Defining safer aesthetic practice: An International Public Health analysis of Education, Regulation, Digital Technology and Policy for Botulinum Toxin

Background: Botulinum neurotoxin type A (BoNT-A) is the most performed aesthetic procedure worldwide. Unregulated practice has driven growing public health concerns and imminent regulatory reform. This thesis investigates international practice across regulation, education, workforce, pharmacovigilance, and policy. / Methods: A mixed-methods design combined qualitative, quantitative and experimental approaches. Regulatory governance was benchmarked through legislative and case-law analysis. Pharmacovigilance assessed international databases. Educational provision was mapped internationally and extended through the development and randomised-crossover evaluation of a digital simulation platform. Workforces were profiled internationally with socioeconomic sub-analysis. Behavioural and policy responses were studied using discrete choice experiments with policy simulations. / Results: Stronger regulation was associated with lower practitioner density (r = –0.74, p < 0.001) and greater medical predominance. Pharmacovigilance analysis demonstrated clear underreporting with a large gap between expected and reported complications. International education mapping of 1,163 courses and 248 online resources revealed course volume was inversely correlated with quality (r = –0.58, p = 0.001), and overall poor quality of resources. Digital simulation platform produced cumulative gains in knowledge (+27%) and efficiency (+9%). Workforce profiling of 34,468 practitioners across 21 countries demonstrated significant heterogeneity. In the UK, 28% were doctors, 25% nurses and 25% aestheticians, whilst internationally medical practitioners predominated. In the UK, practitioner density was 6.7-fold higher in the most deprived quintile, with reduced medical access (OR 0.82, 95% CI 0.70–0.96) and increased salon provision (OR 2.18, 95% CI 1.42–3.34). Discrete choice experiments (n = 778) revealed education-stratified safety preferences, a gap between patient expectations and practitioner perceptions, and policy-dependent trade-offs between safety, access and workforce sustainability. / Conclusions: International practice demonstrates variation in aesthetic BoNT-A education and provision related to regulatory frameworks, with public health implications. This thesis provides the first international benchmarks linking regulation, training, workforce, and patient behaviour, and proposes strategies to improve safety and equity.