A mixed-method study about performance-enhancing agents: Exploring the insights of university students, public, and sports club stakeholders

Amna M Othman; Maha Saber-Ayad; Hamzah Alzubaidi; Qutayba Hamid; Nabil Sulaiman

doi:10.4103/abhs.abhs_34_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 1 | Issue : 4 | Page : 211-218

A mixed-method study about performance-enhancing agents: Exploring the insights of university students, public, and sports club stakeholders

Amna M Othman¹, Maha Saber-Ayad², Hamzah Alzubaidi¹, Qutayba Hamid², Nabil Sulaiman³
¹ Pharmacy Practice and Pharmacotherapeutics Department, College of Pharmacy, The University of Sharjah, Sharjah, UAE
² Clinical Sciences Department, College of Medicine, The University of Sharjah, Sharjah, UAE
³ Department of Family and Community Medicine and Behavioural Sciences, College of Medicine, The University of Sharjah, Sharjah, UAE

Date of Submission	12-May-2022
Date of Decision	01-Aug-2022
Date of Acceptance	05-Aug-2022
Date of Web Publication	31-Oct-2022

Correspondence Address:
Prof. Nabil Sulaiman
Department of Family and Community Medicine and Behavioural Sciences, College of Medicine, The University of Sharjah, P.O. Box 27272, Sharjah
UAE

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/abhs.abhs_34_22

Abstract

Background: This mixed-method study explored knowledge, perceptions, and practices of performance-enhancing agents (PEAs) among university students, the public, and sports club stakeholders in the United Arab Emirates (UAE). Methods: A mixed-method study was conducted; a total of 353 participants (289 students and 64 members of the public) completed the web-based survey, and 34 sports club stakeholders and 6 community pharmacists were interviewed. Results: These showed that most sports club stakeholders were unfamiliar with the prohibited substances in the UAE. Moreover, some interviewees were unwilling to learn more about PEAs. Out of the participants, 72% of the students and 78% of the public had positive perceptions about prohibiting certain and harmful types of PEAs in sports and reported unfavorable views toward doping agents’ users. Regarding the personal experience with banned substance(s), 5.7% of the students and 3.2% of the public reported using them. There was a clear diversity among sports club stakeholders regarding the problem of doping in the UAE. Conclusion: There were gaps in knowledge about World Anti-Doping Agency’s role. Participants have the impression that doping is prevalent among bodybuilders, non-athletes, and young individuals in private gyms. In conclusion, there is a significant gap in knowledge of doping among university students and sports club stakeholders, highlighting the need for tailored education programs specifically designed for sports club stakeholders, and students aiming at reducing PEAs use.

Keywords: Doping, mixed-method study, performance, students, trainers, youth

How to cite this article:
Othman AM, Saber-Ayad M, Alzubaidi H, Hamid Q, Sulaiman N. A mixed-method study about performance-enhancing agents: Exploring the insights of university students, public, and sports club stakeholders. Adv Biomed Health Sci 2022;1:211-8

How to cite this URL:
Othman AM, Saber-Ayad M, Alzubaidi H, Hamid Q, Sulaiman N. A mixed-method study about performance-enhancing agents: Exploring the insights of university students, public, and sports club stakeholders. Adv Biomed Health Sci [serial online] 2022 [cited 2023 Jun 9];1:211-8. Available from: http://www.abhsjournal.net/text.asp?2022/1/4/211/359981

Background

Performance-enhancing agents (PEAs), used for several medical conditions, are misused by athletes and non-athletes. An example of abuse includes excessive or unnecessary use, non-adherence to the proper use of medication, continued use despite the side effects, and being careless about withdrawal symptoms on abrupt cessation [1]. Over the years, using PEAs in and out of competition has been considered a significant problem that leads to bad influences on athletes and sports clubs. According to the World Anti-Doping Agency (WADA), doping in sports violates one or more anti-doping codes. The violations include consumption, presence, or evidence of the use of banned PEAs and the application of the prohibited method [2]. Despite the enormous efforts established by sports authorities, doping is still prevalent in sports [3,4]. The WADA code’s main aims are to reach the athlete’s fundamental right to participate in doping-free sport; promote health, fairness, and equality for athletes; as well as guarantee well-regulated and effective anti-doping programs at the international and national levels relating to the detection and prevention of doping [5]. Athletes often use those PEAs to enhance their power, speed, focus and help overcome fatigue, injury healing time, and reduce weight [6]. The WADA Anti-doping testing reported an increase in the number of samples analyzed worldwide by 7.1% from 2016 to 2017. Consequently, positive results for prohibited substances have decreased from 1.60% in 2016 to 1.43% in 2017 [7]. The most frequently used PEAs were: anabolic steroids, stimulants, diuretics, and other masking agents [7]. Other studies found that stimulants, cannabis, nicotine, caffeine, and alcohol are the most commonly misused agents by elite athletes [8],[9],[10]. Understanding the factors that promote using PEAs is essential to finding the proper process to defeat using them, starting with the athlete support network and the young generation [11],[12],[13]. In 2009, the United Arab Emirates (UAE) signed the international convention against doping in sports. Since then, there have been social activities and campaigns to raise awareness toward playing fair and enhance the knowledge of risks associated with doping in sports. The influence of such campaigns on the perceptions, behavior, knowledge, and practices of the general population has not yet been explored. The prevalence of PEAs use has been examined in several studies. Also, the preponderance of studies has discussed the perspectives of athletes. However, only a few of them investigated the main sources of those agents and the factors that encourage or discourage athletes from using them. The aims of this study were to measure knowledge, perceptions, and practices of PEAs among university students and the public in the UAE. This study also aims to investigate sport club stakeholders and pharmacists’ views, as they are direct and indirect influencers for the PEAs use by athletes.

Materials and methods

This study used a mixed-method approach to achieve the aim. The first stage was a web-based survey conducted among a total of 353 participants (289 students and 64 members of the public). In the second stage, semi-structured individual interviews were conducted among 34 sport clubs’ stakeholders (managers, coaches, physiotherapists, rehabilitations, and sport clubs’ doctors) and 6 community pharmacists.

Quantitative web-based survey

Participants

The electronic questionnaire was sent by email to all undergraduate students and staff of the University of Sharjah, the general population, the NADO (National Anti-Doping Committee) staff, and sports club stakeholders. A total of 353 participants completed the survey. Participants had to be UAE residents, 18 years old or older, willing to participate in the study.

Instrument

A 29-item, web-based, self-administrated survey was developed to measure knowledge, perceptions, and practices of doping among young university students, the public, and sports club stakeholders in the UAE. The survey was developed based on a literature search, the WADA website, and research team discussion [14].

The questionnaire included four sections. The first assessed sociodemographic characteristics and had questions about age, gender, educational level, year of study (students), occupation (public), range of family/personal income, nationality, playing any sport regularly for at least once a week, and the types of sport. In the second section, participants were asked about their knowledge of WADA’s role, when PEAs are prohibited from using, the type of sanctions imposed on athletes who dope, and the complications of the PEAs. Participants were also asked about the prohibited substances in competing; the choices included the most commonly used PEAs (amphetamine, anabolic steroids, cannabinoids, diuretics, masking agents, growth hormones, and stimulants), as well as allowed substances (caffeine, carbohydrates, proteins, and vitamins). The participants’ knowledge of prohibited substances was assessed using the scoring system; the highest score was 10, and one point was awarded for each correct answer.

In the third section, participants were asked about their perceptions toward the use of PEAs, including prohibiting certain PEAs (i.e., harmful PEAs such as anabolic agents, narcotics, and cannabinoids), the stringency of penalties for a positive drug test, the worthiness of risk associated with the use of PEAs, and how to obtain information about the safe and effective use of drugs in sports. In addition, a validated tool of the 17-Performance Enhancement Attitude Scale (PEAS) for adult and adolescent athletes [15] was used to assess the attitudes toward using PEAs. Five items were removed from the scale to make the scale more suitable for the UAE community. Lastly, in the fourth section, the likelihood of athletes who dope getting away with it was included. Participants were asked about their personal experiences and people they know who use PEAs, the main reasons behind the use of PEAs, and the sources of PEAs from their estimates.

The survey was available in both Arabic and English languages. The English survey was translated to Arabic and back-translated to ensure validity, accuracy, and readability. The questionnaire was pilot-tested with two academics and three laypeople; minor changes were introduced according to their feedback. Dealing with data as anonymous was confirmed for all participants. A reminder email was sent after 4 months.

Statistical analysis

Data were described in terms of mean ± standard deviation (SD), frequencies, and percentages when appropriate. Categorical data were compared using the χ² test. In measuring perception questions, results were calculated and compared the total scores of PEAS using the non-parametric Mann–Whitney test (P-value> 0.05).

Qualitative in-depth semi-structured interviews

Study design

A total of 40 semi-structured individual interviews were conducted to gain an in-depth understanding of sports club stakeholders’ and community pharmacists’ perceptions, awareness, and information about athletes’ doping in sports.

Setting

The qualitative study was conducted in 15 sports clubs, 3 sports authorities, and 3 community pharmacies in six cities in the UAE (Abu Dhabi, Dubai, Sharjah, Fujairah, Ras al-Khaimah, and Umm Al Quwain).

Participants

Participants were stakeholders of sports clubs, including managers, coaches, physiotherapists, rehabilitation experts, sports club doctors, and community pharmacists. Eligibility criteria were adults (≥18 years) who speak Arabic or English and UAE citizens or residents. Two sports club lists were obtained from the UAE National Anti-Doping Committee (UAE-NADO) database and the University of Sharjah database to identify potential participants. In addition, the research assistant recruited community pharmacists conveniently from two chain pharmacies that sell sports-related products.

Data collection and analysis

The interviews were face-to-face or by phone (to cover a wide geographic area). Written consent forms were obtained before conducting the face-to-face interviews, and verbal consent was obtained for the participants who did the interviews over the phone. Participants were given the option to choose the preferred language to conduct the interview, which was conducted in either Arabic or English by a bilingual researcher. Following analysis data of 35 interviews, data saturation was reached. Five additional participants were recruited to ensure achieving data saturation. On average, the interview took about 30 min. All interviews were audiotaped and transcribed verbatim. Arabic transcripts were translated to English by the interviewer (AO). All transcripts were imported into NVivo (QSR NUD*IST Vivo: version 10). Thematic analysis was used whereby the researcher (AO) examined the data to identify meaningful phases and coded them into free nodes. Subsequently, free nodes were sorted under common themes. The study team continually revised the data coding process, and minor discrepancies were discussed and resolved.

Results

Quantitative results

A total of 353 completed the survey: 289 students (age: 18–20± years, 34% males) and 64 members of the public (40± years, 45.3% males). The majority of the public’s respondents had a university education (98.4%), and 93.8% of the public respondents had a full-time job. The sample included respondents from diverse backgrounds, UAE citizens, and expatriates. More than half of the students (56.3%) and public respondents (57.1%) engage with sports and prefer regular exercises in gym, such as cardio and weight lifting. The demographics of participants are covered in [Table 1].

Table 1: Sociodemographic characteristics of students (n = 289) and the public (n = 64).

Click here to view

Knowledge

The participants’ information about WADA role was explored; only 4.8% of the students had great information about the WADA role, and 34.9% mentioned that they are aware to some extent. In addition, only 9.5% of public group participants said that they had great information about it. Around 51% of the students and 65.6% of public respondents knew that doping agents are prohibited for both bodybuilders and athletes in local and international competitions. However, most 62.4% of the students and about half of the public respondents could not identify the number of years the athlete could be prevented from competing if he/she dopes. The majority of the students (74.5%) and public participants (69.8%) admitted that PEAs have a harmful consequence on public health and correctly recognized their complications such as heart failure and liver damage. Regarding the students and the public knowledge of identifying the prohibited substances in sports, most students had scores between 5 and 7 (score 5= 14.3%, score 6= 13.9%, score 7= 14.3%), and most public participants had a score of 8 (17. 9%). Only 3.4% and 7.5% of students and the public had the highest score of 10. As shown in [Figure 1], most students estimated that 21–40% of athletes in the UAE use PEAs, whereas one-third of the public respondents believed that 20% or fewer athletes use doping agents to improve their performance.

Figure 1: Percentages of athletes who use performance-enhancing agents, according to students and the public estimates.

Click here to view

Perceptions

About 72% of the students and 78% of the public agreed on prohibiting PEAs. Regarding the perceived strength of the penalties for doping users, current punishments were found stringent by about 50% of students and 44.4% of the public respondents. Moreover, 17% of students and 15.9% of the public stated that using PEA is worth its risks. Considering the source of information that athletes should seek, most of the students and public nominated doctors (86% and 90%), pharmacists (45% and 31.7%), coaches and trainers (40.6% and 46.7%) as the three top sources of information athletes should use. Furthermore, the modified PEAS was used to explore the perception of the study population. The PEAS scores were 95.2% and 77.9% for students and the public, respectively.

Practices

The survey explored respondents’ use of PEAs. Of students, 5.7% had a personal experience with banned PEAs, and 3.2% of the public used them in the past. Of students, 5.4% stated that they are currently using PEAs, but none of the public did so. Moreover, 27.8% of the respondents knew people in the sports community or gym who use PEAs, and 21% think so but are unsure. Participants were asked to rate how likely they could get away from penalties if they tried to use a banned substance during the competition; the preponderance of the students (27.5%) and the public (37.1%) stated that they could get away quite likely. Finally, students stated several reasons for athlete doping: enhancing performance at local or international competitions, getting results easily and quickly, and changing the body shape. Most public respondents (79%) stated that “it’s an easy and quick approach to achieve goals.” Regarding the sources of PEAs, participants were asked to give their guesstimates about how athletes obtain the PEAs from what they have heard or know; students and the public gave the highest estimates for local gym stores (59.8% and 74.1%), other athletes (74.1% and 54.3%), and online shopping (58.3% and 72.4%). [Table 2] represents different estimations for PEAs sources.

Table 2: Sources of performance-enhancing agents, according to students (n = 276) and the public (n = 58) estimates.

Click here to view

Qualitative results

In total, 40 participants were individually interviewed. Two main themes were identified. The first main theme was knowledge about PEAs with three subthemes: (i) familiarity with prohibited substances, (ii) complications of doping, and (iii) reasons behind the use of PEAs. The second main theme was perceptions about PEAs use with four subthemes: (i) attitudes toward athletes PEAs use, (ii) perceptions about the impact of sanctions, (iii) the use of PEAs, and (iv) doping problem in the UAE.

Theme 1: Knowledge about PEAs

Participants had significant deficits in their knowledge, specifically concerning banned substances and WADA list contents. Only a few interviewees were able to state some agents listed in the WADA list.

Some interviewees disinclined to learn or gain more information about the WADA list, specifically managers and pharmacists. Interviewees in general were familiar with complications and adverse effects of PEAs.

When we asked participants about the reasons(s) that encourage athletes to use of PEAs, the most reasons expressed by participants were as follows: the desire to increase self-confidence, yearning for financial gains by achieving exceptional records in the fastest and easiest way possible, and an aspiration to become famous.

Theme 2: Perceptions about PEAs use

Concerning the perceptions of authorities and sports club stakeholders, there was a collective unfavorable view of the use of doping substances by athletes. The findings from the interviews suggest that the use of PEAs is a multifaceted issue which has social, athletic, health, and economic implications. This was further elaborated by a doctor and a manager who pointed out and underlined that fact. According to a trainer, interviewee mentioned that those athletes would experience issues that can affect their life.

There were opposing views about the current sanctions. Some participants appreciated the existing sanctions, and they described it as it is stringent enough. They considered that the use of PEAs had declined remarkably over the years as the current regulation brought various sanctions, including preventing athletes from participating in competitions for up to 8 years.

In contrast, some interviewees suggested that the sanctions should be more stringent, as punishing the athlete only will not solve the problem. Some interviewees stated that doping should be considered as a criminalization.

Some of the interviewees argued that it is possible to determine and differentiate between PEAs-users and non-users’ athletes by assessing his/her performance during the training, changes in athletes’ behaviour, and mode. In contrast, some interviewees, managers mainly, strongly advocated that the only way to determine the use of PEAs by the athlete is through the National Anti-doping Agents’ testing processes. There was a clear diversity among interviewed stakeholders regarding the prevalence of PEAs, and some of the interviewees (two managers and coaches) emphasized that the use of PEAs is prevalent in the UAE.

Regarding the sources and introducers of PEAs, the majority of interviewees reported that owners and coaches introduce doping agents to athletes, in sports clubs and gyms. These parties, along with the pharmacies, are the agents where athletes gain access to the PEAs. The internet, unlicensed workers, and gym stores have a negative role in the distribution of doping agents as mentioned by many interviewees. Some pharmacists pointed out the use of Liv 52 (a herbal medication that contains Caper bush, Black nightshade, Arjuna, Yarrow, and Tamarisk).

One other aspect of the use of PEAs was pointed out by the interviewees, which is the unintentional consumption of prohibited substances, for example, by taking flu medications which are prescribed by the doctors working in private clinics and hospitals or given by pharmacists who are unaware of existence of banned substances in these medicines. [Table 3] shows the themes, subthemes, and selected quotations.

Table 3: Themes and subthemes among sports club stakeholders and community pharmacists (n = 40).

Click here to view

Discussion

This was the first mixed-method study about doping in sports in the UAE. In this current study, we used a mixed-method (the web-based surveys and semi-structured individual interviews) to gain an in-depth understanding of knowledge, perception, and practices toward doping of students, the public, sports club stakeholders, and community pharmacists. Overall, the majority of respondents were not familiar with the WADA role, similar to the results shown by a survey conducted for undergraduate pharmacy students in Qatar [14]. Almost all public participants in our study had a university degree or higher, and some were working in anti-doping organizations. Thus, they had better scores than the students in classifying the prohibited and allowed substances. Nevertheless, university students did not have good ratings, which might reflect insufficient information about doping substances in the undergraduate curriculum. All survey participants were somewhat knowledgeable about PEAs complications compared with sports club stakeholders. Defects of knowledge identified among the interviewed representatives of the sports clubs may raise questions and doubts about the effectiveness of the implementation of rules and sanctions to prevent the use of PEAs in sports in the UAE. Similar results are revealed by studies done among young and adult Korean athletes [16] and professional Ugandan athletes [17]. They showed that about 50% of the participants indicated their familiarity with general information about doping, such as the testing procedures and rule violations. However, in a study done in Alain, UAE, the majority of gym users were familiar with the anabolic steroid effects, such as increased muscle mass, but only a minority were aware of the associated health risks [18]. The discrepancy may be explained by the different cohorts included in different studies. No significant difference was shown among students’ year of study. According to the findings, 50% and 62.3% of the public and students were not able to recognize the number of years athletes are banned from competing due to the detected use of prohibited drugs. This implies that there is limited knowledge about penalties of PEAs use and what might lead the athletes and sport clubs’ stakeholders to be more permissive with PEAs. The perception toward doping is an important variable because it is considered a predictor of using the PEAs by athletes [19]. The PEAS was mostly chosen by many studies to measure attitudes of doping, as this scale has been evaluated and considered as a sound candidate measurement tool of doping attitudes, with excellent reliability and validity estimates [20]. In this study, the majority of students and the public agreed on prohibiting certain types of PEAs and believed that penalties are stringent enough, and agreed that the PEAs are not worth the associated risks, although about 15% stated that it is worth it. However, the majority of gym users of the city of Alain, UAE stated that anabolic steroids improve their strength, develop a better body shape, enhance their performance, and help in winning the competitions [18]. Furthermore, 27% of the respondents reported that the benefits of AS exceed the associated risks. This may reflect increased awareness about the risks of AS in the last decade, which was also concluded in a study done in Saudi Arabia [21]. Some investigators consider the risk of doping as only an added tiny part to the overall risk of some sports. They believe that legalization of doping is likely to encourage more rational use of drugs, with an overall decrease in the rate of associated health problems through allowing medically supervised doping [22]. Students rated healthcare professionals as the most used source of information on drugs by athletes, whereas the public voted for internet search engines and other athletes. The majority of both groups stated that athletes should seek doctors’ advice for safe and effective use of medications, which was also rated by the majority of pharmacy students in Qatar [14]. Results of Kim and Kim [16] showed that more permissive attitudes toward doping were demonstrated by the athletes younger than 18 years in the motor skill group than those in the team category. Brand et al. [19] used a picture-based doping—BIAT (brief implicit association test) an indirect measurement of attitudes—and compared between bodybuilding athletes and handball players. To validate the outcome of the BIAT attitude test, they used the PEAS as a direct test. Less negative estimations of doping were shown by bodybuilders, compared with handball players. However, results of Muwonge et al. [17] exhibited that previously doping athletes and bodybuilders had higher mean PEAS scores than handball players. The prevalence of PEAs use has been examined in several studies in addition to measuring knowledge, attitude, perception, and practice of athletes. Still, only a few investigated the main sources of those agents and the driving forces to use them. The present study found that personal experience and current use of PEAs among students were low. Additionally, no one stated the current consumption of PEAs from the public participants. This might be because the public sample was highly educated, and some of them are currently working in the field of anti-doping. Moreover, pharmacists interviewed mentioned the high purchases of Liv 52 by athletes, which helps to prevent liver disorders [23] and might indicate the use of oral steroids by the athletes.

In Saudi Arabia, urine sample databases were analyzed and reviewed for Saudi Arabia athletes to investigate the use of prohibited PEAs sourced from sports events and were gathered outside and inside sports competitions in a period from 2008 to 2016 [5]. The prevalence of doping substances use among athletes was 6.6% in 2012 and dropped to 1% in 2015. Bodybuilders had the highest prevalence, followed by track and field athletes and football players. A previous study investigated doping prevalence in two distinct sporting occasions in 2011: the World Championship in Athletes (WCA) in South Korea and the Pan-Arab Games (PAG) in Qatar [24]. The investigators showed that doping prevalence was about 43% at WCA in Korea, whereas it was 57% at PAG in Qatar. The researchers stated that by using this technique, the prevalence of doping appears to be much higher than that indicated by biological testing. The study concluded that doping was highly unchecked in the elite athletes, despite having newly developed techniques. In contrast, another study done in Korea between 2013 and 2014 showed that only 1–2.8% of Korean elite athletes used PEAs [16]. Moreover, a study from Uganda [17] reported use by 3.9% of athletes. This may be related to more stringent regulations followed in those countries compared with the UAE, including the duration of banning the athlete from practice.

Conclusion

This study revealed gaps in knowledge among sports club stakeholders, highlighting the need for better education programs specifically designed for sport clubs’ stakeholders, including managers and coaches and healthcare providers. There is also a need for raising awareness and improving knowledge about doping in the university curriculum.

Study limitations

The strengths associated with this study include that this study used mixed methods that enabled an in-depth understanding of the factors associated with the use of PEAs. However, this study has some limitations that should also be acknowledged. This quantitative part of the study was carried out in a single university, which may not provide the general perception of students; however, the University of Sharjah receives local and international students from various countries. Moreover, the survey was distributed online and data were self-reported.

Acknowledgements

The authors are thankful to all the participants for sharing their insights about doping agents. The authors acknowledge Dr. Abdelaziz Saeed Al Mheiri for his time and efforts in providing lists of sports club stakeholders with their contact details.

Authors’ contributions

AMO assisted in all stages of research including recruitment of all participants, contributing to data processing, writing of the draft, and submitting the manuscript. NS and QH secured the funding and supervise all the stages of research, including data interpretations. All authors contributed critically and substantially to data interpretation. All authors were involved in revising and editing the manuscript. The authors approved the version to be published and all took the responsibility for the content of the publication.

Ethical statement

The study was reviewed and approved by the Human Research Ethics Committee at the University of Sharjah in 05/02/2018 (reference number: REC-18-01-30-01-S).

Financial support and sponsorship

This work was supported by the UAE National Anti-doping Committee (NADO) under grant number 120308.

Conflicts of interest

The authors report no conflicts of interest.

Data availability statement

The data used to support the findings of this study are included within the article and its supplementary material.

Declaration of patient consent

Not applicable.

References

1.	Vahia VN Diagnostic and Statistical Manual of Mental Disorders 5: A quick glance. Indian J Psychiatry 2013;55:220-3.
2.	WADA. World Anti-Doping Code. 2019. 2019. Available from: https://www.wada-ama.org/en/resources/the-code/world-anti-doping-code [Last accessed on 18 June 2018].
3.	de Hon O, Kuipers H, van Bottenburg M Prevalence of doping use in elite sports: A review of numbers and methods. Sports Med 2015;45:57-69.
4.	Davis N Sport doping study revealing wider usage published after “scandalous” delay \| Sport \| The Guardian. 2017.
5.	Al Ghobain M The use of performance-enhancing substances (doping) by athletes in Saudi Arabia. J Family Community Med 2017;24:151-5.
6.	McDuff DR, Morse ED, White RK Professional and collegiate team assistance programs: Services and utilization patterns. Clin Sports Med 2005;24:943-58.
7.	World Anti-doping Agency. Anti-Doping Testing Figures. 2017.
8.	Diehl K, Thiel A, Zipfel S, Mayer J, Schneider S Substance use among elite adolescent athletes: Findings from the Goal study. Scand J Med Sci Sports 2014;24:250-8. https://doi.org/10.1111/j.1600-0838.2012.01472.x.
9.	Drobnic F, Galilea PA Doping control adverse results prevalence worldwide for 13 consecutive years. Apunt Med l’Esport 2018;53:11-8. https://doi.org/10.1016/j.apunts.2017.09.002.
10.	Mündel T Nicotine: Sporting friend or foe? A review of athlete use, performance consequences and other considerations. Sport Med 2017;47:2497-506. https://doi.org/10.1007/s40279-017-0764-5.
11.	Sullivan PJ, Feltz DL, LaForge-MacKenzie K, Hwang S The preliminary development and validation of the Doping Confrontation Efficacy Scale. Psychol Sport Exerc 2015;16:182-90. https://doi.org/10.1016/j.psychsport.2014.04.011.
12.	Baron DA, Reardon CL, Baron SH Doping in sport. Clinical Sports Psychiatry: An International Perspective. John Wiley and Sons; 2013:21-32. https://doi.org/10.1002/9781118404904.ch3.
13.	Boardley ID, Smith AL, Mills JP, Grix J, Wynne C Empathic and self-regulatory processes governing doping behavior. Front Psychol 2017;8:1495. https://doi.org/10.3389/fpsyg.2017.01495.
14.	Awaisu A, Mottram D, Rahhal A, Alemrayat B, Ahmed A, Stuart M, et al. Knowledge and perceptions of pharmacy students in Qatar on anti-doping in sports and on sports pharmacy in undergraduate curricula. Am J Pharm Educ 2015;79:119.
15.	Nicholls AR, Madigan DJ, Levy AR A confirmatory factor analysis of the performance enhancement attitude scale for adult and adolescent athletes. Psychol Sport Exerc 2017;28:100-4. https://doi.org/10.1016/j.psychsport.2016.10.010.
16.	Kim T, Kim YH Korean national athletes’ knowledge, practices, and attitudes of doping: A cross-sectional study. Subst Abuse Treat Prev Policy 2017;12:7. https://doi.org/10.1186/s13011-017-0092-7.
17.	Muwonge H, Zavuga R, Kabenge PA Doping knowledge, attitudes, and practices of Ugandan athletes: A cross-sectional study. Subst Abuse Treat Prev Policy 2015;10:37. https://doi.org/10.1186/s13011-015-0033-2.
18.	Al-Falasi O, Al-Dahmani K, Al-Eisaei K, Al-Ameri S, Al-Maskari F, Nagelkerke N, et al. Knowledge, attitude and practice of anabolic steroids use among gym users in Al-Ain district, United Arab Emirates. Open Sport Med J 2009;2:75-81. https://doi.org/10.2174/1874387000802010075.
19.	Brand R, Wolff W, Thieme D Using response-time latencies to measure athletes’ doping attitudes: The brief implicit attitude test identifies substance abuse in bodybuilders. Subst Abuse Treat Prev Policy 2014;9:36.
20.	Petróczi A, Aidman E Measuring explicit attitude toward doping: Review of the psychometric properties of the Performance Enhancement Attitude Scale. Psychol Sport Exerc 2009;10:390-6. https://doi.org/10.1016/j.psychsport.2008.11.001.
21.	Al Nozha OM, Fadel HT Student perception of the educational environment in regular and bridging nursing programs in Saudi Arabia using the Dundee Ready Educational Environment Measure. Ann Saudi Med 2017;37:225-31.
22.	Kayser B, Mauron A, Miah A Viewpoint: Legalisation of performance-enhancing drugs. Lancet2005;366:S21. https://doi.org/10.1016/S0140-6736(05)67831–2.
23.	Huseini HF, Alavian SM, Heshmat R, Heydari MR, Abolmaali K The efficacy of Liv-52 on liver cirrhotic patients: A randomized, double-blind, placebo-controlled first approach. Phytomedicine 2005;12:619-24.
24.	Ulrich R, Pope HG Jr, Cléret L, Petróczi A, Nepusz T, Schaffer J, et al. Doping in two elite athletics competitions assessed by randomized-response surveys. Sports Med 2018;48:211-9.