will explore the impact of the SCHOOLFirst website in promoting long-term changes in concussion knowledge and confidence, as well as if using the website leads to changes in behaviours specific to better supporting students with a concussion return to the school environment and school-related activities. This study provides initial support for the SCHOOLFirst website as a meaningful and impactful resource for educators to better support their students with concussion, specifically the understudied population of pre-service teachers.

Declaration of interest

Nick Reed (NR) is a holder of a Canada Research Chair (Tier 2) in Pediatric Concussion and reports receiving grants and research funding from the Canadian Institutes of Health Research (CIHR), Ontario Neurotrauma Foundation (ONF), Public Health Agency of Canada (PHAC), Parachute Canada, Special Olympics Canada, Greater Toronto Hockey League, Dr. Tom Pashby Sport Safety Fund, Holland Bloorview Kids Rehabilitation Hospital and Scotiabank. NR is an investigator in a multicentre study funded by the National Football League (NFL) Scientific Advisory Board; he does not receive any research funding or financial benefit. NR is a minority shareholder in 360 Concussion Care, an interdisciplinary concussion clinic. All other authors have no conflicts of interests to declare.

Footnotes

Acknowledgments

The SCHOOLFirst tool and website were jointly produced by researchers, healthcare professionals, knowledge translation experts, school administrators and staff, family members and youth. The team would like to thank and acknowledge the York Region District School Board (Ontario, Canada) and Parachute, Canada’s leading injury prevention organization, for their collaboration. Additionally, we would like to thank the University of New Brunswick Faculty of Education for their interest in educating their students about concussion through our concussion education workshop and participating in the study.

Funding

The SCHOOLFirst website was funded by the Public Health Agency of Canada. In addition, this research was undertaken, in part, thanks to funding from the Canada Research Chairs Program.

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Demographic Variables	No.	Frequency,
	Responses	n (%)
Grades eligible to teach	30
Elementary^a		10 (33.3)
Intermediate/Secondary^b		17 (56.7)
Both		3 (10.0)
Subjects taught^c	13
Physical education		7 (53.8)
Science		7 (53.8)
French/French immersion		2 (15.4)
English		2 (15.4)
Math		1 (7.7)
Music		1 (7.7)
Social studies		1 (7.7)
Years of experience in education	30
0–5 years		28 (93.3)
5–10 years		2 (6.7)
Experience supporting a student with a concussion	30
Yes		7 (23.3)
No		16 (53.3)
Unsure		7 (23.3)

SUS Questionnaire N = 30	Frequencies, % (n)
	1 –Strongly	2 –Disagree	3 –Neither agree	4 –Agree	5 –Strongly
	disagree		nor disagree		agree
I think I would use this website frequently.	0.0 (0)	3.3 (1)	33.3 (10)	53.3 (16)	10.0 (3)
I found this website unnecessarily complex.	43.3 (13)	46.7 (14)	6.7 (2)	3.3 (1)	0.0 (0)
I thought this website was easy to use.	0.0 (0)	0.0 (0)	10.7 (3)	60.7 (17)	28.6 (8)
I think I would need assistance to be able to use this website.	60.0 (18)	36.7 (11)	3.3 (1)	0.0 (0)	0.0 (0)
I found various functions in this website were well integrated.	0.0 (0)	0.0 (0)	10.0 (3)	66.7 (20)	23.3 (7)
I thought there was too much inconsistency in the website.	60.0 (18)	36.7 (11)	3.3 (1)	0.0 (0)	0.0 (0)
I would imagine that most people would learn to use this website very quickly.	0.0 (0)	0.0 (0)	6.7 (2)	63.3 (19)	30.0 (9)
I found the website very cumbersome to use.	40.0 (12)	50.0 (15)	6.7 (2)	3.3 (1)	0.0 (0)
I feel confident using the website.	0.0 (0)	0.0 (0)	6.7 (2)	66.7 (20)	26.7 (8)
I need to learn a lot of things before I could use this website.	43.3 (13)	46.7 (14)	10.0 (3)	0.0 (0)	0.0 (0)