To our knowledge, this is the first study that has examined the associations between PA and mental health outcomes among Australian individuals with AA. The study results indicated that majority (81.9%) of the participants did not meet recommended PA guidelines and all participants were symptomatic for anxiety and depression. In addition, scalp involvement (50% and above) was a significant predictor for symptomatic depression, anxiety, stress and not meeting the recommended PA guidelines.
The findings from this study are in agreement with an earlier study conducted in 1991 where high rates of anxiety (39%) and depression (39%) were reported in a cohort of 31 individuals with AA in the United States [25]. Similar high trends of anxiety and depression were also observed in a study conducted in Iran, with a high percentage of participants suffering from anxiety (47%) and depression (56%) respectively [26].
A study in Brazil indicated that hair loss was a common complaint among 157 women with AA and it was associated with a high prevalence of depression (29%) [27]. In another study conducted among 3568 individuals with AA at tertiary care hospitals in Boston, United States indicated that during an 11-year period, mental health conditions such as depression or anxiety were found to be as high as 25.5% [3].
Individuals with minimal hair loss are able to cover the loss with remaining hair and are less likely to experience depression, anxiety and stress [19]. In a qualitative study conducted in the United Kingdom, individuals with AA indicated that hair loss was viewed as a negative attribute and reported the experience of stigmatisation, including being stared at, and receiving comments that hair loss was a sign of illness [28]. Wearing a wig to conceal hair loss has a positive impact on mental health status, but managing the noticeability of wigs can to lead to significant negative interpersonal consequences, including avoidance of social situations and exercise [28]. The participants further explained that wearing a wig also led to reduced activity, in particular sports activity, was avoided due to concerns about having to take off the wig or it falling off.
The IPAQ-SF was used in this study to measure the total PA. This scale has been recommended for population based studies due to its ease of administration, but it may tend to overestimate PA due to the lack of sufficient information about specific domains [29]. Nevertheless, the proportion of participants who did not meet PA guidelines (81.9%) in the current study was much higher than that in the general Australian population (52%; ABS, 2016). One reason for the low PA levels among participants in the current study could be that some participants wear a wig to conceal hair loss, which may lead to reduced activity, particularly sports activity [28]. Interventions in the form of PA in individuals with AA to improve mental health conditions have not been reported before. However, a study conducted in the United States found that individuals with AA were motivated to seek an alternative coping strategy such as PA due to their dissatisfaction with their current medical treatments. More than half of the respondents pursued exercise, while others tried yoga and other relaxation techniques (50.4%) [30]. However, the outcome of the utilisation of PA was not reported in the study cited above.
Over the past two decades the literature in PA and mental health has been rising, but it appears that the positive outcomes have not been well utilised by health practitioners [31] as a management strategy. However, a study on willingness of psychologist to promote PA as psychological management, which involved 236 psychologist revealed that 83% reported often recommending PA, 67% often provided PA advice, and 28% often did PA counseling [32]. This study indicated that there was a high level of PA recommendation as part of mental health management among psychologists despite having minimal formal training in exercise promotion [32] .
Several studies have shown that PA had a positive impact on mental health in the Australian population [13], suggesting that it is feasible intervention for people with AA. The effects of PA are similar to those of psychotherapy and are apparent in a relatively short period of time (4 to 8 weeks) [31]. However, other findings suggest that a one size fits all intervention may not be suitable for individuals with AA [33]. Preferences for PA, and perceived barriers vary widely across populations especially in AA where the hair loss noticeability plays an important role in determining PA participation [28].
PA has a high level of acceptability as a management among individuals experiencing mental health conditions [34]. To support the change and promotion of PA interventions for individuals with AA, more research is needed to explore the interests of people with AA [35]. Individualised PA intervention should be implemented addressing the barriers and enablers to PA. Such personalised interventions have been successfully implemented in other clinical populations [33].
There are several limitations of the current study that should be noted. This was a pilot study, and gender of the participants was not recorded and thus gender effects could not be determined, and also the sample size was small, limiting the analysis of smaller subsets within the sample.