Barriers and enablers in doping, anti-doping, and clean sport: A qualitative meta-synthesis informed by the theoretical domains framework and COM-B model

To protect the integrity of sport, and the health of athletes, global anti-doping programmes seek to prevent doping, and elicit anti-doping and clean sport behaviours, through education, deterrence, detection, enforcement, and rules. To guide programme development, this meta-synthesis of qualitative research applied a behavioural science framework to identify barriers and enablers to doping, anti-doping, and clean sport. A systematic search of electronic databases up to May 2022, followed by critical appraisal, resulted in 73 included articles. Fifty-two articles reported the athlete perspective, thirteen included athletes, athlete support personnel (ASP), and other experts, and eight focused on ASP only. Rigorous methods of thematic synthesis were drawn upon to construct analytical themes in line with the theoretical domains framework (TDF) and the capability, opportunity, and motivation model of behaviour (COM-B). A wide range of barriers and enablers were identified which influenced capability, opportunity, and motivation to participate in a clean sport environment. The weight of evidence pointed to limitations in the current anti-doping education system in providing athletes and ASP with the knowledge and skills to protect against doping, as well as the significant influence of social and cultural norms in shaping doping and clean sport behaviours through a shared social identity, and risky contexts leading to moments of vulnerability to doping. We identified a need for anti-doping programmes to move beyond the current focus on athlete capability, and address the opportunity and motivation components of clean sport behaviours through a targeted and tailored focus on education, training, persuasion, modelling and environmental restructuring interventions.

Context matters: athletes' perception of dopers' values, actions and vulnerabilities

Background

Although athletes seem to hold uniform views towards non-dopers, their perception of dopers is more nuanced, reflecting positive and negative attributes. Research also indicates that rarely a single factor can explain doping, but a host of reasons that intertwine. A holistic understanding of how values play a role in decisions in anti-doping and the elements that influence athletes' doping vulnerability is timely and warranted.

Methods

We recruited elite athletes from 13 countries representing 27 sports at a national or international level (N = 60) to participate as part of a larger research project. Data were collected via focus group interviews focusing on values, value priorities and perceptions about the role of values in doping as a phenomenon and in dopers' actions. Data were analysed using iterative thematic analysis.

Results

Three themes were identified: (1) athletes' personal stance on doping, (2) dopers in the eyes of the anti-doping-compliant athletes, and (3) doping vulnerability is a balance. Athletes in this study strongly opposed doping but showed empathy and understanding toward athletes who doped under certain circumstances. Furthermore, athletes believed that "clean" and "doping" athletes are not always distinguished by the values they hold, leading to the realisation that all athletes can be vulnerable to doping at some point. This vulnerability is a balance between risks and protective factors in a complex interaction between environmental, personal, and situational influences. Each element (e.g., values, environment) can be a motivator or a barrier. Consequently, doping vulnerability is highly idiosyncratic and dynamic.

Conclusion

If doping is not due to a lack of moral values but the consequences of combined risk factors that override the guiding function of values, then doping can happen to anyone, "good" athletes included. Developers and facilitators of anti-doping education programmes are advised to embrace this important aspect. The results also contribute to developing the doping vulnerability concept as a balance between risks and protective factors and draw attention to the clean athlete vulnerability, which is rooted in the combination of strategic performance enhancement via non-prohibited means, their exposure to anti-doping requirements and the constant high level of suspicion that surrounds them.

Prevalence and correlates of androgen dependence: a meta-analysis, meta-regression analysis and qualitative synthesis

PURPOSE OF REVIEW

To investigate the prevalence and correlates of androgen dependence among users. A meta-analysis, meta-regression analysis, and qualitative synthesis were conducted based on a systematic literature search in Google Scholar, ISO Web of Science, PsycNET, and PubMed.

RECENT FINDINGS

Twenty-six studies were included in the review and 18 studies ( N  = 1782) in the statistical analysis. The overall lifetime androgen dependence prevalence was 34.4% [95% confidence interval (CI): 27.8-41.7, Q  = 113.1, I2  = 85.0, P  < 0.001]. Although males (36.1%, P  < 0.001) and females (37.0%, P  = 0.188) did not differ ( Q  = 0.0, P  = 0.930) in dependence prevalence, controlling for other study characteristics, higher study male sample proportion was related to higher dependence prevalence. Combined interview and questionnaire assessments showed higher prevalence compared to interviews only. Publications from 1990-1999 generated higher prevalence compared to 2000-2009 and 2010-2023 publications. Dependents were associated with a wide array of demographic inequalities, and biophysical, cognitive, emotional, and psychosocial problems.

SUMMARY

One of three persons who initiate androgen use experiences dependence along with various serious disorders. Androgen use and dependence should be considered an important public health issue requiring targeted health interventions.

Are dietary supplement users more likely to dope than non-users?: A systematic review and meta-analysis

In the past decade, a body of evidence has reported that dietary supplement use is related to prohibited performance enhancing substance use (i.e., doping). To help international and national sport organisations understand the degree to which dietary supplement use is related to doping, the objectives of this systematic review and meta-analysis were to 1) compare the prevalence of doping between dietary supplement users and non-users and 2) identify whether supplement use is related to doping social cognitive factors. We searched for studies sampling athletes and that measured both dietary supplement use and doping in EMBASE, MEDLINE, PsychINFO, CINAHL and SPORTDiscus from database creation to May 2022. Risk of bias was assessed using JBI Critical Appraisal Checklist for cross-sectional studies and the STROBE checklist. Twenty-six cross-sectional studies, involving 13,296 athletes were included. Random-effect models revealed that doping was 2.74 (95% CI=2.10 to 3.57) times more prevalent in dietary supplement users (pooled prevalence = 14.7%) than non-users (6.7%), and that users reported stronger doping intentions (r=0.26, 0.18 to 0.34) and attitudes (r=0.21, 0.13 to 0.28) compared to non-users. Preliminary evidence also suggests that dietary supplement users were less likely to dope if they were more task oriented and had a stronger sense of morality. Results of the review are limited by the cross-sectional design used in all studies and lack of consistency in measurement of dietary supplement use and doping. Data indicate that athletes using dietary supplements are more likely to self-report doping Anti-doping policy should, therefore, target dietary supplement use in anti-doping education programmes by providing alternative strategies for performance enhancement or highlighting the safest ways they can be consumed. Similarly, as a large proportion of athletes use dietary supplements without doping, further research is needed to understand the factors that protect a dietary supplement user from doping. No funding was received for the review. A study protocol can be found here: https://osf.io/xvcaq.

Corrigendum: Hidden figures: Revisiting doping prevalence estimates previously reported for two major international sport events in the context of further empirical evidence and the extant literature

[This corrects the article DOI: 10.3389/fspor.2022.1017329.].

Refinement of the extended crosswise model with a number sequence randomizer: Evidence from three different studies in the UK

The Extended Crosswise Model (ECWM) is a randomized response model with neutral response categories, relatively simple instructions, and the availability of a goodness-of-fit test. This paper refines this model with a number sequence randomizer that virtually precludes the possibility to give evasive responses. The motivation for developing this model stems from a strategic priority of WADA (World Anti-Doping Agency) to monitor the prevalence of doping use by elite athletes. For this model we derived a maximum likelihood estimator that allows for binary logistic regression analysis. Three studies were conducted on online platforms with a total of over 6, 000 respondents; two on controlled substance use and one on compliance with COVID-19 regulations in the UK during the first lockdown. The results of these studies are promising. The goodness-of-fit tests showed little to no evidence for response biases, and the ECWM yielded higher prevalence estimates than direct questions for sensitive questions, and similar ones for non-sensitive questions. Furthermore, the randomizer with the shortest number sequences yielded the smallest response error rates on a control question with known prevalence.

Hidden figures: Revisiting doping prevalence estimates previously reported for two major international sport events in the context of further empirical evidence and the extant literature

Background

High levels of admitted doping use (43.6% and 57.1%) were reported for two international sport events in 2011. Because these are frequently referenced in evaluating aspects of anti-doping, having high level of confidence in these estimates is paramount.

Objectives

In this study, we present new prevalence estimates from a concurrently administered method, the Single Sample Count (SSC), and critically review the two sets of estimates in the context of other doping prevalence estimates.

Methods

The survey featuring the SSC model was completed by 1,203 athletes at the 2011 World Championships in Athletics (WCA) (65.3% of all participating athletes) and 954 athletes at the 2011 Pan-Arab Games (PAG) (28.2% of all participating athletes). At WCA, athletes completed both UQM and SSC surveys in randomised order. At PAG, athletes were randomly allocated to one of the two surveys. Doping was defined as "having knowingly violated anti-doping regulations by using a prohibited substance or method."

Results

Estimates with the SSC model for 12-month doping prevalence were 21.2% (95% CI: 9.69-32.7) at WCA and 10.6% (95% CI: 1.76-19.4) at PAG. Estimated herbal, mineral, and/or vitamin supplements use was 8.57% (95% CI: 1.3-16.11) at PAG. Reliability of the estimates were confirmed with re-sampling method (n = 1,000, 80% of the sample). Survey non-compliance (31.90%, 95%CI: 26.28-37.52; p < 0.0001) was detected in the WCA data but occurred to a lesser degree at PAG (9.85%, 95% CI: 4.01-15.69, p = 0.0144 and 11.43%, 95% CI: 5.31-11.55, p = 0.0196, for doping and nutritional supplement use, respectively). A large discrepancy between those previously reported from the UQM and the prevalence rate estimated by the SSC model for the same population is evident.

Conclusion

Caution in interpreting these estimates as bona fide prevalence rates is warranted. Critical appraisal of the obtained prevalence rates and triangulation with other sources are recommended over "the higher rate must be closer to the truth" heuristics. Non-compliance appears to be the Achilles heel of the indirect estimation models thus it should be routinely tested for and minimised. Further research into cognitive and behaviour aspects, including motivation for honesty, is needed to improve the ecological validity of the estimated prevalence rates.

Women's Footprint in Anti-Doping Sciences: A Bibliometric Approach to Research Impact

Bibliometrics, via the exploitation of large-scale publication data, is a facile approach to explore gender-related trends, especially gender equality in academic publishing and authorship. For the first time, this study aims to investigate the gender-related trends in anti-doping sciences to (1) explore the relational structure of gender aspects of authorial, topical, and methodological features, (2) give recognition to women's contribution to anti-doping research, and (3) identify unique “gendered” potentials for advancing anti-doping research. To deliver on these aims, we employed bibliometric tools to publication records in anti-doping. After constructing a database containing academic publications on any aspect of anti-doping with at least one woman among the authors, we applied state-of-the-art methods from bibliometric science mapping and network analysis. The Lotka distribution model showed that the anti-doping research is a closed community with only 70 authors appearing more than once. Male authors being the majority (66.2%), women are under-represented in this field. The most important authorship position in the academic articles is mainly occupied by men, publications with male corresponding authors were in 774 out of 991 anti-doping related papers. The close connection of the top twenty most influential authors, men and women, to the World Anti-Doping Agency in some professional capacity suggest that the Agency have an influence on the anti-doping research beyond directly providing funding. In terms of geographical regions, publications with female authors were dominated anti-doping research in Italy, Romania, and Spain. In research networks to date, women have outperformed male authors in information centrality, which means that women in anti-doping research have had higher level of control over the information flow in the field than their male counterparts. The results of this study confirm the potential of bibliometric approach in the identification of emerging research topics and quantifying gender differentiation in the field of anti-doping. Due to their higher information centrality, women are better positioned for problem-focused multidisciplinary research both within anti-doping community, and with researchers in cognate fields. Bibliometric analyses have proved to be a powerful tool for monitoring and advancing anti-doping research impact via identifying new avenues for multidisciplinary work, better gender representation, and diversity.

The Meaning of “Clean” in Anti-doping Education and Decision Making: Moving Toward Integrity and Conceptual Clarity

With the World Anti-Doping Agency's International Standard for Education (ISE) coming into effect in 2021, the clean-sport movement is at a pivotal stage. Through this conceptual paper we juxtapose the sector-wide anti-doping education as set out in the ISE on the decision-making process at the individual level. We discuss three critical issues for the clean-sport movement. First, we make the case for doping being a “wicked” problem and outline the possible implications of this for prevention and detection. Second, we consider why we need to address regulative, normative, and cognitive components of clean sport if we are to maximize its legitimacy. Third, we critically expose the fluidity with which clean sport is defined, and the implications of defining clean sport in substance- vs. rule-based terms, which, respectively, lead to theorizing clean sport as “drug-free” vs. “cheating-free” sport. Finally, we consider the role and key components of anti-doping education and how the relevance of certain components may be dependent on the way clean sport is defined. Conceptualizing doping as a sport integrity issue, we move away from the archaic and delimiting view of clean sport as drug-free sport and conclude with recommendations on how to reconcile values-based education, awareness raising, information provision and anti-doping education within the broader scope of integrity, to support informed decision making and personal agency. To connect anti-doping education to individual-level decision making, we recommend a staggered approach in which specific education content is linked to different influences in the decision-making process, to different stages of athlete development, and to different educational goals. Emphasizing and encouraging sensemaking in anti-doping decision making offers a pragmatic approach for anti-doping education. Conceptual clarity and precise mapping of the educational goal, content, and delivery is vital for valid and meaningful evaluation of the effectiveness of anti-doping education.

GRADE IT—A Literacy-Based Assessment Tool for Generating Research-Based Assessment Data to Evidence the ImpacT of Anti-doping Education via Athletes' Capability to Make the Right Decision

The International Standard for Education (ISE) mandates Code Signatories to plan, deliver, and evaluate anti-doping education. Performance-based evaluation of anti-doping education requires alignment between educational goals, content, and defined outcomes. Based on an existentialist teaching and learning philosophy, we aimed to develop and test an anti-doping impact evaluation tool, to assess the impact of anti-doping education on doping awareness, literacy (DAL), perceived trust, and legitimacy. We propose that the impact of anti-doping education is best captured through assessment of situation-specific (social) cognitive mediators of actions that influence athletes' choices in the context of sport-related goals. In phase one, we aimed to develop and test the Generating Research-based Assessment Data to Evidence the ImpacT of anti-doping education (GRADE IT) evaluation tool that comprised a set of social cognitive components: anti-doping knowledge, DAL, perceived trust, and legitimacy of anti-doping (organizations). In phase two we assessed whether anti-doping education impacts knowledge, the three DAL stages (functional, interactive, and critical literacy), perceived trust and legitimacy. Phase one enrolled 986 junior elite athletes, and we showed that all GRADE IT components performed well. After revision of the tool for phase two, we validated the assumption that anti-doping education impacts the likelihood that athletes will make the “right” choice (based on a new set of data from 1,255 junior elite athletes). Comprehensive education was associated with higher scores for all stages of DAL, as well as perceived trust and legitimacy. Even athletes reporting no education had positive scores for all included outcomes, supporting the assumption that most athletes wish to engage in clean sport behaviors and might need anti-doping education not to prevent them from doping, but rather to reinforce their commitment to clean sport. In conclusion, GRADE IT, which is available in 23 languages, is a suitable tool for application to young, emerging athletes to satisfy the ISE requirement for evaluating anti-doping education programs. Researchers and practitioners alike are advised to collect additional data to further validate the tool for adult athletes, and to apply it longitudinally to identify if changes in doping prevention policies have a delayed effect on DAL, perceived trust, and legitimacy.

Racing Clean in a Tainted World: A Qualitative Exploration of the Experiences and Views of Clean British Elite Distance Runners on Doping and Anti-Doping

Background: Doping has been a prominent issue for the sport of athletics in recent years. The endurance disciplines, which currently account for 56% of the global anti-doping rule violations in athletics, appear to be particularly high risk for doping. Objective: Using this high-risk, high-pressure context, the main purpose of this study was to investigate the human impact of doping and anti-doping on "clean" athletes. The secondary aim of the study was to better understand the reasons for, and barriers to, competing "clean" among this group of athletes. Method: Semi-structured interviews were conducted with 11 elite distance runners from the UK to explore: (1) the reasons and motivations for competing clean. (2) Perceptions of the anti-doping system, and experiences of being part of that system. (3) Views on the prevalence and causes of doping and the impact of doping on the lives of clean athletes. The interviews were audio-recorded, transcribed verbatim, and analysed using Reflexive Thematic Analysis. Results: Four major themes were identified: (1) The participants in this study have not been tempted to use prohibited substances or methods; they compete in their sport for the personal satisfaction of seeing how good they can be, rather than in pursuit of winning at all costs. (2) Anti-doping does not currently prevent doping effectively and is not implemented evenly across the globe. (3) Doping was perceived as a major issue and was felt to be borne out of certain sporting cultures in which doping is enabled. (4) Doping has impacted the careers of clean athletes in irreversible ways and presents a continuing challenge to the psychological preparation for competition. Conclusions: Clean athletes suffer negative consequences from both doping and anti-doping. ADOs must collaborate across borders to ensure a more even implementation of anti-doping activities, to facilitate a more level playing field on the global stage. ADOs must also acknowledge the existence of a large group of athletes who would never consider deliberately doping and make anti-doping work for these athletes too.

Using Behavioural Reasoning Theory to Explore Reasons for Dietary Restriction: A Qualitative Study of Orthorexic Behavioural Tendencies in the UK

Orthorexia Nervosa (ON) has gained increased attention in academia since 1997. However, like other “Exia” conditions, there is debate around its inclusion in the Diagnostic and Statistical Manual of Mental Disorders. This study aimed to examine the experiences of those following a diet indicative of ON in the United Kingdom. This information is essential to the development of diagnostic criteria and classification of ON. Behavioural Reasoning Theory was used to explore reasons contributing to the development of ON. Ten individuals (two males and eight females), aged 23–35 years, took part in semi-structured interviews. Inductive thematic analysis was used to analyse the results. Four themes emerged from the data—journey, social, rules/control, and ethical considerations which highlighted contributing factors to the development of ON behaviours, the impact of these behaviours on individuals' social lives, and a strive for control. These findings are the first to suggest that ON involves a more complex set of behaviours than current definitions and proposed diagnostic criteria suggest and highlight the need to consider a variety of reasons for restricted diet when developing diagnostic criteria, screening tools, and classification in the DSM.

Functionality of the Crosswise Model for Assessing Sensitive or Transgressive Behavior: A Systematic Review and Meta-Analysis

Tools for reliable assessment of socially sensitive or transgressive behavior warrant constant development. Among them, the Crosswise Model (CM) has gained considerable attention. We systematically reviewed and meta-analyzed empirical applications of CM and addressed a gap for quality assessment of indirect estimation models. Guided by the PRISMA protocol, we identified 45 empirical studies from electronic database and reference searches. Thirty of these were comparative validation studies (CVS) comparing CM and direct question (DQ) estimates. Six prevalence studies exclusively used CM. One was a qualitative study. Behavior investigated were substance use and misuse (k = 13), academic misconduct (k = 8), and corruption, tax evasion, and theft (k = 7) among others. Majority of studies (k = 39) applied the "more is better" hypothesis. Thirty-five studies relied on birthday distribution and 22 of these used P = 0.25 for the non-sensitive item. Overall, 11 studies were assessed as high-, 31 as moderate-, and two as low quality (excluding the qualitative study). The effect of non-compliance was assessed in eight studies. From mixed CVS results, the meta-analysis indicates that CM outperforms DQ on the "more is better" validation criterion, and increasingly so with higher behavior sensitivity. However, little difference was observed between DQ and CM estimates for items with DQ prevalence estimate around 50%. Based on empirical evidence available to date, our study provides support for the superiority of CM to DQ in assessing sensitive/transgressive behavior. Despite some limitations, CM is a valuable and promising tool for population level investigation.

One Does Not Fit All: European Study Shows Significant Differences in Value-Priorities in Clean Sport

Doping violates the Spirit of Sport and is thought to contradict the values which underpin this spirit. Values-based education (VBE) has been cited as a key element for creating a clean sport culture across age groups. Culturally relevant VBE requires understanding of the values that motivate athletes from different countries to practice their sport and uphold clean sport values. WADA's new International Standards for Education makes this study both needed and timely. Overall, 1,225 athletes from Germany, Greece, Italy, Russia, and the UK responded to measures assessing their general values, Spirit of Sport values, and their perceived importance of “clean sport”. MaxDiff analysis identified the most important values to participants based on their respective country of residence. Correlation analysis was conducted to assess the relationship between importance of clean sport and Spirit of Sport values. There were significant differences between participant nationality and their perceived importance of clean sport [F_{(4, 1,204)} = 797.060, p < 0.000], the most important general values (p < 0.05), and Spirit of Sport values (p < 0.05). Moderate positive correlations were observed between the perceived importance of clean sport and honesty and ethics (r = 0.538, p < 0.005) and respecting the rules of sport (r = 0.507, p < 0.005). When designing the values-based component of anti-doping education programs, athletes' different value-priorities across countries should be considered.

Co-creating a social science research agenda for clean sport: An international Delphi study

BACKGROUND

Doping in sport is a significant issue. To date, research informing doping prevention has lacked a framework guiding research priorities. To ensure research is coordinated, sustainable and focused on end-user priorities, this study co-created the first research agenda for doping prevention.

METHODS

The Delphi method was used to develop this agenda. Based upon two substantive reviews of the doping literature and 12 focus groups across five countries, a questionnaire was developed assessing the importance of 15 research topics and identifying research questions.  Eighty-two anti-doping stakeholders with relevant expertise were invited to be panel members. In Round 1, an expert panel (n = 57; 70% response rate) completed this questionnaire. In Round 2, panel members (n = 33; 58% response rate) ranked for relative importance the eight topic areas rated highest in Round 1, before doing the same for research questions within each topic. Based on these rankings, a draft agenda was created. In Round 3, panel members (n = 26; 79% response rate) rated the degree to which they accepted this agenda, the feasibility of its delivery and identified possible barriers and facilitators to implementation.

RESULTS

The results of Round 1 and Round 2 were used to create a draft agenda consisting of 18 research questions stratified across eight topic areas. This agenda was either fully (n = 16) or mostly (n = 9) accepted by the panel in Round 3 (96.2%). Research topics included the effectiveness of interventions/education programmes, environmental influences, long-term development of protective and risk factors in athletes and their entourage, athletes' experiences of anti-doping procedures and athletes' place in the anti-doping system.

CONCLUSIONS

A rigorous exercise created an agenda for doping prevention research. Adoption and application of this agenda should lead to better coordination, more efficient use of funding, enhanced uptake of research findings and more effective doping prevention education.

'Clean athlete status' cannot be certified: Calling for caution, evidence and transparency in 'alternative' anti-doping systems

Athletes, sponsors and sport organisations all have a vested interest in upholding the values of clean sport. Despite the considerable and concerted efforts of the global anti-doping system over two decades, the present system is imperfect. Capitalising upon consequent frustrations of athletes, event organisers and sponsors, alternative anti-doping systems have emerged outside the global regulatory framework. The operating principles of these systems raise several concerns, notably including accountability, legitimacy and fairness to athletes. In this paper, we scrutinise the Clean Protocol™, which is the most comprehensive alternative system, for its shortcomings through detailed analysis of its alleged logical and scientific merits. Specifically, we draw the attention of the anti-doping community - including researchers and practitioners - to the potential pitfalls of using assessment tools beyond the scope for which they have been validated, and implementing new approaches without validation. Further, we argue that whilst protecting clean sport is critically important to all stakeholders, protocols that put athletes in disadvantageous positions and/or pose risks to their professional and personal lives lack legitimacy. We criticise the use of anti-doping data and scientific research out of context, and highlight unintended harms that are likely to arise from the widespread implementation of such protocols in parallel with - or in place of - the existing global anti-doping framework.

Assessing psychological and nutritional impact of suspected orthorexia nervosa: a cross-sectional pilot study

BACKGROUND

To date, research on the dietary patterns of individuals with potential orthorexic symptoms is lacking. This cross-sectional pilot study aimed to explore the feasibility of assessing dietary patterns with psychological traits and states of individuals with possible orthorexic tendencies.

METHODS

Dietary intakes of 10 individuals (two males and eight females) were assessed using 24-h recall. Mean age of participants was 28.3 years; mean body mass index was 21.2 kg m^-2 . Nutrient intakes were compared with current dietary guidelines and the Eatwell Guide (Public Health England, 2016). Participants completed the ORTO-15, the Eating Attitude Test (EAT-26), the Obsessive-Compulsive Inventory-Revised edition (OCI-R), Paulhus's Spheres of Control (SoC), the Rosenberg's Self-Esteem Scale (RSES) and the Multidimensional Body-Self Relations Questionnaire (MBSRQ).

RESULTS

High levels of disparity across participants' psychometric scores and 24-h recall results were observed. There was no single pattern of self-imposed dietary restrictions among participants. Described dietary practices failed to meet the guidelines for several nutrients.

CONCLUSIONS

The results of this pilot study suggest that an extensive investigation of the diets of individuals with possible orthorexic tendencies in a large-scale study would contribute to the understanding of this condition. In addition, the use of multiple psychometric instruments is recommended for diagnosing orthorexic nervosa.

"Doing What Is Right and Doing It Right": A Mapping Review of Athletes' Perception of Anti-Doping Legitimacy

BACKGROUND

The creation of the World Anti-Doping Agency in 1999 and the first implementation of the Anti-Doping Code in 2004 established institutional and legal level legitimacy for the anti-doping movement. Subsequently, a distinct line of research examining athletes' perceptions of anti-doping has emerged. This study aims to review the literature on legitimacy via athletes' perceptions of the underpinning values, fairness and effectiveness of anti-doping rules and procedures.

METHODS

A systematic mapping review with computerised literature search of seven databases (EBSCOHost, PubMed, Ingenta, ScienceDirect, SCOPUS, SPORTDiscuss and Google Scholar) was used, followed by hand-search of reference lists and relevant journals. Based on Tyler's (2006) psychological components of legitimacy (proper, just, and appropriate), a bespoke conceptual map and analytical framework was developed and employed for retrospective categorisation.

RESULTS

Thirty-nine studies representing 15,434 participants met the inclusion criteria. About half of the eligible studies discussed legitimacy components without identifying them as such. Identification of studies for legitimacy concepts faced considerable ambiguity in measures and interpretation, particularly in distinguishing between elements of being 'just' and 'appropriate'. Single focus on one aspect was rare but only 11 of the 39 studies included all three elements of perceived legitimacy. Overall, athletes agreed that anti-doping is 'doing the right thing' to protect clean sport but their views differed on whether the existing anti-doping system is effective and implemented fairly (i.e., 'doing anti-doping in a right way'). Owing to the ad hoc measurements and diverse methodology, quantitative meta-analysis was not feasible.

CONCLUSION

Legitimacy is an important concept in anti-doping. Attention to globally equal and fair implementation of testing and sanctioning is warranted. Legitimacy perceptions can be improved by better communication from anti-doping organisations to highlight progress with detection, greater transparency and explicit support for athletes who were affected by doping. Future research requires standardised conceptual framework and measures.

Effects of orthodox religious fasting versus combined energy and time restricted eating on body weight, lipid concentrations and glycaemic profile

For seven weeks, 37 overweight adults followed a hypocaloric diet based on Orthodox Fasting (OF). A hypocaloric, time restricted eating (TRE) plan (eating between 08:00 to 16:00 h, water fasting from 16:00 to 08:00 h) was followed by 23 Body Mass Index (BMI)-matched participants. Anthropometric, glycaemic and inflammation markers and serum lipids were assessed before and after the diets. Both OF and TRE groups demonstrated reductions in BMI (28.54 ± 5.45 vs 27.20 ± 5.10 kg/m², p < 0.001 and 26.40 ± 4.11 vs 25.81 ± 3.78 kg/m² p = 0.001, respectively). Following the intervention, the OF group presented lower concentrations of total and low-density lipoprotein-cholesterol, compared with the pre-fasting values (178.40 ± 34.14 vs 197.17 ± 34.30 mg/dl, p < 0.001 and 105.89 ± 28.08 vs 122.37 ± 29.70 mg/dl, p < 0.001, respectively). Neither group manifested significant differences in glycaemic and inflammatory parameters. Our findings suggest that OF has superior lipid lowering effects than the TRE pattern.

Corrigendum: "I Want It All, and I Want It Now": Lifetime Prevalence and Reasons for Using and Abstaining from Controlled Performance and Appearance Enhancing Substances (PAES) among Young Exercisers and Amateur Athletes in Five European Countries

[This corrects the article DOI: 10.3389/fpsyg.2017.00717.].

Would You Use It With a Seal of Approval? Important Attributes of 2,4-Dinitrophenol (2,4-DNP) as a Hypothetical Pharmaceutical Product

BACKGROUND

2,4-Dinitrophenol (2,4-DNP) is an effective but highly dangerous fat burner, not licensed for human consumption. Death cases reported for 2,4-DNP overdose, particularly among young adults, have raised concerns about the ineffective regulatory control, lack of education and risks associated with impurity, and the unknown concentration of 2,4-DNP purchased on the Internet.

METHODS

Using a sequential mixed method design and based on a hypothetical scenario as if 2,4-DNP was a licensed pharmaceutical drug, first we conducted a qualitative study to explore what product attributes people consider when buying a weight-loss aid. Focus group interviews with six females and three males (mean age = 21.6 ± 1.8 years) were audiorecorded, transcribed verbatim, and subjected to thematic analysis. Sixteen attributes were identified for the Best-Worst Scale (BWS) in the quantitative survey with 106 participants (64% female, mean age = 27.1 ± 11.9 years), focusing on 2,4-DNP. Demographics, weight satisfaction, and risk for eating disorder data were collected.

RESULTS

In contrast to experienced users such as bodybuilders, our study participants approached 2,4-DNP cautiously. Attributes of 2,4-DNP as a hypothetical weight-loss drug comprised a range of desirable and avoidable features. Of the 16 selected attributes, BWS suggested that long-term side effects were the most and branding was the least important attribute. Effectiveness and short-term side effects were also essential. Those in the >25 year group showed least concerns for legality. Neutral BWS scores for cost, treatment, degree of lifestyle changes required, and specificity required for the hypothetical weight-loss drug to be effective were likely caused by disagreement about their importance among the participants, not indifference.

CONCLUSION

With advances in research, 2,4-DNP as a pharmaceutical drug in the future for treating neurodegenerative diseases and potentially for weight loss is not inconceivable. Caution is warranted for interpreting the BWS scores. Owing to the difference in what data represent at individual vs. population levels, with pooled data, the method correctly identifies attributes by which most people are satisfied but misrepresents attributes that are individually very important but not universally agreed. Whilst this may be an advantage in marketing applications, it limits the utility of BWS as a research tool.

Inhibitory Effects of Diclofenac on Steroid Glucuronidation In Vivo Do Not Affect Hair-Based Doping Tests for Stanozolol

In vitro studies show that diclofenac inhibits enzymatic steroid glucuronidation. This study was designed to investigate the influence of diclofenac on the excretion of stanozolol and 3′-hydroxystanozolol via analyses in hair, blood and urine in vivo in a rat study. Brown Norway rats were administered with stanozolol (weeks 1–3) and diclofenac (weeks 1–6). Weekly assessment of steroid levels in hair was complemented with spot urine and serum tests. Levels of both stanozolol and 3′-hydroxystanozolol steadily increased in hair during stanozolol treatment and decreased post-treatment, but remained readily detectable for 6 weeks. In contrast, compared to control rats, diclofenac significantly reduced urinary excretion of 3′-hydroxystanozolol which was undetectable in most samples. This is the first report of diclofenac altering steroid metabolism in vivo, detrimentally affecting detection in urine, but not in hair, which holds considerable advantages over urinalysis for anti-doping tests.

Can We Better Integrate the Role of Anti-Doping in Sports and Society? A Psychological Approach to Contemporary Value-Based Prevention

In sport, a wide array of substances with established or putative performance-enhancing properties is used. Most substances are fully acceptable, whilst a defined set, revised annually, is prohibited; thus, using any of these prohibited substances is declared as cheating. In the increasingly tolerant culture of pharmacological and technical human enhancements, the traditional normative approach to anti-doping, which involves telling athletes what they cannot do to improve their athletic ability and performance, diverges from the otherwise positive values attached to human improvement and enhancement in society. Today, doping is the epitome of conflicting normative expectations about the goal (performance enhancement) and the means by which the goal is achieved (use of drugs). Owing to this moral-functional duality, addressing motivations for doping avoidance at the community level is necessary, but not sufficient, for effective doping prevention. Relevant and meaningful anti-doping must also recognise and respect the values of those affected, and consolidate them with the values underpinning structural, community level anti-doping. Effective anti-doping efforts are pragmatic, positive, preventive, and proactive. They acknowledge the progressive nature of how a "performance mindset" forms in parallel with the career transition to elite level, encompasses all levels and abilities, and directly addresses the reasons behind doping use with tangible solutions. For genuine integration into sport and society, anti-doping should consistently engage athletes and other stakeholders in developing positive preventive strategies to ensure that anti-doping education not only focuses on the intrinsic values associated with the spirit of sport but also recognises the values attached to performance enhancement, addresses the pressures athletes are under, and meets their needs for practical solutions to avoid doping. Organisations involved in anti- doping should avoid the image of "controlling" but, instead, work in partnerships with all stakeholders to involve and ensure integration of the targeted individuals in global community-based preventive interventions.

"I Want It All, and I Want It Now": Lifetime Prevalence and Reasons for Using and Abstaining from Controlled Performance and Appearance Enhancing Substances (PAES) among Young Exercisers and Amateur Athletes in Five European Countries

Doping use in recreational sports is an emerging issue that has received limited attention so far in the psychological literature. The present study assessed the lifetime prevalence of controlled performance and appearance enhancing substances (PAES), and used behavioral reasoning theory to identify the reasons for using and for avoiding using controlled PAES in young exercisers across five European countries, in the context of the “SAFE YOU” Project. Participants were 800 young amateur athletes and exercisers (M = 21.56; SD = 2.69) from Cyprus, Germany, Greece, Italy, and UK who completed an anonymous questionnaire that included measures of self-reported use of controlled PAES, as well as reasons for using and not using controlled PAES. The results of the descriptive analyses demonstrated that almost one out five exercisers in the sample had a previous experience with controlled PAES. Higher prevalence rates were found in Greece and Cyprus and lower in Italy. The most frequently reported reasons for using controlled PAES included achieving the desired results faster; pushing the self to the (physical) limits; and recovering faster after exercise/training. Furthermore, the most frequently reported reasons for not using controlled PAES involved worry about any possible adverse health effects; not feeling the need for using them; and wanting to see what can be achieved naturally without using any controlled PAES. The findings of the present study indicate that the use of controlled PAES is fast becoming a crisis in amateur sports and exercise settings and highlight the need for preventive action and concerted anti-doping education efforts.

No Laughing Matter: Presence, Consumption Trends, Drug Awareness, and Perceptions of "Hippy Crack" (Nitrous Oxide) among Young Adults in England

In clinical settings, nitrous oxide gas is a safe anesthetic used during childbirth, in dentistry, and to relieve anxiety in emergencies. Colloquially known as "hippy crack"' or "laughing gas," it is increasingly taken recreationally for its euphoric and relaxing effects and hallucinogenic properties. Using a self-reported survey, we gathered quantitative and qualitative information on users and non-users of hippy crack among a young population regarding: consumption patterns, knowledge, risk awareness and intentions toward future abuse. Quantitative responses from a total of 140 participants were analyzed for frequencies and relationships, whereas qualitative data were evaluated via identifying the reoccurring themes. Overall, 77.1% (n = 108) had heard of hippy crack and 27.9% (n = 39) admitted to past-year use. Prior users mostly indicated intended future use, had an average low number of past-year uses but some with > 20 occasions, had a varied number of inhalations per occasion (often 1-10) with an effect lasting up to 5 min, and a majority preferred social rather than lone use. For non-users, 79.2% said they would take hippy crack with the vast majority (94%) preferring a social setting. The results show a concerning gap between available evidence and awareness of side effects. Despite serious reported side effects, including psychosis and myeloneuropathy-especially on the young developing brain-only a minority (29.3%) was aware of any side effects. In contrast, in a hypothetical scenario depicting a first social encounter with hippy crack, the qualitative responses were in contrast to qualitative outcomes revealing that participants would try (n = 30)/not try (n = 25) it, would feel under pressure to try it (n = 6) with only 11 opting to exit the situation. In summary, this first report of trends and perceptions of the use of hippy crack among young adults in the England highlights a lack of concern with side effects, coupled to a willingness to partake. Because typical users are young with risks to the still developing brain, education about the nitrous oxide abuse is warranted to prevent impaired brain development. Further studies to investigate the possible effects of nitrous oxide on the developing brain in young adults would advance meaningful prevention.

"It Was Me on a Good Day": Exploring the Smart Drug Use Phenomenon in England

The non-medical use of prescription medication for the pursuit of increasing cognitive and intellectual capacities (defined neuroenhancement) has received growing attention from the scientific community and policymakers alike. To date, limited qualitative data exist exploring the nature of the phenomenon, especially as a potentially emerging trend among university students in England. Existing American literature suggests that students believe that neuroenhancement helps the individual to maximize his/her time, consenting a suitable balance between work and leisure. Students' motivation to experiment with neuroenhancement appears to be more in line with a need to regulate emotions surrounding study/work settings than to actually improve cognitive abilities beyond normal levels. This study aimed to qualitatively explore representations, motivations, beliefs, and consumption styles of a cohort of university student users residing in England. Through snowball sampling, 13 informants were contacted and interviewed regarding their experience with neuroenhancers. Narrations were analyzed and interpreted using qualitative analysis software and Grounded Theory methodology. Participants belonged to a broad variety of university courses and were predominantly habitual consumers of modafinil. Neuroenhancers were acquired either through friends or via the Internet. Motivations regarded the need to "catch up" and be on par with high achieving students. The entire cohort had previously experimented with other psychotropic substances. Synthetic compounds in particular were believed to be "gateway" drugs to using neuroenhancers. Experimentation with neuroenhancement can be seen as a self-governing strategy aimed at achieving continued focused productivity. Participants acknowledged sustainable benefits in neuroenhancement as it optimized work performance. The majority of the cohort also contemplated the possibility of using these drugs in the future once they entered the workforce. Neuroenhancing drug users expressed "situated morality," differentiating between using these substances for assessments (exams) or during revisions, finding only the former as an immoral conduct. In the present scenario, it appears that neuroenhancement is practiced by small numbers of students. Nonetheless, the instrumental views of psychotropic substances held by many young adults and the globalization of these practices make the normalization of neuroenhancement a plausible possibility of the future.

Russian roulette with unlicensed fat-burner drug 2,4-dinitrophenol (DNP): evidence from a multidisciplinary study of the internet, bodybuilding supplements and DNP users

Background

2,4-Dinitrophenol (DNP) poses serious health-risks to humans. The aims of this three-stage multidisciplinary project were, for the first time, to assess the risks to the general public from fraudulent sale of or adulteration/contamination with DNP; and to investigate motives, reasons and risk-management among DNP-user bodybuilders and avid exercisers.

Methods

Using multiple search-engines and guidance for Internet research, online retailers and bodybuilding forums/blogs were systematically explored for availability of DNP, advice offered on DNP use and user profiles. Ninety-eight pre-workout and weight-loss supplements were purchased and analysed for DNP using liquid-chromatography-mass-spectrometry. Psychosocial variables were captured in an international sample of 35 DNP users (26.06 ± 6.10 years, 94.3 % male) with an anonymous, semi-qualitative self-reported survey.

Results

Although an industrial chemical, evidence from the Internet showed that DNP is sold ‘as is’, in capsules or tablets to suit human consumption, and is used ‘uncut’. Analytical results confirmed that DNP is not on the supplement market disguised under fictitious supplement names, but infrequently was present as contaminant in some supplements (14/98) at low concentration (<100mcg/kg). Users make conscious and ‘informed’ decisions about DNP; are well-prepared for the side-effects and show nonchalant attitude toward self-experimentation with DNP. Steps are often taken to ensure that DNP is genuine. Personal experience with performance- and appearance enhancing substances appears to be a gateway to DNP. Advice on DNP and experiences are shared online. The significant discrepancy between the normative perception and the actual visibility suggests that DNP use is-contrary to the Internet accounts-a highly concealed and lonesome activity in real life. Positive experiences with the expected weight-loss prevail over the negative experiences from side effects (all but two users considered using DNP again) and help with using DNP safely is considered preferable over scare-tactics.

Conclusion

Legislation banning DNP sale for human consumption protects the general public but DNP is sold ‘as is’ and used ‘uncut’ by determined users who are not dissuaded from experimenting with DNP based on health threats. Further research with stakeholders’ active participation is imperative for targeted, proactive public health policies and harm-reduction measures for DNP, and other illicit supplements.

Electronic supplementary material

The online version of this article (doi:10.1186/s13011-015-0034-1) contains supplementary material, which is available to authorized users.

Using the prototype willingness model to predict doping in sport

To enable preventive measures to be designed, it is important to identify modifiable distal and proximal factors underlying doping behavior. This study investigated aspects of the prototype willingness model in relation to doping. A cross-sectional study was conducted involving 729 competitive athletes. Following ethical approval, athletes (mean age = 28.8 ± 10.1 years; 63% male) completed an online questionnaire, which assessed doping-related attitudes, norms, prototype perceptions, outcome expectancies, and behavioral willingness. Using hierarchical multiple regression analysis, 54.4% of the total variance in willingness to dope was explained. Specifically, past doping, attitudes, and favorability of performance enhancing substance user prototypes were the strongest unique predictors of willingness to dope. Athletes appeared most willing to dope if they were to suffer an injury, a dip in performance, or think others are doping and getting away with it. National-level athletes displayed significantly greater willingness to dope (Kruskal-Wallis γ2 = 35.9, P < 0.001) and perceived themselves as significantly more similar to a doper (Kruskal-Wallis γ2 = 13.4, P = 0.004) than athletes competing at any other level. The findings highlight the importance of extending anti-doping provision beyond elite-level sport and the need to target athletes' doping-related perceptions.

A call for policy guidance on psychometric testing in doping control in sport

One of the fundamental challenges in anti-doping is identifying athletes who use, or are at risk of using, prohibited performance enhancing substances. The growing trend to employ a forensic approach to doping control aims to integrate information from social sciences (e.g., psychology of doping) into organised intelligence to protect clean sport. Beyond the foreseeable consequences of a positive identification as a doping user, this task is further complicated by the discrepancy between what constitutes a doping offence in the World Anti-Doping Code and operationalized in doping research. Whilst psychology plays an important role in developing our understanding of doping behaviour in order to inform intervention and prevention, its contribution to the array of doping diagnostic tools is still in its infancy. In both research and forensic settings, we must acknowledge that (1) socially desirable responding confounds self-reported psychometric test results and (2) that the cognitive complexity surrounding test performance means that the response-time based measures and the lie detector tests for revealing concealed life-events (e.g., doping use) are prone to produce false or non-interpretable outcomes in field settings. Differences in social-cognitive characteristics of doping behaviour that are tested at group level (doping users vs. non-users) cannot be extrapolated to individuals; nor these psychometric measures used for individual diagnostics. In this paper, we present a position statement calling for policy guidance on appropriate use of psychometric assessments in the pursuit of clean sport. We argue that, to date, both self-reported and response-time based psychometric tests for doping have been designed, tested and validated to explore how athletes feel and think about doping in order to develop a better understanding of doping behaviour, not to establish evidence for doping. A false 'positive' psychological profile for doping affects not only the individual 'clean' athlete but also their entourage, their organisation and sport itself. The proposed policy guidance aims to protect the global athletic community against social, ethical and legal consequences from potential misuse of psychological tests, including erroneous or incompetent applications as forensic diagnostic tools in both practice and research.

Stimulus-response compatibility tests of implicit preference for food and body image to identify people at risk for disordered eating: a validation study

The aim of this study was to incorporate implicit measures of relevant social cognition into eating disorder research. Fifty-three females diagnosed with an eating disorder (ED), and 41 at-risk females were recruited via ED support websites, along with 23 healthy females for comparison. Computerised online tests assessing subconscious normative ideal body image (IBI-BIAT) and personalised self-identification body image (PBI-BIAT) associations and food preferences (FP-AAT) were administered, followed by the modified version of the Eating Disorder Examination Questionnaire (EDE-Q). Anthropometric data, age, need for social approval, self-reported measures of self-esteem, normative perception and body image satisfaction were recorded. Self-reported diagnosed ED status was corroborated with BMI and EDE-Q. Diagnostic performance of the implicit measures was assessed with ROC analysis. Those diagnosed with ED showed significantly stronger automatic preferences for and self-identification with thin body image, compared to healthy females, but no differences were found in food preferences. The IBI-BIAT showed better diagnostic power than PBI-BIAT, correctly classifying 87% of the diagnosed participants. No correlation was found between IBI-BIAT and the explicit measures. The results suggest that the underlying subconscious social cognitive factors of pathological eating are linked to body image, not to food items per se.

Estimating the prevalence of socially sensitive behaviors: attributing guilty and innocent noncompliance with the single sample count method

Prevalence estimation models, using randomized or fuzzy responses, provide protection against exposure to respondents beyond anonymity and represent a useful research tool in socially sensitive situations. However, both guilty and innocent noncompliance can have a profound impact on prevalence estimations derived from these models. In this article, we introduce the maximum-likelihood extension of the single sample count (SSC-MLE) estimation model to detect and attribute noncompliance through testing 5 competing hypotheses on possible ways of noncompliance. We demonstrate the ability of the SSC-MLE to estimate and attribute noncompliance with a single sample using the observed distribution of affirmative answers on recent recreational drug use from a sample of university students (N = 1,441). Based on the survey answers, the drug use prevalence was estimated at 17.62% (± 6.75%), which is in line with relevant drug use statistics. Only 2.51% (± 1.54%) were noncompliant, of which 0.55% (± 0.44%) was attributed to guilty noncompliance (i.e., have used drugs but did not admit) and 2.17% (± 1.44%) to innocent noncompliers with no drug use in the past 3 months to hide. The SSC-MLE indirect estimation method represents an important tool for estimating the prevalence of a broad range of socially sensitive behaviors. Subsequent applications of the SSC-MLE to a range of transgressive behaviors with varying sensitivity will contribute to establishing the SSC-MLE's performance properties, along with obtaining empirical evidence to test the underlying assumption of independence of noncompliance from involvement. Freely downloadable, user-friendly software to facilitate applications of the SSC-MLE model is provided.

Detecting cocaine use? The autobiographical implicit association test (aIAT) produces false positives in a real-world setting

BACKGROUND

The autobiographical Implicit Association Test (aIAT) is a novel application of the implicit association concept for detecting life events. It has been used to reveal concealed knowledge in clinical and forensic settings, including detecting drug use. In this study, we aimed to explore the functionality of the aIAT to identify drug use in real-world settings.

METHODS

The study used mixed methodology with known groups of drug users and nonusers. Recreational cocaine users (n = 23) and non-users (n = 23) were recruited through ethnographic methodology and assessed using a bespoke brief aIAT for cocaine use. An identical aIAT test for heroin detection was also administered to a sub-sample of 10 cocaine users and 13 nonusers. The accuracy of the cocaine aIAT was measured through ROC analysis. Paradoxical aIAT results were explored by integrating craving, consumption measures and life-story interviews into the analysis.

RESULTS

Whilst the two brief aIATs showed good concurrent validity for cocaine users by accurately detecting drug using status for 18 of the 23 users (78.3%), the test falsely reported 61% cocaine users in the non-user comparison group. The average D-scores were 0.257±0.246 for the cocaine users and 0.134±0.367 for the non-users, showing no discriminatory power (t(44) = 1.339, p = 0.187; AUC = 0.605, p = 0.223). Results were independent from craving and recent cocaine use. The comparison group's cocaine and heroin aIAT scores correlated significantly (r(13) = 0.776, p = 0.002) whilst an accurate absence of such relationship was evidenced in the cocaine using sample (r(10) = 0.061, p = 0.866). Triangulation with life-story interviews suggests that in the absence of an autobiographical event, this test may measure an alternative cognitive construct linked to the Self-concept.

CONCLUSION

The aIAT is a variant of an attitude measure and can be better rationalized if propositional thinking is implied to explain outcomes. The Relational Frame and Social Knowledge Structure theories can perhaps provide a more plausible theoretical background. Further work is required to clarify which factors underlie this testing technique's functioning. Reappraisal is advised before further forensic use of the instrument to ensure that general associations not related to autobiographical memory do not confound results.

The multi-player performance-enhancing drug game

This paper extends classical work on economics of doping into a multi-player game setting. Apart from being among the first papers formally formulating and analysing a multi-player doping situation, we find interesting results related to different types of Nash-equilibria (NE). Based mainly on analytic results, we claim at least two different NE structures linked to the choice of prize functions. Linear prize functions provide NEs characterised by either everyone or nobody taking drugs, while non-linear prize functions lead to qualitatively different NEs with significantly more complex predictive characteristics.

Determination of stanozolol and 3'-hydroxystanozolol in rat hair, urine and serum using liquid chromatography tandem mass spectrometry

Background

Anabolic androgenic steroids, such as stanozolol, are typically misused by athletes during preparation for competition. Out-of-competition testing presents a unique challenge in the current anti-doping detection system owing to logistic reasons. Analysing hair for the presence of a prohibited drug offers a feasible solution for covering the wider window in out-of-competition testing. To assist in vivo studies aiming to establish a relationship between drug levels detected in hair, urine and blood, sensitive methods for the determination of stanozolol and its major metabolite 3^′-hydroxystanozolol were developed in pigmented hair, urine and serum, using brown Norway rats as a model system and liquid chromatography tandem mass spectrometry (LC-MS/MS).

Results

For method development, spiked drug free rat hair, blood and urine samples were used. The newly developed method was then applied to hair, urine and serum samples from five brown Norway rats after treatment (intraperitoneal) with stanozolol for six consecutive days at 5.0 mg/kg/day. The assay for each matrix was linear within the quantification range with determination coefficient (r²) values above 0.995. The respective assay was capable of detecting 0.125 pg/mg stanozolol and 0.25 pg/mg 3^′-hydroxystanozolol with 50 mg hair; 0.063 ng/mL stanozolol and 0.125 ng/mL 3^′-hydroxystanozolol with 100 μL of urine or serum. The accuracy, precision and extraction recoveries of the assays were satisfactory for the detection of both compounds in all three matrices. The average concentrations of stanozolol and 3^′-hydroxystanozolol, were as follows: hair = 70.18 ± 22.32 pg/mg and 13.01 ± 3.43 pg/mg; urine = 4.34 ± 6.54 ng/mL and 9.39 ± 7.42 ng/mL; serum = 7.75 ± 3.58 ng/mL and 7.16 ± 1.97 ng/mL, respectively.

Conclusions

The developed methods are sensitive, specific and reproducible for the determination of stanozolol and 3^′-hydroxystanozolol in rat hair, urine and serum. These methods can be used for in vivo studies further investigating stanozolol metabolism, but also could be extended for doping testing. Owing to the complementary nature of these tests, with urine and serum giving information on recent drug use and hair providing retrospective information on habitual use, it is suggested that blood or urine tests could accompany hair analysis and thus avoid false doping results.

Understanding how adherence goals promote adherence behaviours: a repeated measure observational study with HIV seropositive patients

BACKGROUND

The extent to which patients follow treatments as prescribed is pivotal to treatment success. An exceptionally high level (> 95%) of HIV medication adherence is required to suppress viral replication and protect the immune system and a similarly high level (> 80%) of adherence has also been suggested in order to benefit from prescribed exercise programmes. However, in clinical practice, adherence to both often falls below the desirable level. This project aims to investigate a wide range of psychological and personality factors that may lead to adherence/non-adherence to medical treatment and exercise programmes.

METHODS

HIV positive patients who are referred to the physiotherapist-led 10-week exercise programme as part of the standard care are continuously recruited. Data on social cognitive variables (attitude, intention, subjective norms, self-efficacy, and outcome beliefs) about the goal and specific behaviours, selected personality factors, perceived quality of life, physical activity, self-reported adherence and physical assessment are collected at baseline, at the end of the exercise programme and again 3 months later. The project incorporates objective measures of both exercise (attendance log and improvement in physical measures such as improved fitness level, weight loss, improved circumferential anthropometric measures) and medication adherence (verified by non-invasive hair analysis).

DISCUSSION

The novelty of this project comes from two key aspects, complemented with objective information on exercise and medication adherence. The project assesses beliefs about both the underlying goal such as following prescribed treatment; and about the specific behaviours such as undertaking the exercise or taking the medication, using both implicit and explicit assessments of patients' beliefs and attitudes. We predict that i) the way people think about the underlying goal of their treatments explains medication and exercise behaviours over and above the effects of the behaviour-specific thinking and ii) the relationship between adherence to exercise and to medical treatment is stronger among those with more favourable views about the goal. Results from this study should identify the key contributing factors to inform subsequent adherence research and afford a more streamlined assessment matrix. The project also aims to inform patient care practices. UK CLINICAL RESEARCH NETWORK REGISTRATION NUMBER: UKCRN 7842.

Interactive network analytical tool for instantaneous bespoke interrogation of food safety notifications

BACKGROUND

The globalization of food supply necessitates continued advances in regulatory control measures to ensure that citizens enjoy safe and adequate nutrition. The aim of this study was to extend previous reports on network analysis relating to food notifications by including an optional filter by type of notification and in cases of contamination, by type of contaminant in the notified foodstuff.

METHODOLOGY/PRINCIPAL FINDINGS

A filter function has been applied to enable processing of selected notifications by contaminant or type of notification to i) capture complexity, ii) analyze trends, and iii) identify patterns of reporting activities between countries. The program rapidly assesses nations' roles as transgressor and/or detector for each category of contaminant and for the key class of border rejection. In the open access demonstration version, the majority of notifications in the Rapid Alert System for Food and Feed were categorized by contaminant type as mycotoxin (50.4%), heavy metals (10.9%) or bacteria (20.3%). Examples are given demonstrating how network analytical approaches complement, and in some cases supersede, descriptive statistics such as frequency counts, which may give limited or potentially misleading information. One key feature is that network analysis takes the relationship between transgressor and detector countries, along with number of reports and impact simultaneously into consideration. Furhermore, the indices that compliment the network maps and reflect each country's transgressor and detector activities allow comparisons to be made between (transgressing vs. detecting) as well as within (e.g. transgressing) activities.

CONCLUSIONS/SIGNIFICANCE

This further development of the network analysis approach to food safety contributes to a better understanding of the complexity of the effort ensuring food is safe for consumption in the European Union. The unique patterns of the interplay between detectors and transgressors, instantly revealed by our approach, could supplement the intelligence gathered by regulatory authorities and inform risk based sampling protocols.

Enzymatic digestion and selective quantification of underivatised delta-9-tetrahydrocannabinol and cocaine in human hair using gas chromatography-mass spectrometry

Gas chromatography-mass spectrometric (GC-MS) methods for drug analysis routinely employ derivatising reagents. The aim of this paper was to develop a method for the analysis of two recreational drugs, delta-9-tetrahydrocannabinol (Δ(9)-THC) and cocaine in hair samples using GC-MS, without prior derivatisation, thus allowing the sample to be reanalysed in its original form. An enzymatic digestion technique was also developed. Ten hair samples, that were known positive for either Δ(9)-THC and/or cocaine, were enzymatically digested, extracted, and then analysed by GC-MS. All samples measured contained Δ(9)-THC and one sample contained cocaine. The limits of detection (LOD) and quantification (LOQ) were 0.02 ng/mg and 0.05 ng/mg, respectively, for cocaine and 0.015 ng/mg and 0.02 ng/mg, respectively, for Δ(9)-THC. The wide detection window, ease of direct analysis by GC-MS, lower detection limits of underivatised samples, and the stability of drugs using this technique may offer an improved method of analysis.

Gateway to doping? Supplement use in the context of preferred competitive situations, doping attitude, beliefs, and norms

Nutritional supplement (NS) use is widespread in sport. This study applied an integrated social cognitive approach to examine doping attitudes, beliefs, and self-reported doping use behavior across NS users (n = 96) and nonusers (n = 116). Following ethical approval, 212 competitive athletes (age mean = 21.4, s = 4.5; 137 males) completed self-reported measures of doping-related social cognitions and behaviors, presented in an online format where completion implied consent. Significantly more NS users (22.9%) reported doping compared with nonusers (6.0%; U = 4628.0, P < 0.05). NS users presented significantly more positive attitudes toward doping (U = 3152.0, P < 0.05) and expressed a significantly greater belief that doping is effective (U = 3152.0, P < 0.05). When presented with the scenario that performance-enhancing substances are effective and increase the possibility of winning, NS users were significantly more in favor of competing in situations that allow doping (U = 3504.5, P < 0.05). In sum, doping use is three-and-a-half times more prevalent in NS users compared with nonusers. This finding is accompanied by significant differences in doping attitudes, norms, and beliefs. Thus, this article offers support for the gateway hypothesis; athletes who engage in legal performance enhancement practices appear to embody an "at-risk" group for transition toward doping. Education should be appropriately targeted.

New non-randomised model to assess the prevalence of discriminating behaviour: a pilot study on mephedrone

Background

An advantage of randomised response and non-randomised models investigating sensitive issues arises from the characteristic that individual answers about discriminating behaviour cannot be linked to the individuals. This study proposed a new fuzzy response model coined 'Single Sample Count' (SSC) to estimate prevalence of discriminating or embarrassing behaviour in epidemiologic studies.

Methods

The SSC was tested and compared to the established Forced Response (FR) model estimating Mephedrone use. Estimations from both SSC and FR were then corroborated with qualitative hair screening data. Volunteers (n = 318, mean age = 22.69 ± 5.87, 59.1% male) in a rural area in north Wales and a metropolitan area in England completed a questionnaire containing the SSC and FR in alternating order, and four questions canvassing opinions and beliefs regarding Mephedrone. Hair samples were screened for Mephedrone using a qualitative Liquid Chromatography-Mass Spectrometry method.

Results

The SSC algorithm improves upon the existing item count techniques by utilizing known population distributions and embeds the sensitive question among four unrelated innocuous questions with binomial distribution. Respondents are only asked to indicate how many without revealing which ones are true. The two probability models yielded similar estimates with the FR being between 2.6% - 15.0%; whereas the new SSC ranged between 0% - 10%. The six positive hair samples indicated that the prevalence rate in the sample was at least 4%. The close proximity of these estimates provides evidence to support the validity of the new SSC model. Using simulations, the recommended sample sizes as the function of the statistical power and expected prevalence rate were calculated.

Conclusion

The main advantages of the SSC over other indirect methods are: simple administration, completion and calculation, maximum use of the data and good face validity for all respondents. Owing to the key feature that respondents are not required to answer the sensitive question directly, coupled with the absence of forced response or obvious self-protective response strategy, the SSC has the potential to cut across self-protective barriers more effectively than other estimation models. This elegantly simple, quick and effective method can be successfully employed in public health research investigating compromising behaviours.