AbstractObjectives

Doping-related knowledge, beliefs and attitude influence adolescent athletes’ susceptibility to prohibited performance-enhancing substances. They might be modified by different cultural backgrounds. This study’s aim was to analyse the geographical heterogeneity of doping-related knowledge, beliefs and attitude among adolescent elite athletes.

Design

Cross-sectional study.

Method

A questionnaire was distributed to athletes participating in the Winter Youth Olympic Games 2020 in Switzerland. Main outcomes (‘subjective and actual knowledge’, ‘beliefs’ and ‘attitude’) were stratified for athletes’ region of origin. Geographical heterogeneity was tested with a two-way ANOVA, two multiple regression analyses were conducted to assess independent associations of knowledge, age and athletes’ geographical region with doping-related beliefs and attitude.

Results

533 athletes (54% females, mean age: 16.0 ± 1.0 years), completed the questionnaire (response rate: 33%). Actual knowledge was moderate-to-good (9.2 ± 2.9 correct answers out of 13), scores of attitude and beliefs showed favourable patterns. Considerable geographical heterogeneity was found for knowledge (p < 0.001), beliefs (p = 0.004) and attitude (p < 0.001). Higher subjective and actual knowledge were favourably associated with attitude (ß = -0.096, p = 0.049; ß = -0.316, p < 0.001) and beliefs (ß = 0.120, p = 0.016; ß = 0.212, p < 0.001), independent of age and geographical region.

Conclusions

This study demonstrates a considerable geographical heterogeneity of doping-related knowledge, beliefs and attitude, which are three essential target factors of doping prevention in adolescent elite athletes. This evidence should encourage medical doctors and other professionals to change their educative anti-doping approach from teaching knowledge about negative consequences into investigating and forming a young athlete’s mind-set.

1. INTRODUCTIONDoping-related knowledge, beliefs and attitude are key factors in several of the most accepted theoretical concepts of doping behaviour, such as the theory of planned behaviour9.

Chan, D. K. C. H., S.; Dimmock, J.A.; Lentillon-Kaestner, V.; Donovan, R.J.; Burgin, M.; Hagger, M.S., Modal salient belief and social cognitive variables of anti-doping behaviors in sport: Examining an extended model of the theory of planned behavior. Psychology of Sport and Exercise 2014, 1-11.

and the deterrence theory19.Lazuras L. Barkoukis V. Rodafinos A. et al.Predictors of doping intentions in elite-level athletes: a social cognition approach.. Good knowledge about the negative health and legal consequences of doping is believed to deter athletes from active doping behaviour19.Lazuras L. Barkoukis V. Rodafinos A. et al.Predictors of doping intentions in elite-level athletes: a social cognition approach.. Some evidence in elite coaches indicates a stronger association of a person’s perceived knowledge with proactive anti-doping behaviour (e.g. informing other athletes or stakeholders) than of actual knowledge5.

Blank, C. L., V.; Fürhapter, C..; Müller, D.; Schobersberger, W., Doping in Sports: West-Austrian Sport Teachers’ and Coaches’ Knowledge, Attitude and Behavior. Dtsch Z Sportmed 2014, 65, 289-293.

. However, the knowledge-based approach only had limited success in the past, considering the large difference between an estimated prevalence of doping behaviour in competitive sport of more than 30%20.Lentillon-Kaestner V. Ohl F. Can we measure accurately the prevalence of doping?.,29.Uvacsek M. Nepusz T. Naughton D.P. et al.Self-admitted behavior and perceived use of performance-enhancing vs psychoactive drugs among competitive athletes. and less than 2% adverse analytical findings in doping tests. Beliefs about success in sport and the perception of use of banned performance-enhancing substances are assumed important for the decision-making for or against doping in a high pressure-situation3.Barkoukis V. Lazuras L. Tsorbatzoudis H. Beliefs about the causes of success in sports and susceptibility for doping use in adolescent athletes.,23.Moston S. Engelberg T. Skinner J. Self-fulfilling prophecy and the future of doping.,25.Ntoumanis N. Ng J.Y. Barkoukis V. et al.Personal and psychosocial predictors of doping use in physical activity settings: a meta-analysis.. Attitude is defined as an evaluative judgement that is based on personal experiences and modified by socio-environmental influences, like peer-related perceived normative behaviour, as well as cultural norms and moral14.

Fazio, R. H., Attitudes as objective-evaluation associations: determinants, consequences, and correlates of attitude accessibility. In "Petty, R.E. & Krosnick K.A.: Attitude Strength". pp:247-82. Psychology Press, 2014 1995.

. It is accepted as a predictor of doping intentions, leading to higher or lower probability of the decision to dope in a pressure situation22.Morente-Sanchez J. Zandonai T. Zabala Diaz M. Attitudes, beliefs and knowledge related to doping in different categories of football players.. Knowledge, beliefs and attitude are assumed to be modified by sporting culture, perceived peer-related behaviour, moral norms and self-determination8.Blank C. Kopp M. Niedermeier M. et al.Predictors of doping intentions, susceptibility, and behaviour of elite athletes: a meta-analytic review.,12.Engelberg T. Moston S. Skinner J. The final frontier of anti-doping: A study of athletes who have committed doping violations.,25.Ntoumanis N. Ng J.Y. Barkoukis V. et al.Personal and psychosocial predictors of doping use in physical activity settings: a meta-analysis.,27.

Smith, A. C. T. S., B.; Oliver-Bennetts, S.; McDonald, S.; Ingerson, L.; Anderson, A.; Dickson, G.; Emery, P.; Graetz, F., Contextual influences and athlete attitudes to drugs in sport. SMR 2010, 13, 181-197.

. Existing evidence suggests to consider these specific cultural characteristics, as they might lead to a geographical heterogeneity of knowledge, beliefs and attitude8.Blank C. Kopp M. Niedermeier M. et al.Predictors of doping intentions, susceptibility, and behaviour of elite athletes: a meta-analytic review.,21.Morente-Sanchez J. Zabala M. Doping in sport: a review of elite athletes' attitudes, beliefs, and knowledge.,25.Ntoumanis N. Ng J.Y. Barkoukis V. et al.Personal and psychosocial predictors of doping use in physical activity settings: a meta-analysis.. This assumption carries a high relevance, as it implicates that the effectiveness of anti-doping education is not only determined by its measures but also by the place and context it is exerted as well as the cultural background of the target group.Adolescent athletes are still in the process of developing their personal attitude and understanding of success, making them highly susceptible for primary preventive measures24.Nicholls A.R. Madigan D.J. Levy A.R. A Confirmatory Factor Analysis of the Performance Enhancement Attitude Scale for adult and adolescent athletes.. They are also more vulnerable than adult athletes to unfavourable external factors, such as high peer pressure as well as extrinsic expectations from coaches13.Erdman K.A. Fung T.S. Doyle-Baker P.K. et al.Dietary supplementation of high-performance Canadian athletes by age and gender. and parents18.The relation between perceived parent-created sport climate and competitive male youth hockey players' good and poor sport behaviors.. This constellation puts adolescent elite athletes at special risk for the development of unfavourable doping-related beliefs and attitude, but also provides the opportunity to effectively strengthen their resilience to future situational temptations or external pressure to dope8.Blank C. Kopp M. Niedermeier M. et al.Predictors of doping intentions, susceptibility, and behaviour of elite athletes: a meta-analytic review.. Furthermore, an increasing use of dietary supplements and prohibited substances was observed in this age-group10.The use of anabolic androgenic steroids and polypharmacy: a review of the literature.,15.Anabolic-androgenic steroid use among young male and female athletes: is the game to blame?..In summary, there is evidence for an essential role of knowledge, beliefs and attitude, especially when it comes to the susceptibility of adolescent athletes to use prohibited performance-enhancing substances, which might be modified by different cultural backgrounds6.

Blank, C. L., V.; Schaiter, R.; Müller, D.; Schobersberger, W., Associations between Doping Knowledge, -Susceptibility and Substance Use of Austrian Junior Elite Athletes? J J Sports Med. 2014, 1 (1).

,22.Morente-Sanchez J. Zandonai T. Zabala Diaz M. Attitudes, beliefs and knowledge related to doping in different categories of football players.. Accordingly, the aim of this study was to analyse the geographical heterogeneity of doping-related knowledge, beliefs and attitude among adolescent elite athletes. We hypothesized that it is high for all three factors and that the athlete’s geographical region has an independent effect on all of them.2. METHODS

1,783 athletes (age: 14 to 19 years) participated at the Youth Olympic Winter Games 2020 in Switzerland. A questionnaire on doping-related knowledge, beliefs, and attitude was distributed to all athletes at the Olympic Villages in Lausanne and St. Moritz by three research team members. To further boost the response rates, Chief Medical Officers and Chefs de Mission of every nation were also informed an asked to encourage their athletes to participate in the study. The questionnaire was live for 14 days during the games and took approximately 10 minutes to complete.

Participants could choose between English, German, Spanish, French and Russian. The questions were defined in an easy-to-answer format. Age, sex and nationality were the only person-related information requested, to ensure participants’ anonymity and blinded data analyses. The three main sections of the questionnaire were “knowledge”, “beliefs” and “attitude” regarding the use of banned performance-enhancing substances.

We measured knowledge about the use of banned performance-enhancing substances using 22 items from a questionnaire that was developed in accordance with the International Standards of the World Anti-Doping Code31.WorldAntiDopingAgency, WORLD ANTI-DOPING CODE INTERNATIONAL STANDARD and based on a questionnaire previously used in Austrian junior elite athletes6.

Blank, C. L., V.; Schaiter, R.; Müller, D.; Schobersberger, W., Associations between Doping Knowledge, -Susceptibility and Substance Use of Austrian Junior Elite Athletes? J J Sports Med. 2014, 1 (1).

. A 5-point Likert scale (1 = “not at all” to 5 = “very well”) was used to cover subjective knowledge based on the question: “How well do you know or feel informed about…?”. Accordingly, a higher mean score indicated a stronger feeling of having adequate knowledge. Actual knowledge about anti-doping rules of the World Anti-Doping Code 2015 and about consequences of anti-doping rule violations was assessed with 13 items in a “true-false-don’t know” format. “Don’t know” and “false” answers were recorded with 0, correct answers with 1. A summative score of 13 indicated 100% correct answers, whereas a score of 0 indicated 0% correct answers.Beliefs about the causes of success in sport were measured using 18 items of the validated “Beliefs about the Causes of Success in Sport Questionnaire”11.Dimensions of Achievement-Motivation in Schoolwork and Sport.. A 5-point Likert scale (1 = “strongly disagree” to 5 = “strongly agree”) was used to cover the two domains “attribution of success to intrinsic factors” (success as a consequence of continuous state of high intrinsic motivation) and “attribution of success to extrinsic factors” (success as a consequence of natural ability, of illegitimate behaviours and of external factors (e. g. being lucky)). A mean score from all items was calculated using inverted scales for the items covering the domain “attribution of success to extrinsic factors”. In this way, a higher mean score indicated more favourable beliefs regarding the use of banned performance-enhancing substances.We measured attitude towards the use of banned performance-enhancing substances with an 8-item version of the widely used “Performance Enhancement Attitude Scale”30.

Vargo, E. J. J., R.A.; Agyeman, K.; MacPhee, T.; McIntyre, R.; Ronca, F.; Petróczi, A., Perceptions of assisted cognitive and sport performance enhancement among university students in England. Performance Enhancement & Health 2015, 3 (2), 66-77.

. This version showed higher model fit than the original 17-item version in adults and non-inferiority in adolescents24.Nicholls A.R. Madigan D.J. Levy A.R. A Confirmatory Factor Analysis of the Performance Enhancement Attitude Scale for adult and adolescent athletes.. A 6-point Likert scale (1 = “strongly disagree” to 6 = “strongly agree”) was used to cover the four ethical domains correctness, fairness, moral and truthfulness, on which an athlete’s doping-related attitude is based 30.

Vargo, E. J. J., R.A.; Agyeman, K.; MacPhee, T.; McIntyre, R.; Ronca, F.; Petróczi, A., Perceptions of assisted cognitive and sport performance enhancement among university students in England. Performance Enhancement & Health 2015, 3 (2), 66-77.

. A lower mean score indicated a more favourable attitude towards the use of banned performance-enhancing substances.590 athletes (33.1%) agreed to participate after they were informed about the study and provided written informed consent (Figure 1). In 57 cases, none of the three main sections was filled in completely. Thus, we were not able to include those cases into statistical analyses, due to risk of bias. Each of the main sections has an internal consistency and validity, which can only be reached, if all questions of that section were answered. Therefore, we had to exclude one or more of the three main sections, if they were not filled in completely. This happened in 133 of the remaining 533 cases, that were finally included into statistical analyses.

Figure 1Flow diagram of participant recruitment and data acquisition.

Show full caption

33% of all athletes at the Winter Youth Olympic Games participated in the survey (N = 590). Of those, 90% returned valid data with at least one main section filled in completely (N = 533).

Statistical analyses were performed using SPSS version 25.0 for Windows (SPSS Inc., Chicago, Illinois, USA). We calculated means and standard deviations for ‘subjective knowledge’, ‘actual knowledge’, ‘beliefs’ and ‘attitude’. The internal consistency of subjective knowledge, beliefs and attitude was tested with Cronbach’s α. For the assessment of geographical heterogeneity, results were clustered based on the athletes’ nationality. Clusters were built, according to the geographical regions of ‘North America’, ‘South and Middle America’, ‘Western Europe’, ‘Eastern Europe’, ‘Northern Europe’, ‘Asia’ and ‘Oceania’ (supplemental file 1). ‘Africa’ was represented by only one participant and, therefore, not included in geographically stratified analyses. Geographical heterogeneity of knowledge, beliefs and attitude was analysed with a non-parametric analysis of variance (ANOVA; independent variable: geographical region; dependent variable: knowledge, attitude and beliefs, respectively). Potential sex-related differences of knowledge, beliefs and attitude were analysed with an independent samples t-test. Effects of subjective and actual knowledge, age and the athlete’s geographical region on the dependent variables ‘attitude’ and ‘beliefs’ were tested in two multiple regression analyses. The level of statistical significance was set at p ≤ 0.05. We checked the assumptions of the regression models visually using residual plots. Specifically, we used Tukey-Anscombe plots (residuals versus fitted) and Q-Q plots of the residuals for diagnostics. We used variance inflation factors (VIF) to diagnose potentially problematic collinearity, which was low (VIF ≤ 1.04).

3. RESULTSMean age of the participants was 16.0 ± 1.0 years, 54% were girls. Most athletes were from Eastern Europe (n = 209) followed by Western Europe (155). The number of responders from North and South America, Northern Europe, Asia and Oceania ranged from 13 to 56 athletes (Table 1 and supplemental file 2).

Table 1Participants’ demographic characteristics.

Notes: sd = standard deviation

Internal consistency was excellent for the sections on subjective knowledge (Cronbach’s α = 0.90) and attitude (Cronbach’s α = 0.93) and acceptable for beliefs (Cronbach’s α = 0.71).

Overall mean subjective knowledge about the use of banned performance-enhancing substances was 3.7 ± 0.9 out of 5 and the mean summative score of actual knowledge was 9.2 ± 2.9 out of 13 (70.8%). Both, subjective and actual knowledge, showed geographical heterogeneity (p = 0.12 and p Figure 2).

Figure 2Geographical heterogeneity of subjective knowledge (a), actual knowledge (b), beliefs (c) and attitude (d) regarding the use of banned performance-enhancing substances among participants of the Youth Olympic Winter Games 2020.

Show full caption

Subjective knowledge score (“How well do you know or feel informed about…?”): 5-point Likert scale (1 = “not at all” to 5 = “very well”). Summative score of actual knowledge: 0-13 points with 1 point per correct answer. Beliefs score: 5-point Likert scale (1 = “strongly disagree” to 5 = “strongly agree”). Attitude score: 6-point Likert scale (1 = “strongly disagree” to 6 = “strongly agree”). Higher scores indicate more favourable knowledge, beliefs or attitude regarding the use of banned performance-enhancing substances. Error bars depict 95% confidence intervals.

Overall mean of the beliefs score was 3.5 ± 0.5 out of 5. There was a significant geographical heterogeneity of beliefs (p = 0.004), with lowest scores in Asia (3.3 ± 0.4) and highest scores in Oceania (3.8 ± 0.5; Figure 2, Figure 3). However, there was a similar pattern visible in all geographical regions, with higher item-specific scores for intrinsic factors (success as a consequence of continuous state of high intrinsic motivation; items 1-8 in Figure 3a) than for extrinsic factors (success as a consequence of natural ability, success as a consequence of illegitimate behaviours and success as a consequence of external factors; items 9 – 18 in Figure 3a).

Figure 3Itemised geographical heterogeneity of beliefs (A) and attitude (B) regarding the use of banned performance-enhancing substances among participants of the Youth Olympic Winter Games 2020.

Show full caption

A) X-axis: 5-point Likert scale (1 = “strongly disagree” to 5 = “strongly agree”). The original scores of items 9 to 18, covering attribution of success to extrinsic factors, were inverted in order to facilitate reading (1 = “strongly agree” to 5 = “strongly disagree”). Accordingly, higher scores indicate more favourable beliefs regarding the use of banned performance-enhancing substances.

B) X-axis: 6-point Likert scale (1 = “strongly disagree” to 6 = “strongly agree”). Lower scores indicate a more favourable attitude regarding the use of banned performance-enhancing substances.

Overall mean of the attitude score was 2.5 ± 1.4 out of 6. It showed a significant geographical heterogeneity (p Figure 2, Figure 3b).

There were no significant differences between girls and boys of the scores for subjective knowledge, actual knowledge, beliefs and attitude in any geographical region.

Analyses showed favourable effects on attitude of subjective knowledge (ß = -0.096, p = 0.049), actual knowledge (ß = -0.316, p < 0.001) and age (ß = -0.130, p = 0.007) and an association of an athlete’s geographical region (ß = 0.120, p = 0.011) with attitude. Furthermore, favourable effects on beliefs were observed for subjective (ß = 0.120, p = 0.016) and actual knowledge (ß = 0.212, p < 0.001) but not for age (ß = 0.034, p = 0.49) and the athlete’s geographical region (ß = -0.047, p = 0.33).

4. DISCUSSION

This study aimed to assess geographical heterogeneity among adolescent elite athletes regarding their doping-related knowledge, beliefs and attitude. Actual knowledge was moderate to good and scores of attitude and beliefs showed favourable patterns. We observed a considerable geographical heterogeneity for these important target factors of doping prevention. Higher actual knowledge was favourably associated with lower attitude scores and higher belief scores, independent of age and geographical region.

We observed significant geographical heterogeneity of subjective as well as actual doping-related knowledge. Athletes seem to be well aware of how extended their doping-related knowledge is in comparison to their international competitors, as indicated by the similarity of rankings of subjective and actual knowledge scores. Independent from the athlete’s geographical region, both, subjective and actual knowledge, appear as predictors of favourable attitude and beliefs, with actual knowledge being the stronger effector. These observations are important, as some evidence indicates a stronger association of subjective knowledge than of actual knowledge with proactive anti-doping behaviour (e.g. educating their athletes) in coaches5.

Blank, C. L., V.; Fürhapter, C..; Müller, D.; Schobersberger, W., Doping in Sports: West-Austrian Sport Teachers’ and Coaches’ Knowledge, Attitude and Behavior. Dtsch Z Sportmed 2014, 65, 289-293.

. Accordingly better anti-doping related knowledge might be especially effective in South and Middle America, where athletes’ perception of their knowledge seems to be lower than in other regions. However, the association of knowledge with doping susceptibility was only very weak in previous studies with Austrian elite junior athletes6.

Blank, C. L., V.; Schaiter, R.; Müller, D.; Schobersberger, W., Associations between Doping Knowledge, -Susceptibility and Substance Use of Austrian Junior Elite Athletes? J J Sports Med. 2014, 1 (1).

and young adult recreational athletes25.Ntoumanis N. Ng J.Y. Barkoukis V. et al.Personal and psychosocial predictors of doping use in physical activity settings: a meta-analysis.. Accordingly, good doping-related knowledge might not influence doping behaviour directly, but instead it might support the development of protective factors, such as favourable attitude and beliefs. Thus, knowledge-based education should remain as a major pillar of every preventive anti-doping measure, aiming for high levels of actual knowledge and athletes’ perception of their knowledge in every region of the world. The favourable effect of age on attitude in our study demonstrates, that these measures should be implemented as early as possible in a junior athlete’s life,21.Morente-Sanchez J. Zabala M. Doping in sport: a review of elite athletes' attitudes, beliefs, and knowledge..The results of this study go in line with existing evidence, demonstrating overall favourable beliefs about the use of banned performance enhancing substances among junior elite athletes3.Barkoukis V. Lazuras L. Tsorbatzoudis H. Beliefs about the causes of success in sports and susceptibility for doping use in adolescent athletes.. However, we observed a considerable geographical heterogeneity. Especially Asian and Eastern European athletes seem to attribute success not only to the intrinsic effort exerted during task involvement, but also to extrinsic factors, such as normative ability and fulfilling their coaches’ expectations. Adolescent athletes are still in the process of developing their personal attitude and understanding of success and there may be a diversity in thinking more related to the individual biography, than to external factors, such as the athlete’s origin24.Nicholls A.R. Madigan D.J. Levy A.R. A Confirmatory Factor Analysis of the Performance Enhancement Attitude Scale for adult and adolescent athletes.. This might explain, why athletes’ geographical region was not directly associated with beliefs in our multivariate analysis. Still, the importance of beliefs, as they seem to be shaped by the sporting culture and the moral atmosphere of an athlete’s socio-cultural environment27.

Smith, A. C. T. S., B.; Oliver-Bennetts, S.; McDonald, S.; Ingerson, L.; Anderson, A.; Dickson, G.; Emery, P.; Graetz, F., Contextual influences and athlete attitudes to drugs in sport. SMR 2010, 13, 181-197.

, might be greatest in high-pressure situations when the athlete is tempted or forced to use banned performance-enhancing substances8.Blank C. Kopp M. Niedermeier M. et al.Predictors of doping intentions, susceptibility, and behaviour of elite athletes: a meta-analytic review.,12.Engelberg T. Moston S. Skinner J. The final frontier of anti-doping: A study of athletes who have committed doping violations.,25.Ntoumanis N. Ng J.Y. Barkoukis V. et al.Personal and psychosocial predictors of doping use in physical activity settings: a meta-analysis.. Thus, preventive anti-doping measures in junior athletes should aim to shape their characters and support the development of favourable beliefs about success in sport with the goal to increase their resilience in these high-pressure situations. Effectiveness of these measures might be improved, if they consider the individual’s cultural and moralistic background.An athlete’s doping-related attitude is believed to mediate the effects of social norms, moral about winning, sporting culture, perception of doping-related attitude and behaviour of other athletes, coaches and peers, on doping susceptibility and behaviour12.Engelberg T. Moston S. Skinner J. The final frontier of anti-doping: A study of athletes who have committed doping violations.,23.Moston S. Engelberg T. Skinner J. Self-fulfilling prophecy and the future of doping.,26.Measuring explicit attitude toward doping: Review of the psychometric properties of the Performance Enhancement Attitude Scale.. Our results extend this assumption, demonstrating an effect of an athlete’s geographical region, thus culture, on attitude. They further demonstrate an overall favourable attitude of the participants at the Youth Olympic Games, compared to adult professional athletes30.

Vargo, E. J. J., R.A.; Agyeman, K.; MacPhee, T.; McIntyre, R.; Ronca, F.; Petróczi, A., Perceptions of assisted cognitive and sport performance enhancement among university students in England. Performance Enhancement & Health 2015, 3 (2), 66-77.

, but also a striking geographical heterogeneity. Asian athletes achieved the highest scores in all items of the attitude section, which might indicate that the development of a high resilience in high-pressure situations might be effectively supported by focusing on their attitude. However, the predictive value of attitude for doping susceptibility and behaviour has exclusively been assessed in Caucasian populations so far and this association might be substantially different in another cultural context. More sophisticated investigations need to assess variable effects of single factors on the complex mechanisms behind the decision to dope in the light of different cultural influences.Recent anti-doping research revealed, that deterrence and education about potential legal or physical harms have not lead to a substantial reduction in doping behaviour12.Engelberg T. Moston S. Skinner J. The final frontier of anti-doping: A study of athletes who have committed doping violations.. Instead, interventions are being emphasized, that aim for an individual approach to an athlete, considering his or her personal and cultural background, experiences they have made with peers and coaches, as well as the motivators and purpose of competition in their lives