Abstract
Introduction
Alopecia areata (AA) is an immune-mediated hair loss condition with substantial psychosocial impact. The impact of AA on social interactions at work has not been established.
Methods
We administered the Negative Acts Questionnaire-Revised Scale to the National Alopecia Areata Foundation database to evaluate workplace bullying in patients with AA.
Results
Ultimately, 673/1,120 individuals who met inclusion criteria completed the survey. Most respondents were female (n = 537, 79.8%), Caucasian (n = 508, 75.5%), with an average age of 46.8 ± 14, and employed full-time (n = 427, 63.4%). Our results demonstrate 21.7% (n = 146) of respondents experienced workplace bullying. Participants most frequently faced having their opinions ignored (53.8%, n = 362), being excluded (47.7%, n = 321), and having gossip spread about them (44.0%, n = 296). Notably, 75.0% (n = 120/160) of individuals who self-reported bullying addressed the behavior; however, 30.8% of participants noted the bully continued (30.8%, n = 37). Stress associated with filing a complaint (43.5%, n = 293) and effect on future career options (36.1%, n = 243) were common barriers to report bullying.
Conclusion
This study expands our understanding of the psychosocial impact of AA by confirming individuals with AA experience workplace bullying. Stigma against patients may play a role in this phenomenon. Future work is warranted to identify strategies to reduce bullying against patients with AA.
Keywords: Alopecia, Alopecia areata, Psychosocial impact, Patient-centered care, Bullying, Stigma
Introduction
Alopecia areata (AA) is an immune-mediated disease of hair loss. The resulting deficit impacts patients across social and professional settings [1]. Although stigmatizing attitudes against patients with AA may impact their ability to find work, the impact of AA on their experience at work has not been explored [2, 3]. Herein, we conduct a cross-sectional survey study to evaluate workplace bullying in patients with AA. We hypothesize that patients with AA frequently experience workplace bullying, leading to negative professional and psychosocial consequences.
Methods
A convenience sample of AA patients was surveyed through the National Alopecia Areata Foundation (NAAF) database using Qualtrics (Qualtrics, LLC, Provo, UT, USA) in August 2021. English-speaking participants 18 years of age or older with AA were eligible. This research was approved by the Mass General Brigham Institutional Review Board, and informed consent was implied by voluntary completion of the questionnaire.
The survey instrument was developed to assess the prevalence of workplace bullying among individuals with AA [1], describe the type of bullying experienced [2], characterize actions taken to address the bullying [3], and identify barriers to addressing the bullying [4] (online suppl. Table 1; for all online suppl. material, see www.karger.com/doi/10.1159/000529924). To evaluate the prevalence and type of workplace bullying, the Negative Acts Questionnaire-Revised (NAQ-R) scale was administered. This 22-item validated tool assesses workplace bullying within the last 6 months using a 5-point Likert scale corresponding to frequency of events. Scores range from 22 to 110 and correspond to being never bullied (<40), occasionally bullied (40–56), and severely bullied (>56) [4, 5].
Results
Of 1,120 individuals who initiated the survey, 673 who met the inclusion criteria completed the survey (completion rate 60.1%) (online suppl. Table 2). Most respondents were female (n = 537, 79.8%) and Caucasian (n = 508, 75.5%) with an average age of 46.8 ± 14.7. Most patients were employed full-time (n = 427, 63.4%) (online suppl. Table 2). 21.67% (n = 146) of individuals with AA experience workplace bullying with an average NAQ-R score of 56.1 ± 15.5 (Table 1).
Table 1.
Prevalence and frequency of bullying based on NAQ-R scores and self-reported data
| Bullying | No | Yes | |
|---|---|---|---|
| never bullied (<40) | occasionally bullied (40–56) | severely bullied (>56) | |
| NAQ-R categories | |||
| Self-reported, N (%) | 513 (76.2) | 160 (23.8) | |
| NAQ-R count, N (%) | 527 (78.3) | 146 (21.7) | |
| NAQ-R scores, mean (SD) | 26.7 (4.8) | 56.1 (15.5) | |
| 46.14 (4.62) | 72.02 (13.31) | ||
The most frequent bullying behaviors experienced included “having your opinion ignored” (53.8%, n = 362), “being ignored or excluded” (47.7%, n = 321), and “spreading of gossips and rumors about you” (44.0%, n = 296). Among individuals who self-reported bullying (n = 160), 75.0% (n = 120) chose to address the behavior most commonly by “[bringing] to the attention of my supervisor or manager” (46.9%, n = 75) or by “[discussing] with my family, friends, or a personal network” (45.0%, n = 72) (Table 2). The most common consequences of addressing the bullying behavior were “the behavior continued” (30.8%, n = 37) and “I left my job” (28.3%, n = 34). The most common barriers to addressing the behavior were “stress associated with filing a complaint” (43.5%, n = 293) and “effect on future career options” (36.1%, n = 243) (Table 2).
Table 2.
Experiences with bullying and barriers to reporting bullying
| Questions | Response | Count | Percentage |
|---|---|---|---|
| Addressing bullying behavior | No, I have not tried to address the bullying behavior | 40 | 25.0 |
| I addressed it directly with the person | 43 | 26.9 | |
| I brought to the attention of my supervisor or manager | 75 | 46.9 | |
| I made an informal or formal complaint to human resources | 23 | 14.4 | |
| I discussed it with a peer | 64 | 40.0 | |
| I discussed it with a senior colleague or mentor | 21 | 13.1 | |
| I discussed with family, friends, or personal network | 72 | 45.0 | |
| I discussed with a lawyer or legal service | 7 | 4.4 | |
| I referred to the police | 2 | 1.3 | |
| (If previous question = they did choose to address the bullying behavior) What was the result of the action(s) you took as identified? | Complaint has not yet been finalized | 16 | 16.7 |
| Complaint was not pursued by the receiving body | 20 | 12.5 | |
| I received an apology | 15 | 9.2 | |
| My employer made changes to the workplace to prevent this behavior in the future | 11 | 20.8 | |
| The behavior stopped | 25 | 30.8 | |
| The behavior continued | 37 | 16.7 | |
| There was retaliation for making a complaint | 20 | 28.3 | |
| I left my job | 34 | 16.7 | |
| Did you experience any of the following as potential barriers in your decision about whether to take action or not? | Effect on future career options | 243 | 36.1 |
| Potential for victimization | 83 | 12.3 | |
| Concern of not being believed or taken seriously | 196 | 29.1 | |
| Loss of reputation for self | 160 | 23.8 | |
| Loss of reputation for perpetrator | 26 | 3.9 | |
| Fear of being blamed | 94 | 14.0 | |
| Loss of support | 160 | 23.8 |
Discussion
This study confirms that individuals with AA experience workplace bullying, adding to our understanding of the psychosocial impact of AA. Patients with AA most commonly reported having their opinions ignored, being excluded, and being victims of gossip in the workplace. Workplace bullying continued even after some individuals addressed the behavior. Common barriers to reporting the incidents included stress associated with filing a complaint and potential effects on future career options.
The motives for workplace bullying of patients with AA are unclear but may stem from stigma against this patient population. One recent study demonstrated that employers feel less comfortable hiring individuals with AA [3]. These employer attitudes in combination with workplace bullying may contribute to the higher rates of work absenteeism, work productivity loss, and unemployment in patients with AA [6, 7]. The culmination of psychosocial obstacles in the workplace and potentially lost income can compound the financial burden and distress experienced by this patient population [7–9]. Thus, future work needs to identify how to reduce bullying against patients with AA through education and awareness and to explore the impact of improved treatments and psychosocial support.
Statement of Ethics
This study protocol was reviewed by the Mass General Brigham Institutional Review Board (#2021P001380), which determined that this project meets the criteria for exemption. Informed consent and authorization were implied by voluntary completion of a questionnaire.
Conflict of Interest Statement
Authors Sara J. Li, BS, Sophia Reyes-Hadsall, BS, and Lara Drake, BA, have no conflicts to declare. Kathie Huang, MD, has received royalty payments for licensing the ALTO, BETA, and BELA tools; participated in clinical trials related to alopecia from Incyte, Lilly, Concert, and Aclaris; and received consulting fees from Concert and Pfizer. Arash Mostaghimi, MD, MPA, MPH, has received royalty payments from Pfizer for licensing the ALTO, BELA, and BETA tools and has participated in clinical trials related to alopecia from Incyte, Lilly, Concert, and Aclaris. In addition, Dr. Mostaghimi has received consulting fees from Pfizer, Concert, Lilly, AbbVie, hims and hers, Digital Diagnostics, and Bioniz.
Funding Sources
No funding was used for this research.
Author Contributions
Authors A.M., K.H., and S.J.L. were involved in conception and study design. Authors S.J.L. and S.R.H. were involved in data collection and analysis. S.J.L., S.R.H., and L.D. were involved in interpretation of the data. All authors, S.J.L., S.R.H., L.D., K.H., and AM, were involved in manuscript draft, revisions, and determining final approval of the manuscript. Dr. Kathie Huang and Dr. Arash Mostaghimi had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Funding Statement
No funding was used for this research.
Data Availability Statement
Data generated or analyzed during this study are included in this article and supplement documents. Further inquiries can be directed to the corresponding author.
Supplementary Material
Supplementary Material
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data generated or analyzed during this study are included in this article and supplement documents. Further inquiries can be directed to the corresponding author.