AGA practitioner challenges: A mixed‐methods pilot survey

Androgenetic alopecia (AGA) practitioner care may be hampered by commercial biases and hair loss' omission from most medical curricula.

anything specific on hair loss itself.Commendable efforts to improve dermatological curricula have often been unsuccessful. 1actitioner roles are further challenged by the widespread presence of AGA commercial influences.Approximately 70% of popular hair loss Facebook pages are funded, written or influenced by businesses 3 as is more than 60% of hair loss research. 4,5For example, Alfonso et al. 6 conducted an international study on the psychosocial impact of AGA published in the journal Current Medical Research and Opinion (hereafter referred to as the Alfonso study).It has been cited 159 times according to Google Scholar (as of June 5, 2023) and is funded by Merck.According to Open Payments Data, 7 in 2019 alone, Merck made over 40 000 payments, totaling almost $345 million, to medical professionals for research.Such commercial influences matter.For example, research abstracts can include "spin" or selective and exaggerated reporting of findings that unduly influence how medical professionals interpret the benefits of different interventions. 8Specifically, Alfonso et al. also indicate that finasteride had the highest success rate (62%) of any AGA intervention particularly compared to hair transplants (20%).However, on closer reading, the hair transplant success rate of 20% is based on a sample of just five men whereas finasteride's success rate is based on a larger sample of 29 men.This difference is not highlighted by the authors perhaps because, at the time, the study's funder, Merck sold finasteride.
Commercial biases increase the difficulty in ascertaining the most successful, safe and evidence-supported responses to AGA.Two reviews found that 27% 9 and 68% 5 of dermatological and AGA studies referenced interventions (e.g., drugs or transplants) without any meaningful discussion of their limitations.Comprehensive, evidence based guidance for AGA interventions may not be widely disseminated.As Manabe et al. 10 (pp.1031-1032) note: The fact remains that therapies with no scientific basis, and which, from the dermatological perspective, are entirely without effect, are still prevalent.

| AGA practitioner views are understudied
Previous research about AGA practitioners' views and experiences is rare.2][13] In the first, 11 466 doctors from a market database across the US, Germany, Spain, Japan, and Korea took part.The study was funded by Merck.The second study, 12 funded by GlaxoSmithKline, included 338 AGA practitioners (and 835 men who had recently undergone a hair transplant) from Latin America and Asia.Finally, a survey has been periodically conducted with members of the International Society of Hair Restoration Surgeons; most recently with 197 members in 2022. 13Collectively, these surveys highlight differences in practices and knowledge across AGA practitioners.They emphasize the need for further education on AGA and the challenge for practitioners in providing good patient care.

| MATERIAL S
A wider survey assessed AGA practitioners' understanding and experiences.This study focuses on the survey responses relating to the following subtopics: (1) AGA commercial influences (questions 1a-1j), and (2) constraints around evidenced-based AGA responding (including diagnosis, general ethical dilemmas, the societal influence on AGA, AGA's psychological impact and informed consent; questions 2a-2h).These questions are presented in full in Table 1.To aid readability, questions are also integrated below in the results, some responses are collapsed and percentages are calculated excluding blank responses (~n = 6).The data that support the findings of this study are available from the osf: https://osf.io/wyp46.A fuller version of the results is available here: https://osf.io/8s6va.

| Procedure
Participants took part in an online survey from November 2020 to September 2021.Dermatological and AGA practitioner organizations or networks (largely US and UK based) were identified through a combination of internet searches and cross-referencing from key repositories (e.g., the British Association of Dermatologists lists organizations here: https://www.bad.org.uk/derm-groups-chari ty/ and the ISHRS lists global council members here: https://ishrs.org/about/globa l-counc il/).Thirty-five organizations were approached up to three times (a full list of organizations is available upon request from the first author).Four Additionally, two networks allowed direct posts to their members through their social media (World Scalp Micropigmentation Forum and Scalp Micropigmentation: Team Micro International Community).One indicated they could not pass on the survey as they did not pass on research requests generally.The remaining 28 organizations/ networks did not reply.As an incentive to participate, participants were offered a £10 UK e-voucher.Ethical approval from the lead author's institution (LREC 29-MAY-20) and informed consent for the survey were gained.

| Analytical strategy
Frequencies and percentages of the quantitative responses are reported below.Content analysis allowed for categorization of the qualitative responses alongside presentation of illustrative quotes by the first author.These categories were reviewed against raw responses and between both authors.

| (1a-1c 3) Alfonso study views
Participants were asked to read the abstract of the Alfonso study and were assessed on their understanding and views of it.This included 1a-1d) how correctly they understood four key aspects of the study and their views regarding the study's 1e) evidence and 1f) commercial funding.

| (1a-1d) Understanding of the Alfonso study
Participants were quantitatively asked whether five, false, statements about the Alfonso study were true, false or whether they were unsure.Each statement was written by us (the authors).The statements were designed to explicate an implicit message we believed Alfonso et al. were promoting.For example, the first statement we assessed participants' understanding with was: (1a) "Most of the men with AGA indicated their self-esteem was impaired".
We believed Alfonso et al. promoted this message based on their abstract sentence that: "62% agreed that AGA could affect selfesteem".However, each statement was false as close reading of the Alfonso study would reveal.Thirty-four participants responded.42% on average, indicated at least one of the statements was true and 26%, on average, indicating they were unsure.Just 33%, on average, correctly identified at least one statement was false.The question statements (1a-1d), participants' responses and context from Alfonso study is reported in full in Table 2   "Men consider the consequences of their AGA/ hair thinning to be very serious" Numerical 2h "Male pattern AGA does affect male patients on a day-to-day basis" Numerical evidence quality.Most (61%; n = 19) indicated the evidence quality was high/ convincing.Participants selected the following reasons/ strengths to explain why: because "it took place in 5 different countries" (n = 13), followed by because "it used a quantitative questionnaire" (n = 11), because "it had a large sample" (n = 10), because "it is published" (n = 9) and because "there were many authors" (n = 5).
Participants selected the following weakness(es) as reasons/weaknesses to explain why: because "it does not appear to use validated measures" (n = 9), followed by because "most of the men never had treatment" (n = 7), because "other (unspecified)" (n = 7) and because "it is funded by a pharmaceutical company" (n = 6).for their business and may not be impartial in their selecting criteria" and "These companies have a vested interest").were "dissatisfied with their appearance", 58% disagreed that with "men with hair are much more sexy" and 43% agreed that AGA "makes men look more experienced" (p.1832).
statements: (1h) "Most or all research on AGA is independent and objective"; (1i) "Most knowledge about AGA comes from medical sources" and (1j) "AGA forums are largely independent spaces for those with AGA to discuss their AGA".
(1g) Twenty-one participants estimated a percentage of commercially funded research ranging from 0 to 95%.The average estimated was 25% (SD = 32).Furthermore, (1h) 61% of participants disagreed that "most or all research on AGA is independent and objective", (1i) 36% disagreed that "Most knowledge about AGA comes from medical sources" and (1j) 11% disagreed that "AGA forums are largely independent spaces".

| (2a) Norwood Hamilton scale
Participants were asked to quantitatively indicate their agreement with the following statement: "Male pattern AGA can be diagnosed with the Norwood-Hamilton scale".Of the 28 that responded, 71% indicated they strongly or somewhat agreed, 14% indicated neutrally and 14% indicated they strongly or somewhat disagreed.

| (2b) Ethical dilemmas
Participants were qualitatively asked: "What (if any) ethical dilemmas do they face in their work?".Twenty responded including three that indicated they experienced no ethical dilemmas and 1 which indicated unclearly.Among the remaining 16, five wrote treatment limitations, inefficacy or cost were dilemmas (e.g., "Sometimes a patient can present in a distressed state pleading for a cure for hair loss, when one knows that any treatment is unlikely to be successful"").
A further four revealed pressure to unnecessarily or inappropriately treat worried them (e.g., "when to say no, if I do not think the patient will benefit or what they are asking for is unreasonable").Two more indicated the lack of treatment evidence was an ethical concern (e.g., "Most research around treating AGA is very limited and the field is full of anecdotal or non-human based studies").An additional, two indicated that being mistaken for a medical professional concerned them (e.g., "As a trichologist people think that I am medically qualified so I have to be clear about the limits of my responsibility in treatments").Finally, a further two highlighted the practices of other unethical practitioners presented dilemmas (e.g., "Only the ability to whistleblow and expose wrongdoing to the patient within theatre").

| (2c, 2d) Society's influence
2c) Participants were qualitatively asked: "What role do they think, if any, society (e.g., social media advertising) has on men's AGA experiences?".30 responded.Some responses were multiply categorized forming 42 responses.The majority (86%; n = 36) indicated society played a significant and detrimental role, especially through advertising, celebrity culture, reality TV and social media (e.g., "Social media exacerbates insecurity across the board", "Open to abuse, advertising standards are low to non-existent").Some of these responses noted that society particularly impacted younger men (e.g., "There is a feeling of 'loss' for many young men who lose their hair") or that indicated snake oil remedies and treatment advertising was specifically harmful (n = 4; e.g., "lots of 'miracle' products are advertised that are a waste of money").
Of the remaining responses, three (7%) were positive about society, arguing it promoted solutions (i.e., interventions) or facilitated discussion of AGA distress ("Social media advertising is helpful in promoting treatments as well").Finally, three (7%) responses were unclear.
(2d) Participants were qualitatively asked: "What, if anything, do you think can be done to positively influence society (e.g., social media advertising) so that it might benefit men's AGA experiences?".
Twenty-seven responded with some responses multiply categorized, forming 33 (100%) responses.These were coded into the following: 10 (30%) responses indicated AGA interventions needed to be made more transparent, accessible and normalized so distressed men could access them (e.g., "Encouraging those celebrities etc.
who have had e.g.hair transplant to be open about it").Another 10 (30%) responses indicated society needed better representation of men who had AGA (e.g., "More visible role models who are AGA and don't feel the need to seek treatment").Seven (21%) indicated some interventions could be harmful and required regulation (e.g., "Stop shaming for financial gain" and "Less influence by expensive AGA clinic advertising").Five (15%) responses indicated they were unsure or that they felt there was nothing that could be done (e.g., "Nothing. Cannot close down internet and commercial influences preying on men").Finally, 1 (3%) response indicated "education" was required.

| (2e-2h) Importance of informed consent and AGA's psychosocial distress
Participants were quantitatively asked to indicate their agreement with four questions (2e-2h) about informed consent and psychological distress relating to AGA.These questions were used previously by Lulic et al. 12 Most responses indicated informed consent was important (93%) and psychological distress significant (77%; akin to participants in Lulic et al. 12 ).Full details are presented in Table 3.

| AGA' commercial influences summary
Our analysis found evidence of misinformation arising from commercial biases.An average of 42% of participants were misled by four false statements about the Alfonso study. 6A further 26% indicated they were unsure.This was, at least, in part because Alfonso et al. 6 wrote misleading statements in the abstract (that the study results sometimes contradicted).Less than half of participants were critical about the Alfonso study, 6 for example, believing the evidence was unconvincing (35%) or the commercial funding was a bias (47%).
This reflects the Alfonso study's influence generally; where it has been cited over 150 times and has been used to inform dermatological guidance. 14The Alfonso 6 study had substantial limitations.
For example, it used non-validated measures, lacked a control group and had a skewed framing (that presented AGA as only negative).
Participants were only shown the Alfonso abstract, within a survey and thus may not have had time to read it thoroughly.Nonetheless, this brevity reflects practitioners' reality of having little time to read research in the context of a busy practice.It is concerning that the Alfonso study's commercial influence and limitations may not be recognized.
More broadly, participants underestimated the prevalence of commercial influences on AGA information sources.For example, participants estimated 25% of AGA research was commercially biased when evidence has found at least 66% is. 4,5Commercial influences abound in the AGA 'information landscape' generally.
For example, 68% of 600 popular hair loss intervention Facebook pages 3 ; 54% of 90 hair loss intervention YouTube videos 15 ; and 46% of 73 alopecia intervention YouTube videos 16 12 Latin American practitioners and AGA men echoed this.These findings are encouraging and cohere with official recommendations for AGA practice. 18,19They also emphasize the importance of a pressurefree, timely and informed discussion between practitioners and AGA men.
Additionally, practitioners in this study and in Lulic et al. 12 believed AGA to be distressing for men including on a day-to-day basis.
However, systematic reviews 20,21 have found that biased samples of overly distressed AGA men (e.g., attending clinics) and other methodological issues meant the psychosocial impact was somewhat exaggerated and more likely to be mild to moderate.Indeed, this may explain why substantially fewer of Lulic et al.'s 12 835 AGA men (58%) indicated the psychosocial impact was severe compared to the study's practitioners (77% see Table 1).

| Recommendations
The results from this survey show there is a need to carefully highlighted: "[the] need for physicians to spend sufficient time with patients discussing male AGA, treatment approaches and what patients wish to get out of treatment" (p.901).These surveys provide valuable insight into AGA practitioner's practices.Their strengths include their large sample sizes.However further research, that is not commercially funded and gathers practitioners' views in a more in-depth manner is needed.For example, it is unclear what influence commercial links have or what specific ethical dilemmas practitioners face.Thus, this pilot survey aims to identify practitioner's views on commercial biases (via ten questions: 1a-1j) and constraints on AGA evidenced-based responding (via eight questions: 2a-2h).
indicated they would try to pass on the survey (these were The Institute of Trichologists, Registered Trichologists, British Association of Hair Restoration Surgeons and the International Society of Hair Surgeons). .
4.1.3| (1e) View of evidence of the Alfonso studyParticipants were quantitatively asked to indicate every strength or limitation of the Alfonso study that they believed influenced its TA B L E 1 Question details used in the study including response scales.

4. 1 . 4 |
(1f) View on commercial funding of the Alfonso study Participants were qualitatively asked their views on Merck's funding of the Alfonso study.Half (51%; n = 17) indicated that the funding did not change their view of the study.Participants explained they believed/ assumed the study was not biased as commercial influences are common, as the conclusions seem reasonable, as the interventions are regulatorily approved or as the findings correlated with their own professional experience (e.g., "i assume the rese[a]rchers were independant" and "most studies have some Pharma input").Slightly less than half (48%; n = 16) indicated that Merck's funding of the study did change their view of the study.Participants explained this was because funders' vested interest in the AGA intervention, finasteride, may bias the study (e.g., "Questions etc. may be framed to produce the answers the investigators want"; "they [may] have a vested interest in pursuing the most favorable results

4. 1 . 5 |
(1g-1j) Independence of AGA information Participants were quantitatively asked to estimate 1g) "What percentage (if any) of research on the psychosocial impact of AGA they thought was commercially funded?"Participants were next quantitatively asked to indicate their agreement with the following TA B L E 2 Participants' (N= 34) responses assessing (1a-1d) understanding of the Alfonso study."Most of the men with AGA indicated their self-esteem was impaired" scrutinize research including its framing, funding and design (e.g., sample sizes).The free research tools Pubpeer (https://pubpe TA B L E 3 Participant responses to importance of informed consent and AGA's psychological distress questions (2e-2h) in comparison with Lulic et al.12 participant responses.