Physical activity, acceptance and mental health in people with Alopecia Areata: the use of a mixed-methods approach to inform an evidence-based intervention

Alopecia Areata (AA) is a non-life-threatening chronic autoimmune condition characterised by hair loss that can affect all parts of the body. However, the scalp is often affected initially and in some cases the face (eyebrows and eyelashes) and other parts of the body. There are no curative or preventative therapies that sustain the remission of hair loss. Hair loss can lead to anxiety and depression and negatively affects the quality of life (QoL). Few studies have examined mental health issues in people with AA and the success of recommended interventions has been limited. Behavioural activation (BA) through physical activity (PA) is known to have a positive impact on mental health and QoL in the general population. More research is required to determine whether PA can form part of effective therapy for people with AA who have poor mental health. This thesis aimed to (1) investigate the relationship between PA, health-related QoL and mental health in people with AA; (2) identify factors that influence PA behaviours; and (3) implement an evidence-based intervention based on the outcomes of aims (1) and (2) designed to improve the mental health status in people with AA. Study 1 examined the relationship between mental health and PA in people diagnosed with AA. Participants (n=83) completed the following self-report questionnaires; International Physical Activity Questionnaire-Short Form (IPAQ-SF) and the Depression and Anxiety Stress Scale (DASS-21) using the Qualtrics survey platform. The findings showed that 81.9% of the participants did not meet PA guidelines. It was also found that participants with more than 50% scalp hair loss who did not meet World Health Organisation (WHO) recommended PA guidelines were significantly more likely to experience symptoms of severe depression (p=.003), moderate anxiety (p=.04) and mild stress (p=.003) than those meeting guidelines. The findings showed that meeting or exceeding PA participation guidelines was associated with better mental health status in people with severe AA. Study 2 addressed the relationships between PA and mental health but also included health-related QoL.  An international cohort of participants (n=148) completed the IPAQ-SF, DASS-21 and 36-Item Short-Form Health Survey (SF-36) using the Qualtrics survey platform. Multivariate analysis of variance was used to examine the associations between these variables. Sixty-one percent (n=91) did not meet recommended WHO PA guidelines. However, those who meet PA guidelines had significantly better physical functioning (p= .018) and vitality (p = .004) scores than those who did not meet the PA guideline. For the DASS-21 dimensions, the mean score for all three dimensions were improved however no significant differences were found. Therefore, study 3 examined the perceived barriers and enablers of PA participation in people with AA. In study 3, constructivist grounded theory methodology was used to explore the perceived barriers and enablers to PA. Qualitative data were collected from a focus group (8 participants [33.38±10.81years], (male, n= 3 and female, n=5)) and individual telephone interviews (8 participants [33.89±11.87years], (male, n= 2 and female, n=6)). An explanatory model with four phases was developed: (1) onset of AA; (2) reaction to AA; (3) adjustment to AA; and (4) acceptance of AA. Acceptance of AA condition is a process through which the person adapts to the new situation and accepts any limitations imposed by the AA. The main finding to emerge from study 3 was that acceptance was observed to be the key enabler for PA participation.  Study 4 examined the relationship between acceptance of AA, PA participation and distress symptoms. Participants (n=244) completed the IPAQ-SF, Acceptance of Illness Scale (AIS) and DASS-21 questionnaires using the Qualtrics survey platform. Analysis of variance and binomial logistic regression analysis was used to examine the associations between these variables. A total of 56.6% of participants failed to meet recommended WHO PA guidelines. Higher acceptance levels were associated with an increased likelihood of PA participation. Participants who demonstrated a lower level of acceptance of AA reported significantly higher levels of anxiety (p = .0005) and depression (p = .009) symptoms than those with higher acceptance of AA. Findings from studies 3 and 4 strongly suggested that an evidence-based intervention should prioritise increasing acceptance of AA and PA participation to improve the mental health outcomes.  Acceptance and commitment therapy (ACT) is a psychological therapy that encourages participants to be aware and change the relationships between their thoughts and physical sensations via acceptance, mindfulness and value-based action. Study 5 was a randomised controlled trial that evaluated the effectiveness of self-help six weeks ACT intervention online and a PA intervention(s) using prompts, email reminders and provision of a booklet designed to improve mental health outcomes. A total of 49 participants (male n=7 and female n=42) with a mean age of 38.00± 10.62 years diagnosed with AA were randomised into four groups: (1) ACT + PA; (2) PA only; (3) ACT only and (4) control group. The distress symptoms, acceptance of illness, BA and PA levels of the participants were evaluated at baseline and post-intervention using self-report questionnaires. A wrist-worn activity tracker (Fitbit Inspire) was used to measure PA (active minutes) objectively. The findings showed that the ACT +PA group showed significant improvement in AIS score (p = .03), while the PA only group showed significant improvement in depression (p = .04), and stress score (p = .03). Meanwhile, the ACT only group showed significant improvement in depression (p = .002), anxiety (p = .02), and BA scores (p = .001). The control group did not show any significant changes in any of the dependent variables from baseline to post-intervention. The findings suggest that both ACT and PA-based approaches have the potential to increase decrease distress symptoms and increase acceptance of the condition and BA in people with AA.  In summary three key themes emerged from this thesis. Firstly, this thesis highlighted that people with AA reported low mental health and health-related QoL when the recommended PA guideline was not met. Secondly, acceptance of condition is the key enabler of change in PA participation. A higher acceptance level was associated with an increased likelihood of PA participation. Finally, ACT and PA may be beneficial as intervention strategies to improve acceptance of the condition, BA and distress symptoms in people with AA. The results of these five studies, combined with findings summarised in the literature review, suggest that PA and ACT may be beneficial in improving the mental health status of people with AA.