ARTICLE
Background
Androgenetic alopecia, or male pattern hair loss (MPHL), is a common
condition that has been reported to affect 29-40% of men between 18 and
59 years of age [1-3]. Despite the accepted psychological effects of MPHL,
few studies have been conducted to investigate and quantify this relationship.
Of those which have been reported [4-6] most have relied on selected samples
of men seeking medical attention for their hair loss and may not be representative
of the general population. In addition, many of the earlier studies that
investigated the psychosocial effects of MPHL used scales that are not
specific to this condition. However, these global psychological measures
may not be sensitive enough to detect meaningful effects in men with hair
loss.
Using measures specific to hair loss, Cash et al. [6] documented
the negative psychological effects of hair loss on men and women in a
US survey of patients seeking treatment for androgenetic alopecia, compared
to female control patients. These results were supported by a recent study
conducted in men recruited from a community near Dayton, Ohio [7], which
found that men with hair loss are significantly more distressed, self-conscious
and dissatisfied with their hair appearance relative to men without hair
loss. However, no studies using measures specific to hair loss and population
sampling methodology have been conducted to investigate the effects of
hair loss on men in the general population of various European countries.
This study was designed to address this void by using measures specific
to the problems and concerns expressed by men with hair loss [8] and a
sampling methodology that included men representative of the general population
in four major European countries (Germany, France, Italy and the United
Kingdom).
Materials and methods
Randomly selected samples of men 18 to 40 years of age were surveyed
in each country. This survey was a part of a larger omnibus survey that
is routinely conducted in the UK and Italy every 2 to 4 weeks. The demographic
characteristics of the sample in each country were comparable to that
of the general population in that country. A personal interviewer identified
participants, and the respondent then completed a questionnaire in his
primary language without any assistance from the interviewer.
The questionnaire was initially developed in the United States in American
English to evaluate the impact of hair loss on men's health-related quality
of life. The instrument was translated from American-English into French
for use in France, German for use in Germany, Italian for use in Italy
and British-English for use in the UK using the standard forward-backward
method [9-11]. Prior to data collection, each translated version of the
questionnaire was pilot-tested for comprehension [12] with 10 men in each
country.
Men rated their hair loss using a categorical scale with seven responses:
"a full head of hair", "only a little hair loss", "some hair loss", "moderate
hair loss", "a good bit of hair loss", "a lot of hair loss", and "I am
bald". In addition, men circled the classification that they felt best
matched their hair loss pattern, using the Norwood/Hamilton scale [1,
2]. Men were also asked questions that were specific to hair loss, including
previously validated measures [8] of satisfaction with their hair appearance
(on top of their head, frontal hairline, and overall), degree of bother
due to hair loss, extent of concern about aging, and perceived noticeability
to others [13]. A "hair loss distress" domain score was calculated as
the sum of responses to questions regarding bother and concern about looking
older due to hair loss, whereas a domain score for thinning/shedding included
three questions pertaining to shedding while grooming [7]. Demographic
data, respondent's medical history and data about hairstyle, hair color,
hair length and family history of disease were also collected. Other questions,
identified as most relevant in a previous survey [6], were included on
an exploratory basis to investigate the relationship between hair loss
and worry about appearance and relationships, helplessness, self-confidence
and self-consciousness, preoccupation, impact on social life and job opportunities,
and other pertinent areas specifically related to hair loss. The response
scales of these questions were modified to better conform to the rest
of the present survey. Additionally, data were collected about men's awareness
of hair loss products and remedies, such as surgery, drug therapy, wigs,
and hair styling.
Respondents were categorized into one of the four groups based on their
self-reported degree of hair loss: "a full head of hair", "a little hair
loss", "some hair loss" or "moderate hair loss", and finally, "a good
bit of hair loss", "a lot of hair loss" or "bald".
Differences among men with various degrees of hair loss were assessed
using general linear models (GLM) [14]. Covariates in the model included
marital status (never married, married/cohabitating/widowed/divorced),
age (18-25, 26-30, 31-40), education level (¾ high school, > high
school), and interactions of hair loss and age. Analyses were performed
separately for each country. Bonferroni adjustments for multiple testing
were made for all statistical tests [15]. Spearman rank correlations were
used where appropriate to investigate relationships between individual
variables.
Results
A total of 1,717 men with varying degrees of MPHL were surveyed in France
(n = 502), Germany (n = 508), Italy (n = 383), and the UK (n = 324). The
average (± SD) age of participants was 29.3 (± 6.4) years and
age distributions were comparable among countries. About half of the men
had never been married (51.2%) and half were currently married or cohabiting
(47.7%). Marital status was fairly consistent among countries, except
that fewer men in the UK had never been married (34.6%) and more were
married or cohabiting (59.9%). Overall, 30.1% of the men had completed
college or graduate school; differences between countries probably reflect
the different educational systems. The majority of participants worked
full-time (75%) or part-time (5.7%) and 8.0% were students.
Slightly more than half of the participants (53.5%) in the survey reported
that they had a full head of hair and few men (8.8%) reported more than
moderate hair loss (Table I).
The degree of self-reported hair loss was highly dependent upon patient
age (rs = 0.34, p < 0.001). Of men under 20 years of age,
81.3% reported that they had "a full head of hair", but only 35.2% of
men 35 years or older reported "a full head of hair" with about 30% reporting
at least "moderate hair loss".
Among men reporting hair loss, the average (± SD) age at which
they began to notice hair loss was 23.9 (± 6.8) years of age; however,
men in Italy reported a significantly lower age at which hair loss began
(20.8 years), compared to the other countries (24.6-25.6 years); (p =
< 0.01).
For all four countries, mean scores for the shedding/thinning domain
increased with increasing degree of hair loss (p < 0.0001) (Fig.
1a). These increases were typically independent of age except
in France (p < 0.005) where 18-25 year old men reported higher shedding/thinning
scores than either the 26-30 or the 31-40 year old men (mean ± s.e.:
6.1 ± 0.30, 5.3 ± 0.28, 5.3 ± 0.23 respectively).
Mean scores for the hair loss distress domain also increased with increasing
degree of hair loss in all four countries (p < 0.002) (Fig.
1b). The increase in distress was independent of age for France
and Italy. For Germany, the distress domain scores were generally greater
in younger men, decreasing slightly with increasing age (mean ± s.e.:
4.1 ± 0.33, 3.5 ± 0.19, 3.2 ± 0.14 for men 18-25, 26-30
and 31-40 respectively). However in the UK, men 26-30 reported the highest
distress scores with the older men (31-40 years) reporting the same average
level of distress as the younger men. Hair loss distress in all countries
appeared to be driven mainly by the question pertaining to how bothered
they were by their hair loss rather than concern about looking older due
to hair loss. Marital status and education level were generally not related
to the hair loss distress domain, although a consistent relationship between
education and hair loss measures was found for men in the UK (p < 0.05).
Likewise, the degree of bother due to hair thinning increased with increasing
hair loss in all countries. The degree of concern about looking older
due to hair loss also increased with the degree of hair loss, except in
the UK where the relationship was not significant.
Perceived noticeability of hair loss to others was highly correlated
with self-reported degree of hair loss in all four countries (rs
= 0.73-0.83). Overall, 98% of men with a "full head of hair" reported
that hair loss was "not at all" or "slightly" noticeable while 75% of
the men who reported "a lot of hair loss" or "I am bald" reported that
their hair loss was "very" or "extremely" noticeable to others. In addition,
perceived noticeability to others was strongly related to the satisfaction
measures and degree of bother in each country (rs= 0.58-0.60).
Overall, perceived noticeability to others was somewhat more strongly
related to bother (rs= 0.58) than degree of hair loss (rs=
0.51). As with the other hair loss specific measures, perceived noticeability
also increased with increasing degree of hair loss independent of age
for all countries (p < 0.0001) (Fig.
1c).
In all four countries, men with greater hair loss reported significantly
less satisfaction with their hair appearance (hairline in front, hair
on top of their heads, and hair in general) than men with less hair loss
(p < 0.0001).
The exploratory analyses of measures of worry, helplessness, self-consciousness,
preoccupation and impact on social life yielded results similar to those
presented previously. Men with greater self-reported hair loss reported
significantly greater negative effects for all measures except "opportunity
in your job" (Table 3).
As with previous results, "perceived noticeability to others" was significantly
indicative of greater negative effects for most of the measures.
The general health measures, SF-12 physical (PCS-12) [16] and mental
(MCS-12) domains and the MHI-5 [17], were not related to self-reported
hair loss and were not significantly different from published norms for
men in the United States between the ages of 18 and 34 [16-17].
Discussion
Although less than 12% of men 18 to 40 years of age reported that they
had "a good bit of loss" or greater hair loss, significant negative effects
of hair loss were reported for men surveyed who reported any degree of
hair loss. Men who reported greater hair loss expressed less satisfaction
with hair appearance, a greater degree of bother due to hair loss and
more concern about growing older. In addition, men with greater hair loss
appeared to be more worried, less self-confident and, in general, to have
more negative effects specific to their hair loss than men who reported
less hair loss. Even men reporting only "a little" or "some" to "moderate"
hair loss showed significant negative effects of hair loss relative to
men without hair loss.
Although others have documented the negative effects of hair loss on
men, this is the first study to document the consistency of such effects
across cultures. Generally, trends in the negative effects of hair loss
on men 18 to 40 years of age were similar in France, Germany, Italy, and
the UK. In addition to the degree of self-reported hair loss, "perceived
noticeability to others" was found to be significantly related to most
hair-loss specific measures. Men who perceived their hair loss as more
noticeable to others were less satisfied with their hair appearance and
more bothered by their hair loss. This variable captures the person's
self-conscious awareness of their hair loss. Demographic characteristics
were generally not associated with the hair-loss specific measures. Unlike
the findings from a community study conducted in the US [7] that surveyed
men up to 50 years of age and another former survey [5], we did not consistently
find that younger men were more negatively affected by their hair loss.
It is unknown whether this stems from the lack of a true effect or if
it simply reflects perceptual and cultural differences among countries.
As in previous studies, the general health measures, SF-12 physical and
mental domains and the MHI-5, were not related to self-reported hair loss.
Such measures are often too general and too broadly based to detect important
relationships within specific medical conditions [18, 19]. On the other
hand, disease-targeted measures such as the hair loss specific items in
these surveys, focus on aspects that are affected by a specific condition,
and can be used to identify important concerns of patients with certain
conditions and to measure important changes after treatment [19].
In a previous study by Cash [5], a greater proportion of men with hair
loss reported negative effects of hair loss than men with no hair loss.
This finding was also true for men who were not seeking care for their
hair loss [6]. Our findings also suggest that men with hair loss, the
vast majority of whom are not seeking treatment for hair loss, are more
negatively affected in terms of distress, bother, concern, self-consciousness
and dissatisfaction with hair appearance than men with a lesser degree
of hair loss. This finding was relatively consistent in the different
countries. The random sampling process used in these studies helps minimize
the selection bias associated with studying men seeking treatment, and
better characterizes relationships of these effects and hair loss in the
general community. However, men who are seeking treatment, by definition,
are probably most affected by their hair loss, and may respond to these
instruments quite differently. While treatment-seekers are understandably
more distressed by the condition they seek to remedy, nonclinical samples
of community men also exhibit significant levels of concern and body image
discontent.
Given that the surveys were cross-sectional, no causal inferences can
be made. The degree of hair loss for men who refused to participate is
unknown, and hence, it is difficult to speculate the magnitude of non-response
bias, if any. However, participants in each country appeared to be fairly
comparable to the nation-wide demographics of men in this age group. It
should be noted that substantial regional differences exist between and
even within cultures in terms of perceptions about health and medical
conditions. Despite attempts for cross-cultural validation to achieve
linguistically equivalent instruments, the translated questionnaires could
elicit a different response due to differential interpretation or perceptions
by participants in the different countries. Hence, caution should be used
in interpreting any differences among countries.
CONCLUSION
This study is the first large survey conducted in representative samples
of men in four separate European countries using hair-loss specific measures
to assess how the average man is affected by their hair loss. Male pattern
hair loss appears to have significant negative effects on men 18 to 40
years of age in France, Italy, Germany and the UK. The degree that hair
loss is perceived as noticeable to others appears to be highly related
to these negative effects.
Article accepted on 14/10/99
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