Impact of an educational flyer and sensitization on performance-enhancement attitudes of bodybuilders in United Arab Emirates

Background A high proportion of bodybuilders use supplements to improve performance, with some turning to prohibited substances and methods. The attitudes of bodybuilders towards performance enhancement may be gauged through surveys such as the Performance Enhancement Attitude Scales (PEAS). Educational interventions are recommended as part of anti-doping measures. The objective of this project was to assess the impact of a pharmacy-led intervention using an antidoping educational flyer and the performance enhancement attitude scale to measure the attitude of bodybuilders in the United Arab Emirates (UAE). Methods The PEAS eight-item short form questionnaire was administered to male bodybuilders in the UAE. The PEAS was conducted before and after administration of an educational flyer concerning the problems associated with supplement use among bodybuilders. The Wilcoxon Signed-Rank and Kruskal Wallis tests were used for data analysis. Results A total of 218 bodybuilders, who reported taking dietary supplements, filled out the survey both pre and post viewing the antidoping educational flyer. A difference was observed between the full-time professional bodybuilders, students, and part-time bodybuilders with other primary occupations (p-value <0.05). In addition, PEAS score decreased among the study population for all eight PEAS items (p-value <0.05). Conclusions The pharmacy-led intervention using an antidoping educational flyer and sensitization by PEAS achieved more favorable scores, suggesting a significant shift of opinion toward avoiding use of performance enhancing substances among the bodybuilder study population. More research is required on sustaining the attitude and demonstrating the impact on doping behavior.


Introduction
Exercise in gymnasiums is a feasible way to be physically active in the United Arab Emirates (UAE).Chronic diseases pose significant public health issues among the UAE population. 1 In particular, attitudes about obesity management need improvement. 2There is a lack of public awareness of the importance of engaging in physical activity in the UAE, resulting in high levels of sedentary behavior among young adults. 3Promotion of the benefits of physical activity are therefore required among the UAE population. 4 is acknowledged, however, that gymnasium use may progress from simple exercise regimens to a desire for image enhancement that leads some to bodybuilding. 5Among gymnasium users in the UAE, bodybuilding, either for noncompetitive (recreational) or competitive purposes, is a popular sport.The motivation for bodybuilding is manifold and ranges from the improvement of body image and well-being through to participation in competitive sport. 6ny gymnasium-users take supplements to improve their performance or image enhancement.In a study in Sharjah, it was shown that about half of the men exercising in gyms were using dietary supplements. 7In another study, in Dubai, it was reported that people who were consuming dietary supplements had a high level of knowledge about the supplements that they used and consequently, adverse events were infrequent. 8etary supplements are used widely among bodybuilders.However, in addition, some bodybuilders may use hormonal products, which pose a potential health risk 9 and may lead to illegal doping in the competitive areas of bodybuilding. 10,11ome bodybuilders in the Gulf region reportedly use anabolic steroids, 12 reflecting an increased prevalence of anabolicandrogenic steroid (AAS) use generally across the Eastern Mediterranean Region. 13ny factors contribute to performance enhancement by bodybuilders and its progressive normalization. 14There is a growing body of evidence which suggests that anabolic androgenic steroids are used globally by a diverse population, with varying motivations, including bodybuilders. 15As the trend of bodybuilding is transforming to create a well-defined and moderately muscular body, it is speculated that fitness doping is becoming increasingly common. 16However, the boundary between natural performance enhancement and doping might be blurred for the bodybuilders.Considering the potential adverse effects of AAS use on health, it is important to consider intervention strategies to prevent misuse, both in sport and in the general population. 17Such strategies include targeted education and a greater understanding on doping attitudes through tools such as the Performance Enhancement Attitude Scale (PEAS). 18armacists are well-placed and highly accessible resources of drug information for the public.The opportunity exists to increase pharmacy-led initiatives that support the antidoping movement.
Antidoping assessments and education raise awareness of doping.It is suspected that bodybuilders might be sensitized to the problems of performance enhancement attitude just by filling out the pre-intervention survey.This awareness of perceptions associated with doping, in addition to the educational flyer developed for antidoping education for bodybuilders, was expected to influence attitudes toward higher concern for the risk of performance enhancement substances among bodybuilders in the study population.

Aim
The aim of this project was to assess the impact on local bodybuilders' views of using substances for performance enhancement before and after a pharmacy led intervention using an antidoping educational flyer, as measured by the PEAS.

Research design
The study used a pre-post intervention design.Attitudinal data were collected using a PEAS.An antidoping educational flyer was designed by a sports pharmacy team with a simple infographic design and clear messaging on the risk of doping.Sports pharmacy team members then administered the intervention by presenting the educational flyer to bodybuilders

REVISED Amendments from Version 1
Minor modifications are performed to the manuscript based on comments from the reviewers.It might have improved clarity and some future directions for further research.
Any further responses from the reviewers can be found at the end of the article enrolled in the study.The educational flyer is included as Figure 1.The educational flyer was provided to bodybuilders prior to the post-intervention survey.The second PEAS survey was administered approximately one month after the first administration of the PEAS survey among the study population.

Study population
The study population included self-described bodybuilders in the UAE.The study did not use any brand name or manufacturer names of any performance enhancement substance.Being a male bodybuilder who uses nutritional supplements and consenting to participate in the study were the inclusion criteria.Any level of bodybuilders, including recreational, amateur, or professional athletes, were recruited.Bodybuilders who were not regularly practicing in their gym, could not read English, or were not living in the UAE were excluded from the study population.Background data was collected from the bodybuilders on their level of involvement in bodybuilding and nutritional supplements used.

Sample size, survey technique, and settings
The sample size was calculated using a formula that considers the population size, margin of error, and sampling confidence level.Survey Monkey's sample size calculator accounts for the three factors mentioned above.The bodybuilder population in UAE is approximately 500,000, based on data from Dubai World Trade Centre.Using a 95% confidence interval and margin of error of eight, the calculated sample size was 151 bodybuilders.The sampling strategy included distributing a pre-intervention survey to registered study participants through email and WhatsApp.Body builders were contacted through networking of known bodybuilders, social media groups, and websites.Contact details were collected from those who fill pre-intervention survey.A post-intervention survey following the educational intervention was sent only to those who completed the pre-intervention survey.The survey was conducted using Google Forms and paper-based for convenience while visiting gymnasiums.The total duration of the study was one year.

Study instrument & validation procedure
A modified version of the PEAS, known as the eight-item short form, was used as the survey instrument. 18,19For each item a six-point Likert scale of strongly disagree (1), disagree (2), slightly disagree (3), slightly agree (4), agree (5), and strongly agree (6) was used.The PEAS is an internationally validated instrument.Only in required items, the word "bodybuilding" was added to connect to the athletes of this study population.The meaning of doping was added in parenthesis when it appeared for the first time on the survey.In addition to some background enquiries, the pre-and postsurvey questionnaire included the following eight-items.
1. Legalizing performance enhancements would be beneficial for sports or bodybuilding (competitive or noncompetitive).
2. Doping (consuming prohibited substances) is necessary to be competitive.
3. The risks related to doping (consuming prohibited substances) are exaggerated.
4. Bodybuilders should not feel guilty about breaking the rules and taking performance-enhancing drugs.
5. Doping is an unavoidable part of competitive sport/bodybuilding.6. Doping is not cheating since everyone does it.
7. Only the quality of performance should matter, not the way bodybuilders achieve it.
8.There is no difference between drugs and dietary supplements that are all used to enhance performance.
A higher number for the final score of the PEAS suggests agreement with the statements that support use of performance enhancing substances or the doping culture.

Ethical consideration
Ethical approval to conduct the research was granted by the Institutional Review Board of the Gulf Medical University (IRB/COP/STD/73/Oct-2021). Written informed consent was obtained for participating in the study.No personal identifiers of study participants were collected except email and phone numbers for sending the post-intervention survey.Such contact details were kept confidential.No brand names of bodybuilding supplements or medications were mentioned in the study.All confidential information was maintained by the authors from Gulf Medical University and not shared with the authors from other organizations in this study.

Data analysis
Descriptive and analytical statistical tools were used to compare the attitudes of bodybuilders before and after the pharmacy-led educational intervention.Wilcoxon Signed-Rank test was used to assess performance enhancement attitude (PEA) scores before and after the intervention.Kruskal Wallis tests were used to find the statistical significance of the pre-post intervention among different groups.SPSS version 26 (Armonk) was used for all the analyses.

Results
Of the 322 bodybuilders who filled out the pre-intervention survey, 254 completed the post-intervention surveys (79% response rate). 29For the analysis, 22 respondents were removed due to the lack of matching email or mobile numbers used as identifiers in the pre-survey to post-survey tracking.Other respondents were excluded from the study by not being located in the UAE or reporting they were not consuming dietary supplements.A final total of 218 respondents were used for the data analysis.The majority (98.2%) of study participants found the antidoping educational flyer to be informative, while four (1.8%) participants responded that it was not informative enough.
The study population constituted of 80 bodybuilders of non-sports employment, 16 full-time bodybuilders, 111 university students, and 11 school students.All were male.The Kruskal Wallis test showed a significant difference in the distribution of post-intervention (p-value 0.002) PEA scores but not in pre-intervention (p-value 0.07) among the four subgroups of this study population.
When the average score is compared among the four groups by the median test, the median (average) of the overall prescore across the groups (p-value <0.027), and the average of the overall post-score showed significant difference between the groups (p-value 0.001).It implies that while the median showed a significant difference among full-time bodybuilders, primarily an employee, university students, and school students pre-intervention 29, 24, 22, 25, and post intervention 21, 16.5, 13, 11 respectively, the changes in distribution of PEA scores among them were significant only after the intervention.School students showed the greatest impact of attitude change.
With the intervention of the educational flyer and sensitization, the PEA was changed favorably towards recognition of concerns associated with doping among the participants.Agreement to pro-doping statements in the PEAS survey decreased, meaning disagreement increased with the intervention as shown in Table 1.For tabulation, "strongly agree" and "agree" were combined; likewise, responses of "slightly agree" and "slightly disagree," and "disagree" and "strongly disagree" were combined.As per the Wilcoxon sign rank test, the average performance enhancement attitude levels before and after were significantly different in the study sample.The distribution of attitude scores were reduced from before to after the intervention with statistical significance in addition to median of agreement decreased for 7 out of 8 items (Table 2).
The median score for the pre-intervention survey was 24, and for the post-intervention survey was 14.The decrease in median score demonstrated a movement away from supporting use of performance enhancement substances and toward an anti-doping awareness.

Discussion
The aim of this study was to assess any changes in the attitude of bodybuilders in the UAE about the use of supplements and doping, following the introduction of an antidoping educational flyer.The major finding was that there were significant changes in the attitudes of the study population to performance enhancement through supplement use and doping practices following pharmacy-led education with introduction of an antidoping flyer.Analysis of the responses to the eight-item PEAS survey revealed significantly different scores between pre-and post-intervention, suggesting less support for the use of performance enhancement substance among study participants.Using median, statistical tests proved the significance of the decrease in all eight survey items, except one; 'There is no difference between drugs and dietary supplements that are all used to enhance performance'.Educational interventions and sensitization of sports people have shown similar results in the following studies.
It was found that doping susceptibility perceptions can be immediately reduced with educational interventions.The faceto-face intervention was observed to be more sustainable than online interventions among high-level athletes. 20evertheless, a mobile application was found to be a practical method for disseminating anti-doping education.The application improved knowledge and decreased favorable doping attitudes among coaches.The mobile application had educational modules on nutritional supplements, substances, rules, leadership, and fair play. 21Practical strength training advice provided in addition to anti-doping education to youth athletes was found beneficial in decreasing PEA. 22  Sensitizing those who have potential for doping needs to start early, even in schools.Students who were professionally involved in sports perceived performance enhancement as more acceptable than other students. 24Body image, nutritional supplement use, and weight change behaviors influence adolescents' PEA. 25 Media literacy interventions were effective to decrease doping behaviors of adolescent students. 26It is accepted that attitudes and knowledge about doping are influenced by educational activity. 27,28In addition, it is also possible that the studies itself had sensitized participants against PEA as assumed in our study.

Conclusion
This study showed that the PEAS short-form survey, along with the introduction of an antidoping educational flyer provided by a sports pharmacy team, resulted in decreasing PEA among bodybuilding populations in the UAE.The decline of PEA was significant for all eight items of the PEAS, except one.Bodybuilders, regardless of level of profession in the sport or level of competition, showed reduction in their attitude scores in the post-intervention survey.This study shows the potential for pharmacy-led educational interventions for bodybuilder athletes to influence favorable PEA, in support of the antidoping movement.Future studies are required to understand PEA among bodybuilders deeply and how favorable PEA can be sustained.

Limitations
A limitation of the study was that, even though the UAE is a multicultural society, with English and Arabic being common languages, the survey was only conducted in English; therefore, the study population might not have fully represented the UAE population.Making bodybuilders to fill the survey inperson when they visit pharmacies and follow-up on sustainable decline of PEA could be an ongoing project if resources and time permits.
○ However, I think that there is a blind spot in this paper about the willingness of IPED users to engage with medical services and pharmacists.Lots of literature has pointed to this and, although some improvements have been made with regard to building trust between the two communities, the question of who will actually see the flyer (those who actually engage with pharmacies) is pertinent.I'd like to see some understanding and caveat of that.

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How was the study advertised and how did recruitment actually take place?You say that you were 'distributing a pre-intervention survey to registered study participants through email and WhatsApp', but how did you get these participants' details in the first instance?○ I'd like to see more on limitations of the study and a more tentative tone in your conclusion.Perhaps some acceptance that a qualitative aspect would bolster the data and a nod to the need for the flyer to be trailed for long-term effectiveness.By that I mean that, whilst your sample might have reported less inclination to use IPEDs immediately following the flyer, will this attitude be sustained, especially given the normalization of use in some communities?It implies that the post score changed significantly when compared with the average pre-score, but the average attitude level became stable and is matched among different types of participants".This paragraph is absolutely incomprehensible.It does not become clear whether the terms "among groups" and "across groups" mean "between groups" or "within groups".The results of the statistical procedures used should be explained in more detail and visualized by tables or/and graphs.4.In the results section the authors state that " The distribution of attitude scores were reduced from before to after the intervention with statistical significance in addition to median of agreement decreased for 7 out of 8 items (Table 2).", but in the discussion and conclusion sections they assert that a decrease is measured in all eight items.This discrepancy should be addressed.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound?Yes

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate?Partly Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Sports science, dietetics, statistics, strength training I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
evidence of pharmacist contribution to Antidoping.With a few modifications given below, the work can be processed for publication.
In the background of the study, better to provide some evidence of generic names of drugs or chemicals that favors doping and causes health risks or complications.

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Though the PEAS short form is standard, validated, and internationally acceptable, the reliability of the tool in the study population can be given by providing Cronbach's Alpha value.Because it was mentioned that the tool was modified according to the study need (applicable to bodybuilders and doping strategies).

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In the sample size determination, though the recommended sample size is acceptable, the margin of error needs to be less than or equal to 5%.

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In the results section, the total study population was divided into four groups, named nonsport employment bodybuilders, full-time bodybuilders, University students, and School students.It was mentioned that the median score was significantly different after intervention.There is a need to mention which group shows a high or low median score.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
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©
2024 Panayotov V.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Valentin Panayotov 1 Department of Weightlifting, Boxing, Fencing and Sports for all, National Sports Academy, Sofia, Bulgaria 2 Department of Weightlifting, Boxing, Fencing and Sports for all, National Sports Academy, Sofia, Bulgaria In my opinion several inaccuracies should be addressed: 1.A Bonferroni correction of the pre-post results should be performed.2. Kruskal Wallis test results are not presented and interpreted.3. "When the average score is compared among the four groups by the median test, the median (average) of the overall prescore varied across the groups (p-value <0.001), but the average of the overall pre-score is almost the same between the groups (p-value 0.07).

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Is the work clearly and accurately presented and does it cite the current literature?YesIs the study design appropriate and is the work technically sound?YesAre sufficient details of methods and analysis provided to allow replication by others?YesIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?YesAre the conclusions drawn adequately supported by the results?YesCompeting Interests: No competing interests were disclosed.Reviewer Expertise: Pharmacoepidemiology, Pharmacoeconomics, Pharmacovigilance, Health Education, Epidemiology, Public health, Clinical Pharmacy, and Pharmacy Practice.

Table 1 .
Percentage responses before and after intervention.

Table 2 .
Performance enhancement attitude of bodybuilders before and after intervention.

the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Not applicable Are all the source data underlying the results available to ensure full reproducibility?
○Is

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
https://doi.org/10.5256/f1000research.143473.r236837