Knowledge, attitude, and behaviour regarding doping in sports among physicians and pharmacists: a questionnaire-based study ‎

Muhannad Riadh Mohammed Salih¹*, Arwa Younis Abd¹

¹ Department of Pharmacy, Al-Rasheed University College, Baghdad, Iraq.

Correspondence: Muhannad Riadh Mohammed Salih, Department of Pharmacy, Al-Rasheed University College, Baghdad, Iraq. [email protected]

ABSTRACT

Doping is a very commonly reported issue among athletes. The World Anti-Doping Code (WADC), published by the World Anti-Doping Agency (WADA) has laid down the guideline to be followed in order to avoid anti-doping rule violation (ADRV). To explore the knowledge, attitude, and behavior of the physicians and pharmacists in relation to doping in sports.

In this cross-sectional prospective questionnaire-based study the participants (after obtaining consent) were asked to fill in an electronically sent (online) questionnaire anonymously. Out of 159 participants, the majority (47.2% and 73.6%) had knowledge of past cases of doping and knew the word “doping” (p=0.026). 56.10% of the male participants and 28.8% of the female participants opined that they have knowledge of past cases of doping (p = 0.002). Most respondents (57.2%) knew that over the counter medicines and dietary supplements might contain prohibited substances and 49.1% participants were aware that the name of prohibited substances might not appear on ingredients label (p=0.038). There was a significant difference in the physicians’ and pharmacists’ responses toward who should be mainly as advisor of dietary supplements (p<0.001). Despite small number of participants, our study has underlined the need for conducting awareness program at regular intervals regarding doping among the physicians and pharmacists in our country. However, more studies on this topic with larger sample size are required to actually gauge the knowledge, attitude, and behavior of the physicians and pharmacists in this regard‎.

Keywords: Doping, Knowledge, Attitude and behavior, Physicians, Pharmacists

The participating physicians indicated that nutritionists and physicians should have the major involvement as advisor of dietary supplements for athletes 31(48.4%) and 23(35.9%), respectively. Both coaches’ trainers and pharmacists obtained three votes (4.7%) each, and physical therapists and nurses obtained two votes (3.1%) each. There was a significant difference in the physicians’ and pharmacists’ responses towards who should mainly be considered as advisor for prescribing dietary supplements (P <0.001).

17 (17.3%) of the respondents who thought that doping violation in Iraq is intentional had a perception that the athletes are allowed to use such forbidden substances to enhance their performance, whereas 81 (82.7%) of the participants had a perception that the athletes are not allowed to use such substances in order to enhance their performance. On the other hand, 26 (42.6%) participants who describe doping violation in Iraq as unintentional doping indicated that the athletes are allowed to consume the forbidden substances while 35 (57.4%) indicated that athletes aren't permitted to those substances.

There was a significant difference regarding the belief that the athletes are allowed to consume such products to enhance their performance and the doping violation in Iraq (p=0.001) (Table 5).

*Chi-square test, p<0.05 is considered statistically significant.

There was a significant association between attending a lecture about doping and knowing the word doping (P=0.026). Twenty-nine (90.6%) of participants who had attended a lecture on doping knew the word “doping” (Table 6).

*Chi-square test, p<0.05 is considered statistically significant.

There was a significant association between attending a lecture and understanding the ethical concerns about the use of restricted OTC and other performance enhancing dietary supplements (P=0.038). Twenty-four (75.0%) of participants who have attended a lecture on doping know that the OTC medicines and dietary supplements might contain banned substances. Whereas, 67 (52.8%) participants who have never attended a lecture on doping know that OTC medicines and supplements might contain banned substances (Table 7).

*Chi-square test, p<0.05 is considered statistically significant.

In this study we have explored the understanding, viewpoint and behaviors of the physicians and pharmacists in relation to unethical use of drugs in sports, and to understand the individual and social factors associated with it.

In this questionnaire-based study, majority of the participants were males (107; 67.3%) and pharmacists (95; 59.7%) (Table 1). We could not find any apparent reasons for more male participation.

Most of the respondents (117; 73.6%) were aware of the term “doping”; although majority of them (127; 79.9%) did not attend any lecture regarding doping, most of them (147; 92.5%) wanted to attend such lectures in future. Thus it can be suggested that although there is insufficient awareness program on doping and anti-doping in our setting, the enthusiasm is high on the part of physicians and pharmacists regarding enriching their knowledge in this regard.

Although a small percentage of respondents (43; 27%) thought that the athletes were allowed for using banned substances to enhance their performance, it was nonetheless important enough as an eye opener signifying the importance of awareness program in this regard. Again, many of the participants (76; 47.8%) thought that the athletes were restricted to consume such substances, even for medical reasons.

The majority of the respondents were of the opinion that in Iraq doping violations are intentional (98; 61.6%) and most of them opined (116; 73%) that the athletes are not allowed to consume banned substances to enhance their performance.

Although most of the respondents have not come across cases of doping among athletes (84; 52.8%), and many of them have past experience of such encounter (75; 47.2%); the difference was significant only for the first issue (p<0.002) (Table 3). It is to be noted that male participants reported more number of encounters with cases of doping compared to their female colleagues.

Unintentional violation of rules is of serious concern as it might lead to life time sanctions to temporary ban depending upon the gravity of the circumstances. Majority of the participants (91; 57.2%) knew that OTC medicines and other dietary supplements might contain restricted substances and also that their inclusion might not appear on ingredients label (78; 49.1%).

Although majority (57; 35.8%) thought that doctors should primarily get involved in anti-doping activities for athletes, for advice regarding dietary supplements most of the participants opined that nutritionists should take major role (58; 36.5%). However, considering responses based on profession (physician or pharmacist) it is to be noted that physicians thought it is the nutritionist who should take major role regarding advice of dietary supplements but pharmacists responded that it is primarily their (pharmacists’) responsibility (nutritionists’ role came next to them); the difference of choice based on profession was significant (p<0.001) (Table 4).

Again, analysis of the responses revealed that the association between describing doping violation (intentional or unintentional) in Iraq and whether the athletes are allowed to consume restricted substances was significant (p<0.001) (Table 5). Out of the 98 respondents stating doping violation in Iraq to be intentional, 81 respondents opined that athletes were not permitted to use restricted substances to enhance performance and also among the 61 respondents stating doping violation in Iraq to be intentional, 35 respondents opined that athletes were not allowed to use restricted substances to enhance performance.

In addition, the association between knowing the word “doping” and the experience of attending past lecture on the topic was effective (p=0.026) (Table 6).

Again, there was also a significant association between attending a lecture about doping and knowing the fact that restricted substances are included in OTC medicines and dietary supplements (p=0.038) (Table 7).

Literature search revealed that pharmacists play an important role besides physicians for providing the opportunity for common people including athletes regarding appropriate use of medicines [19].

Although it is the responsibility of all the ASPs to prevent ADRV as well as promote and foster anti-doping awareness among athletes, both the pharmacists and physicians as ASPs have special role in this regard because of their specific knowledge about medicines (mechanism of action, potential for abuse, ability to enhance performance and possible short term and long term adverse drug reactions) [20-22].

In a questionnaire-based study conducted by Shibata K and his colleagues regarding knowledge about doping and the need for education for the same among pharmacy students, they found that majority of the students (95%) were aware of the term similar to our findings (73.6%), although in their study (21%) as well as in ours (20.1%) a small number of participants attended any formal lecture in the subject [16]. This can be attributed to the fact that in today’s world information is easily available especially through internet (on different web pages, social media platforms, news portals, etc.), television, and other media.

Moreover, in both ours and their study, the majority of the participants positively opined about attending a lecture on the topic, suggesting the desire among physicians and pharmacists to be able to perform their responsibilities as ASPs as per the guidelines of the WADC.

Other similar studies conducted in other parts of world reported similar results. A study conducted in France revealed that 83% of the participants (pharmacists) have considered doping to be unhealthy for everyone consuming it and also most of them opined that despite being poorly informed (58%) in this regard pharmacists (88%) are to play an important role in preventing doping [23].

Like our study, the study conducted by Japanese researchers also found wrong conception about use of prohibited substances among athletes; 15% of their participants had the misconception that prohibited drugs are allowed among athletes to enhance their performance, compared to 27% of our participants [16]. Similarly 28% of their participants thought athletes never use any prohibited substances despite clear medical indication, compared to 47.8% of our participants.

Both these wrong conceptions can impair professional capabilities of pharmacists and physicians and jeopardize health of athletes. Again, the basic anti-doping regulation laid down by the WADC strictly states that consumption of any prohibited substance can lead to not only ADRV leading to consequences also jeopardize the concerned athletes’ health. On the other hand, sometimes the athlete might actually need the prohibited substance for the benefit of his or her health. As per WADC under these circumstances, consumption of such drugs is allowed under therapeutic use exemption (TUE) provided independent experts authorize such use based on legitimate medical requirement like [24]. Because of the technicalities involved in such process, athletes can always be best guided by physicians and pharmacists because of their knowledge in the subject.

Thus the need for appropriate education for both the physicians and pharmacists in regard to doping and anti-doping should be kept up to date and provided at regular intervals.

Knowing about past doping cases is of utmost importance as such knowledge would make physicians and pharmacists more cautious in this regard, However, both in our study (52.8%) as well as in the published Japanese study (34%) a large number of the participants did not know about past doping cases.

Unintentional consumption of prohibited substances remains as the most commonly reported cause of ADRV; Compared to the Japanese study (48%) in our study majority of the respondents (61.6%) knew that [25, 26].

Both in our study as well as in the Japanese study, majority of the participants (57.2% and 59%, respectively) knew about the restriction on OTC medicines and similarly prohibited dietary supplements. Although it is well known that such prohibited substances most of the times are not mentioned in the product label, majority of our participants (50.9%) were not aware of it compared to only 13% in the Japanese study [16].

Adequately and appropriately making both the physicians and pharmacists working as ASP is of utmost importance as they are the persons who would guide the athlete in choosing and ultimately consuming such OTC drugs and other dietary supplements.

In our study majority of the pharmacists (46.3%) thought it should be them who should mainly be the advisor for prescribing dietary supplements, whereas physicians thought nutritionists (48.4%) should take the major responsibility.

Similarly, in the study by Shibata K 76% of the participants (pharmacists) thought they should mainly be responsible in anti-doping activities [16].

Finally, it can be said that to improve the knowledge, attitude, and behavior of the pharmacists and physicians regarding doping and anti-doping as per the guidelines by the WADC, the need of conducting awareness program among them at regular intervals is of utmost importance. As attending these programs (lectures) would not only brush up their existing knowledge on doping and anti-doping regulations also would keep them up to date about the new additions (if any) to the existing guidelines laid down by the WADC.

There are certain limitations to our study. As per the initial plans, we at first decided to include participants from Al-Rasheed University College/Pharmacy Department and AL-Kindey College of Medicine and they were supposed to fill in the questionnaire in person physically (hard copies); however, because of the current ongoing COVID-19 pandemic we had introduced some modifications and electronic submission of the said questionnaire using the platforms of the Iraqi Medical Association and the Iraqi Syndicate of Pharmacists was decided. It could be the reason why participation was not as high as expected.

Conclusion

To conclude despite the limitations of our study (few participants), it has underlined the need for awareness program to be conducted at regular intervals regarding doping and ADRV among the physicians and pharmacists in our country. However, more studies on this topic with larger sample size are required to actually gauge the knowledge, attitude, and behavior of the physicians and pharmacists in this regard.

Finally, future studies on this topic should include participants like coaches, trainers, dieticians, managers, agents of the athletes, even parents in case of minors as besides physicians and pharmacists they are also an integral part of the ASP team.

Acknowledgments: None

Conflict of interest: None

Financial support: None

Ethics statement: None

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