The basic questionnaire was designed to assess knowledge, attitude, awareness approaches, and other aspects related to doping agents. The authors created a panel of specialist pharmacists and non-healthcare providers who practice work related to sports and coaching. This panel enhanced the process of questionnaire validation (face and criterion validity). The panel members were as follows: assistant professors in the following disciplines: pharmacotherapy, pharmaceutics, pharmacologists, clinical pharmacists; a pharmacist who is a board member in the Jordanian Pharmacist Association, a pharmacy director of the hospital pharmacy department, and a physician. Non-HCPs associated with sport-related issues were as follows: a director of accounting, an accountant and part-time coach, an engineer, an administrative director, a personnel trainer, and a sports consultant. All panel members agreed on the final form of the questionnaire with its suggested criterion scoring.

Reliability [27, 28] was confirmed by two means: the internal consistency measured by Cronbach’s alpha value and the stability over time (i.e., test-retest reliability). A pilot sample of 40 responders was contacted twice within a 15 days time difference. They were asked to answer the questionnaire to carry out the pre-/post-tests. Overall internal consistency was calculated using the coefficient alpha (Cronbach’s alpha was 0.72), and test-retest reliability was assessed using Pearson’s correlation coefficient (Pearson's r was 0.89). The coefficient alpha results reflect reliable acceptable internal consistency. The results of the stability coefficient indicated stronger test-retest reliability. Accordingly, the measurement error of the questionnaire was less likely to be attributable to changes in the individuals’ responses over time [30, 31].

Jordanians aged between 15-64 years were 6,532,966 (i.e., 61% of Jordanian population) as reported by the Department of Statistics of Jordan as per the census of 2019 [32]. Accordingly, a representative sample size with a Confidence Level (CI) of 95% and 5% marginal error was calculated to be 385 participants, as recommended by Taherdoost [33] and carried out by the sample size calculator [34]. Furthermore, a subsample to represent pharmacists was calculated to be 381 participants, with 95% CI and 5% margin error for a population of no more than 40,000 pharmacists [35].

This study used a cross-sectional design using Google form templates to distribute the survey, which was active for receiving answers between 1^st Dec 2019 till 30^th April 2020. The study protocol was approved by the Hashemite University IRB committee on the 25th of Nov, 2019 (No.9 – Code: 9/25/11/2019). Eligible responders were those pharmacists and non-healthcare providers who would like to voluntarily respond to the survey. The survey link was distributed using social media platforms (Facebook) and WhatsApp applications through the study panel members. Responders were informed that their responses would be treated confidentially and anonymously. There was no personal identifier in the survey. Responders were also informed that they had the choice to withdraw from the survey, as their participation is voluntary. Accordingly, participants who submitted the survey with their answers were considered to have given informed consent for their participation.

A chi-square test of association was conducted between answers to the questions within the survey and speciality of responders, according to the following hypothesis:

The null hypothesis: H0: no association relationship between answers and the speciality (pharmacists vs. non-HCP).

The alternative hypothesis: HA: an association relationship exists between answers and the speciality (pharmacists vs. Non-HCP).

The measure of effect size, magnitude, and strength of association of a nominal-by-nominal relationship was assessed by Carmer V Coefficient, according to the following “crude estimates” for interpreting strengths of relationships.

Total responses were 919. The number of pharmacists who participated in the questionnaire was 550 (59.8%), and the number of non-HCP was 369 (40.2%). While male pharmacists dominated in non-HCP (239, 64.8 percent), female pharmacists dominated in HCP (340, 61.8 percent), resulting in a gender distribution of males and females that was comparable (48.9% males vs. 51.1% females). While 11.4% of male responders had a monthly income between 1001 and 2000 Jordanian Dinar (JD), less than 1% of females had such income. Almost 7% of males had a monthly income of more than 2000 compared with less than 0.06% of females. It was notable that almost half of the females, 49.1%, had no job, while for males, this proportion was 19.8%. 21% of both males and females reported having a monthly income of between 301 and 500 JD. Similarly, both have a proportion of almost 12% for the monthly income of less than 300 JD. Males within both pharmacists and non-HCP generally reported higher-income categories than females. However, no association was reported between income and the usage of doping agents.

Regarding practising sports, around 26% stated that they practice sports many times during the week, while almost 13% stated that they were poor sports performers (several times a year). Pharmacists and non-HCPs had almost similar proportions for participating in sports (X² (5)=8.35, P=0.138). While 74.7% of pharmacists were non-smokers, the proportion was 50.7% for non-HCP. This difference was statistically significant (X² (1) = 56.2, P <0.001).

Interestingly, the majority of the participants claimed to be knowledgeable about the topic of “Doping.” Doping agents were claimed to be known by both pharmacists and non-HCP. A higher proportion of pharmacists (80.9% vs. 74.3%, P=0.017) confirmed their knowledge about doping agents. A higher proportion of pharmacists compared with non-HCP (82.9% vs. 27.4%, P < 0.001) were familiar with the proper definition of doping agents.

Poor knowledge about doping agents classification has been illustrated in the results of the present study. The proportions (pharmacists vs. non-HCP) who correctly identified the doping agent classes are shown in Table 1. It was expected that smokers' vs. non-smokers' responses to the question of whether caffeine is a doping agent would be different. Nevertheless, the analysis showed no significant difference, as 39.8% of non-smokers vs. 34.6% of smokers thought that caffeine belongs to the doping agents (X² (2) = 2.43, P=0.296, Cramer's V=0.051). On another front, a significantly higher proportion of females (62.2%) compared to males (37.8%) considered caffeine as a doping agent (X² (2)=32.926, P<0.001, Cramer's V=0.189).

Pharmacists demonstrated significantly better knowledge about the side effects profile of the doping agents. A higher proportion of the pharmacists were able to identify the side effects of the doping agents compared with non-HCP; impotence (64.7% vs. 51.5%, P<0.001), heart and kidney diseases (74.7% vs. 62.9%, P<0.001), sudden death (70.9% vs. 56.9%, P<0.001), and acne (46.5% vs. 30.4%, P<0.001).

The answers related to questions about formal education were almost similar in both study groups. Approximately 83% of both pharmacists and non-HCPs studied nothing about doping in school or university. Similar results were reported for receiving educational lectures about doping where almost 65% in both groups never received educational support nor read a scientific text about doping agents and their harmful effects. Compared to pharmacists (37.5%), significantly more non-HCPs (49.1%) thought that the sports coach provides the proper scientific guidance on doping to athletes (P<0.001).

According to the findings of this study, 84.9% (n=780) support the use of deterrent penalties to prohibit doping usage or trade. This shows a reliable construct with 79.1% (n=727) of responders who do not support the doping agents to become a legally permitted substance in Jordan. 89.8% (n=825) supported having an organization that prohibits doping agents and reduces their consumption.

Unfortunately, the majority (777, 84.5%) was not aware of the Jordanian Anti-Doping Organization (JADO), and 70.8% of responders (n=651) did not know about any organization that regulates sports anti-doping. Moreover, less than half (399, 43.4%) confirmed that the doping trade is a crime punishable by law. A similar proportion (407, 44.3%) confirmed the presence of Jordanian law to regulate doping. More details are shown in Table 2.

No differences were reported between both study groups in their attitude toward perceived benefits of doping agents for physical (79.3% vs. 81.3%, P=0.45) and mental performance (21.1% vs. 24.9%, P=0.17).

As seen in Table 3, the most common perceived reason for the use of doping agents was to enhance physical performance (82.1%; agree = 316, 34.3%; strongly agree 438, 47.7%) followed by building body mass (80%; agree = 289, 31.4%; strongly agree 447, 48.6%). The weakest perceived driver was improving mental performance (34.9%; agree = 171, 18.6%; strongly agree 150, 16.3%). The distribution of answers between pharmacists and non-HCP was almost similar.

We decided to check the differences in the answers’ distribution based on gender. Against our expectations, data analysis showed that both females and males answered with equal proportions to the questions that explored drivers for doping agents’ usage among athletes. No significant differences were reported between both groups in their perception toward the consumption of doping agents for muscular enhancement, weight management, enhancing physical or mental performance, and copying with others. The only exception was at the sub-analysis with non-HCP females and males in the question about bodyweight management. In that question, a significantly higher (P<0.05) proportion of non-HCP males compared to females agreed that doping usage is for bodyweight management. Approximately 46% of non-HCP males agreed that maintaining body weight is the main reason for doping agents’ usage, while 31% of non-HCP disagreed (X² (4) = 11.18, P=0.025, Cramer's V =0.175). A different trend was noticed in the pharmacists' group, where almost 32.3% of males agreed that maintaining body weight is the main reason for the usage of doping agents compared to 42.7% of females. Yet, the overall analysis showed that the proportions were not statistically significant within the pharmacists' group (X² (4) = 6.73, P=0.151, Cramer's V =0.11).

Less than 10% supported the use of doping agents (5.6% of pharmacists vs. 8.9% of non-HCP, P=0.054) and considered it a moral act (6.2% of pharmacists vs. 8.45 of non-HCP, P=0.2). Pharmacists more than non-HCP supported the elimination of the doping agents user from sports competition (90.5% vs. 82.9%, P=0.001) and considered an individual liability for the use of doping agents (90.0% vs. 48.8%, P=0.018). Similarly, pharmacists more than non-HCP supported the application of deterrent penalties for doping agents users (87.3% vs. 81.3%, P=0.013).

More than 90% of both study groups showed a positive attitude toward creating awareness about the doping agents in the community. Moreover, 87.1% of responders shared responsibility and confirmed that they would like to educate others about the doping agents. Most (94.4%) of the participants supported conducting educational courses and lectures to create awareness about the names, types, and side effects (harms) of the doping agents. The majority (93.8%) supported creating awareness through social media and TV channels. The second-ranked awareness tool recommended by responders (90.8%) was the inclusion of lectures into official courses in universities and schools. Finally, the study participants (82.4%) supported posting brochures, adding road signs, and publishing newspaper articles to enhance awareness about doping agents.

As seen in Table 4, a total of 6.1% (n=56) of respondents used doping agents before. However, non-HCP had a significantly higher proportion of doping agent use compared with pharmacists (9.8% vs. 3.6%, Carmer V = 0.125, P<0.001). A total of 31 out of 56 responders (55.4%) used a diet or drug after taking the doping agents to protect their bodies from side effects. Out of the 56 responders, nine responders did not specify any regimen, while 47 (83.9%) listed the regimen they used to counteract possible side effects, which were as follows: 19 (40.4%) used vitamins, 15 (31.9%) used a diet or natural mixtures, and 13 (27.7%) used a medication regimen such as Clomid^®, Pregnyl^®, Tamoxifen^®. A dominant positive attitude toward such regimens was noticed across both groups. The vast majority (more than 90%) confirmed that they received positive information about such regimens and beneficial claims to reduce the side effects that might follow the doping agents' usage. However, less proportion (77.4%) recommended the use of such regimens to others. More than half (61.3%) did not use regimens to hide the lab test during official competitions. Almost one-third of the doping agents users obtained doping agents through their sports friends or sports coaches.

Almost one-third of pharmacists received a request to obtain the doping agents for customers. Male pharmacists reported that they received significantly more requests than female pharmacists, P<0.001. Both males (84.3%) and females (88.8%) felt a high level of responsibility toward people's education. However, less proportion of both males (63.3%) and females (70.6%) felt a responsibility toward officially reporting doping dealers. Most responders agreed that the medical profession raises awareness about doping (91%). However, male pharmacists reported in higher percentage (6.7%) compared with females (2.1%) that awareness about the doping agents is not related to the medical profession. Results are shown in Table 5.

In the present study, a gap between knowledge, perceptions, and practicalities was identified. Pharmacists, in the present study, claimed their knowledge about the doping agents; however, the in-depth assessment showed a gap in their knowledge. In a Japanese study, 82.2% of pharmacists claimed to be knowledgeable about doping agents [36]. In the present study, the best sub knowledge domain was the knowledge of side effects of the doping agents, where almost two-thirds of the participants reported that the doping agents can cause sexual weakness leading to sterility, and three-quarters of pharmacists reported that the doping agents cause cardiovascular and kidney diseases. These percentages were higher than those reported among German adolescents, where only 33.7% agreed that steroids cause kidney disease; however, 72.7% agreed that the doping agents are harmful [37]. In Saudi Arabia, the participants in a cross-sectional study agreed that the doping agents are considered dangerous for health (36.7%), treason (30.2%), and are against sportsmanship (33.1%) [38].

Remarkably, 82.9% of pharmacists confirmed that they were aware of the correct definition of the doping agents, while only 57% of Slovenian pharmacists and doctors reported in a similar assessment [4] that they did not know the correct definition of the doping agents. Such answers indicate a perception of good general knowledge in the Jordanian medical staff; however, it remains questionable, as in-depth knowledge of the doping agents and their classification showed a gap between self-assessed and actual knowledge.

As the sample included pharmacists and non-pharmacists, the most common and local names, in addition to well-known scientific names, were used to identify the doping agents. Unfortunately, poor knowledge among pharmacists was demonstrated. A comparable level of knowledge with non-HCP was noticed, as well. In almost all questions, less than half of the pharmacists identified correct answers. The only exception was testosterone, where 71.3% of pharmacists had the correct answer. This is not unexpected, as testosterone is mentioned abundantly in medical books, especially those related to pharmacy, as it increases masculinity and shows a male appearance. Moreover, it was agreed previously that the main reason for using the doping agents is bodybuilding. This corresponds to a study of Slovenian pharmacists [4], where 92.8% rated testosterone as a doping agent. Contrary to our expectations, only 24% of pharmacists classified erythropoietin correctly as a doping agent. No statistically significant differences were found when comparing the answers of pharmacists with non-HCPs. This result came against that reported by Slovenian researchers [4], where 98.6% of their sample correctly classified erythropoietin as a doping agent. Classification of the following agents: ginseng, creatine, and phosphodiesterase (PDE) inhibitors as Sildenafil (Vigra^®) and Tadalafil (Cialis^®), has been assessed for the first time with the doping agents.

Despite the strong evidence on both the short- and long-term side effects of AAS, there is very little evidence based on the users' perception of the negative consequences of its usage [12], especially among young adults and adolescents [37]. Pharmacists reported good awareness of side effects in both Qatar [28] and Japan [36]. In the present study, it was found that the first reason to use the doping agents was to enhance physical performance, followed by building body mass. This is in line with many studies, which reported that users aim to improve athletic performance and physical attractiveness, increase body weight, fat-free mass, muscle size, strength, and social recognition [2, 23, 26, 29, 38, 39]. Andrews et al., in their systematic review, listed a detailed reporting from 13 randomized trials about the adverse effects of AAS. The most commonly assessed adverse effects were negative impact on lipids, mood, and liver-associated enzymes [8]. Albano et al., in their very recent review, confirmed that the long-term administration of AAS may lead to serious consequences, such as hypogonadism, cardiac impairment, neurodegeneration, coronary artery disease, and sudden cardiac death [12].

Despite its prevalence and negative consequences, most of the responders did not study doping in schools and universities. A similar result was reported in France, where only 4% of the general practitioners reported having a specific class about doping [40]. Moreover, most responders neither read a scientific text nor attended an awareness lecture about doping. This is in line with results reported by Japanese pharmacists, where 83.5% did not receive any formal lecture about doping [36].

Despite the attitude of prohibiting the doping agents, a high percentage of responders had poor knowledge about JADO. More than half of the participants believed there is no doping law in Jordan. The justification for this is straightforward: increased awareness of JADO and the doping-related laws is crucial. The legal knowledge about doping in Saudi Arabia seemed to be better than in Jordan, as 77.5% of the Saudi sample knew the punishment that followed doping abuse, and 67.6% considered it fair [41]. The phenomenon of awareness about doping agents is a global problem. It is not a unique case in Jordan. In Slovenia, only 55.3% of the community did not know about the anti-doping organization of their country [4]. In Qatar, none of the respondents were aware of the role of the World Anti-Doping Agency (WADA) [28].

In the present study, most participants believed that the most common reasons for using the doping agents are to enhance physical performance, followed by building muscle mass. The results were somehow similar to those from Saudi Arabia, where 69.4% believed that the most common reason for doping was to enhance physical performance, whereas the second most common reason was social recognition (17%) [41]. Nevertheless, such results are contrary to the Syrian study's findings, where 77.9% indicated the most common reason for doping was building muscle mass, followed by enhancing physical performance (52.5%) [2].

In the present research, the overall prevalence of use of the doping agents was 6.1% (3.6% pharmacists and 9.8% non-HCP, P<0.001). Nevertheless, the real-life prevalence would be expected to be higher. This was a self-reported result; the academic endorsement of the questionnaire and ethical approval was announced. Thus, individuals may be reluctant to share information about the use of the doping agents to avoid liability and personal discomfort. It could be argued that respondents who took the doping agents (6.1%) are almost the same respondents who support taking such agents (7.0%) and consider it a moral action (7.1%). It is expected that they participate in sports competitions, where 7.8% of responders and 6.9% did not support eliminating the doping agent users from sports competitions, nor supporting a deterrent punishment for them. A similar trend was also noticed in another study carried out in Syria [2], where the proportion of responders who used the doping agents was almost equal to those considering their use as a moral act. However, the prevalence of the doping agent users in the present study is more than that reported in Syria (4.6%) and in Saudi Arabia (4.3%), but less than the prevalence in Germany (30.1%) [37]. The number of those who consider doping to be a moral act in the Syrian study was more than the number reported in the current study. This percentage reached 15.3% in the Syrian study [2]. In Japan, 10% considered doping as an acceptable violation [36], and in Qatar, 11% did not support doping to be prohibited [28].

In the present study, almost one-third of the doping agent users obtained them through their sports friends. The second-largest providers were sports coaches. Such results confirm the previous findings from Syria [2], Germany [37], and France [40].

Almost half of the doping agent users (55.4%) used a regimen to counteract possible side effects of those agents. The serious risk is that some regimens will increase long-term negative consequences. Medicines such as Clomid^®, Pregnyl^®, and Tamoxifen^® were used by one-third of the doping agent users. Such medicines increase female hormone levels where the rationale of such usage is to create balance with the exogenous anabolic (masculine) hormones. The unseen risk here is having very high levels of such hormones, more than the standard levels in the human body. On the other hand, using a healthy diet (rich in vitamins and natural products) would not be a scientifically validated method to protect against the harmful effects of the doping agents. Our assessment led us to say that such myths of using regimens to counteract side effects are circulated without scientific evidence. Our assessment showed that the most common source to sell such agents were sports coaches and sports friends. Accordingly, the scientific background of sports coaches and conflict of financial interest should be crucially considered by both individuals and authorities when dealing with such regimens.

A positive attitude toward supporting community awareness was not unexpected. Similar results were reported from Slovenia [4]. In the present study, most of the responders supported applying deterrent penalties against the doping agents' abuse. Most responders did not want the doping agents to become legal. With consistent reliability, the vast majority (89.8%) supported the presence of an official Jordanian institution to prohibit doping and reduce its consumption.

Although they felt less responsibility toward reporting claims against doping dealers, both males (84.3%) and females (88.8%) felt a high level of responsibility toward people's education. Such percentages were more than the Slovenian general practitioners and pharmacists (65%) [4] and the Syrian pharmacist (68.5%) [2]. An almost similar percentage was reported by French general practitioners, 89% [40]. About one-third of Jordanian medical staff had been exposed to a prescription containing a doping agent. A similar percentage received a request for providing an illegal doping agent. This is a high percentage when compared to Slovenian and French general practitioners, as their exposure to direct demand for prescribing steroids was 14% [4] and 11%, respectively [40].