Μαρία Αγγέλη1, Μαίρη Χασάνδρα2, Χαράλαμπος Κρομμύδας3, Λίνα Ψούνη4 & Γιάννης Θεοδωράκης5
(1) Τμήμα Επιστήμης Φυσικής Αγωγής και Αθλητισμού, Πανεπιστήμιο Θεσσαλίας, Ελλάδα, Υποψήφια διδάκτωρ , email: marangeli@uth.gr
(2) Τμήμα Επιστήμης Φυσικής Αγωγής και Αθλητισμού, Πανεπιστήμιο Θεσσαλίας, Ελλάδα, Επίκουρη καθηγήτρια, ID: https://orcid.org/0000-0001-8046-3547
(3) Τμήμα Επιστήμης Φυσικής Αγωγής και Αθλητισμού, Πανεπιστήμιο Θεσσαλίας, Ελλάδα, Επίκουρος καθηγητής, ID: https://orcid.org/0000-0002-1461-9459
(4) Τμήμα Επιστήμης Φυσικής Αγωγής και Αθλητισμού, Πανεπιστήμιο Θεσσαλίας, Ελλάδα, Διδάκτωρ ΤΕΦΑΑ ΠΘ
(5) Τμήμα Επιστήμης Φυσικής Αγωγής και Αθλητισμού, Πανεπιστήμιο Θεσσαλίας, Ελλάδα, Καθηγητής, ID: https://orcid.org/0000-0002-5768-2060
DOI: https://doi.org/10.57160/ACPH5367
Περίληψη
Η παρούσα μελέτη αποσκοπεί στην αξιολόγηση της αποτελεσματικότητας ενός σχολικού εκπαιδευτικού προγράμματος με στόχο την εκπαίδευση και την αλλαγή της συμπεριφοράς των Ελλήνων μαθητών μέσης εκπαίδευσης απέναντι στη χρήση ντόπινγκ, το οποίο ονομάστηκε «Το ντόπινγκ καταστρέφει την υγεία και τα σπορ». Το πρόγραμμα βασίστηκε στις αρχές της Θεωρίας της Σχεδιασμένης Συμπεριφοράς και ενισχύθηκε από την καλλιέργεια δεξιοτήτων ζωής. Οι συμμετέχοντες ήταν 65 μαθητές από πέντε σχολεία δευτεροβάθμιας εκπαίδευσης (27 αγόρια και 38 κορίτσια- Μέσος όρος: 15,07 ± 1,17 έτη). Πριν και μετά την εφαρμογή του προγράμματος, οι μαθητές συμπλήρωσαν ηλεκτρονικά μια σειρά από καθιερωμένα ερωτηματολόγια που μετρούσαν την πρόθεση, τις στάσεις, την υποκειμενική νόρμα, τον αντιλαμβανόμενο έλεγχο συμπεριφοράς απέναντι στη χρήση ντόπινγκ και τη μάθηση για το ντόπινγκ, τις γνώσεις για το ντόπινγκ, τη συμπεριφορά άσκησης, τις στάσεις και την ικανοποίηση από την εφαρμογή του προγράμματος DOSPO. Τα αποτελέσματα έδειξαν σημαντικές διαφορές στις γνώσεις των μαθητών σχετικά με τη χρήση ντόπινγκ, την πρόθεσή τους να μάθουν για τη χρήση ντόπινγκ και τη στάση τους απέναντι στην εφαρμογή του προγράμματος. Τα αποτελέσματα αυτά υποδηλώνουν την αποτελεσματικότητα ενός θεωρητικού εκπαιδευτικού σχολικού προγράμματος, το οποίο βασίζεται στις δεξιότητες ζωής, στη γνώση των μαθητών και σε συγκεκριμένες μεταβλητές συμπεριφοράς, γεγονός που μπορεί να αποδειχθεί πολλά υποσχόμενο για την ανάπτυξη μελλοντικών παρεμβάσεων σχολικής αγωγής υγείας.
Λέξεις-κλειδιά: Θεωρία της Σχεδιασμένης Συμπεριφοράς, ντόπινγκ, πρόληψη, δεξιότητες ζωής, έφηβοι
Παραπομπή σε APA 7th edition:
Implementation and evaluation of a school-based educational anti-doping program for Greek high school students
Maria Angeli1, Maria Hassandra2, Charalampos Krommidas3, Lina Psouni4 & Yannis Theodorakis5
(1) Department of Physical Education and Sport Science, University of Thessaly, Greece, Ph.D. Candidate
(2) Department of Physical Education and Sport Science, University of Thessaly, Greece, Assistant Professor ID: https://orcid.org/0000-0001-8046-3547
(3) Department of Physical Education and Sport Science, University of Thessaly, Greece, Assistant Professor ID: https://orcid.org/0000-0002-1461-9459
(4) Department of Physical Education and Sport Science, University of Thessaly, Greece, Psychologist
(5) Department of Physical Education and Sport Science, University of Thessaly, Greece, Professor ID: https://orcid.org/0000-0002-5768-2060
DOI: https://doi.org/10.57160/ACPH5367
Abstract
The present study aimed to assess the effectiveness of a school-based educational program targeting to educate and change the behaviour of Greek high school students toward doping use, named “Doping destroys health and sports” (DOSPO). The program was based on the Theory of Planned Behavior (TPB) principles and was assisted by life skills training. The participants were 65 students from five Greek secondary schools (27 boys and 38 girls; Mage: 15.07 ± 1.17 years). Before and after the program’s implementation, students completed online a number of well-established questionnaires measuring their intention, attitudes, subjective norm, perceived behavioural control (PBC) towards doping use and learning about doping, knowledge about doping, exercise behaviour, attitudes, and satisfaction with the DOSPO program implementation. Results showed significant differences in students’ knowledge of doping use, their intentions to learn about doping use, and their attitudes toward the program’s implementation. Such results indicated the effectiveness of a theory-based, life skills-assisted educational school program on students’ knowledge and specific behaviour variables, which may be proven promising for the development of future school-based health education interventions.
Keywords: Theory of Planned Behavior, doping, prevention, life skills, adolescents
Introduction
Doping, or the use of illegal performance-enhancing drugs (PEDs), has been well-known for decades. Doping is defined by the World Anti-Doping Agency (WADA), “as the occurrence of one or more of the anti-doping rule violations” outlined in Articles 2.1 to 2.10 of the World Anti-Doping Code (WADA, 2021). Doping in sports is under the control of the WADA, which is created to protect all athletes from doping and guarantee effective anti-doping educational programs to prevent doping (ADO Reference Guide, 2015). The prohibited substances and procedures athletes are not allowed to use, are included in WADA’s Prohibited List, which contains almost 400 substances, by the time mentioned, and is reviewed annually (WADA, 2022). Although PEDs are illegal and athletes are aware of it, 14-39% of elite athletes use drugs, intentionally, to enhance their performance (De Hon et al., 2015). Doping use can lead to serious physical health issues, as they can affect the cardiovascular system and the liver, cause diabetes and cancer, and hurt individuals’ mental health, as they have been linked to increased risk of suicide (Bird et al., 2016), low self-esteem (Lovstakken et al., 1999) and other mental and behavioural conditions, such as Muscle Dysmorphia (MD), in which the individual perceives his/her physique as not adequately muscular or lean when instead, appears more muscular or lean than the average people (Pope et al., 1997; Skoufa et al., 2021).
On top of that, doping use has been recognized as a social issue (Timoshenko & Shiva, 2014). Given the fact, that society has undergone rapid changes in the system values, replacing moral ones, with wealth and success, as the ultimate values (Ahmadi & Svedsäter, 2016), many individuals use various types of means to increase their physical and mental performance (Breivik et al., 2009). Social pressure, the link between success factors, ideal body, self-confidence, and the emphasis the media place on the appearance of individuals, especially in younger age groups (Ahmadi & Svedsäter, 2016), elevating the use of doping to a significant social concern. According to literature, doping is used for aesthetic purposes, such as muscle growth and a leaner figure, in recreational sports, gyms, and fitness centres (Barroso et al., 2008; Ehrnborg & Rosén, 2009; Reardon & Creado, 2014). Furthermore, it has been widely spread in various social contexts, such as academic context, known as “brain doping”, or “academic doping” (Franke et al., 2014; Lucke et al., 2011; McCabe et al., 2005) for cognitive improvement purposes, security, and military forces contexts (Whyte et al., 2021) for performance improvement. Besides, it has been linked with increased criminality levels and frequently leads to combined drug use and alcohol abuse (Skårberg, 2009). Indeed, doping use has penetrated several cultural and social contexts, with athletes’ attitudes and the general population’s being more comparable than one may anticipate (Breivik et al., 2009). It seems that the labour domain does not differentiate from the sports environment, where an increase in business performance level is a sign of success (Timoshenko & Shishova, 2014).
Doping use not only affects young athletes but has an impact on inactive students as well (Barkoukis et al., 2016). European School Project on Alcohol and other Drugs (Shah et al., 2019) reported that 1% of young students used PEDs. Throughout adolescence, attractiveness plays a crucial role, and adolescents often present a willingness to consider the dangers of substance use (Arnett, 2000; Steinberg, 2007). This could potentially result in intentional doping use, given that this delicate period is characterized by a mistaken body image (Stojanović & Radovanović, 2020).
Unhealthy behaviours often coexist (Noble et al., 2015). Smoking, eating disorders, frequent alcohol use, and other illegal drug addictions, are positively related to doping use (Irving et al., 2002; Pedersen et al., 2001; Shah et al., 2019). Relevant reviews have stressed that school-based programs can be effective in doping and using of banned substances in sports (Masala et al., 2019; Sipavičiūtė et al., 2020), as early doping prevention through school environment is favourable because they comprise athlete and non-athlete population (Pöppel, 2021).
Even though substantial investment by governments globally into the development of anti-doping measures, the incidence of doping use remains high among both elite (Elbe & Pitsch, 2018) and amateur athletes (Lazuras et al., 2017). Thus, it is urgent to develop effective interventions, emphasizing primary prevention (Pöppel, 2021) rather than detecting doping behaviour. A growing body of literature suggests raising awareness and increasing education as a promising solution for preventing this risky behaviour (Backhouse, 2015; Fares et al., 2021; Nicholls et al., 2017). Youth and adolescents constitute ideal groups for anti-doping initiatives, as attitudes and values are formed during adolescent years, and they tend to be more susceptible to normative social influence (Backhouse et al., 2012; Kohlberg & Hersh, 1977).
The decision to use PEDs is a complicated process involving motivation, beliefs, cognitions, and morality (Ntoumanis et al., 2014; Petróczi, 2007). Regarding adolescents, several studies have tried to examine the psychosocial factors that influence their intentions to use illegal performance-enhancing substances (PES) (Ntoumanis et al., 2014). An increasing body of research has focused on the psychological factors that affect athletes’ usage of illicit substances to improve their athletic performance (Barkoukis et al., 2011; Ehrnborg & Rosén, 2009; Gucciardi et al., 2011; Ntoumanis et al., 2013). Social norms, attitudes towards doping, morality, and self-efficacy are linked to lower intentions to use illicit substances (Barkoukis et al., 2013; Hodge et al., 2013; Lucidi et al., 2008; Ntoumanis et al., 2014; Zelli et al., 2010). This declares that doping use is an intentionally regulated and goal-directed behavior (Connor et al., 2013; Gucciardi et al., 2011; Jalleh et al., 2014; Lentillon-Kaestner et al., 2012).
The Theory of Planned Behavior (TPB) (Ajzen 1991; 2012) has become a framework for predicting and preventing various health behaviors aiming to transform an unhealthy behavior into a healthy one (Baudouin et al., 2020; Delpia et al., 2016; Fertman, 2016; Fishbein & Ajzen, 2011). TPB (Ajzen, 1991) demonstrates that individuals’ behavior is influenced by their intention to perform a specific behavior, which is driven by three factors: their attitudes towards this behavior (evaluation of the behavior), subjective norm (their perceptions of significant others’ beliefs on their ability to perform the behavior) and perceived behavior control (their perceptions on the ease or difficulty to execute the behavior). Cognitive and behavioral approaches are effective (Botvin et al., 1990; Yesalis et al., 2000). For example, in Bates et al. (2019) review, the most promising interventions consisted of behavior change techniques such as persuasion, goal setting, and providing information about health and social consequences, indicating that multifaceted interventions are more efficient.
Concerning doping behaviour, research has adequately used TPB to explain the mental processes that guide individuals to doping use (Ntoumanis et al., 2013; Sipavičiūtė et al., 2020). For example, Ntoumanis et al. (2014) postulate that the most significant factors influencing the decision to use doping substances are the normative beliefs, the attitudes before doping use, and the previous use of legal performance-enhancing substances. Since attitudes and beliefs are established during childhood and early adolescence (Cieciuch et al., 2016; Döring et al., 2016), and intentions to doping use, are positively correlated to attitudes (Nicholls et al., 2017), an anti-doping educational program should emphasize on changing attitudes toward doping use. In support of this argument, several effective anti-doping interventions targeting adolescents, included moral and health messages in their sessions (e.g., Barkoukis et al., 2016; Elliot et al., 2008; Engelberg et al., 2015), as they have been found crucial preventive milestones for this age group.
For example, Jalilian et al. (2011) tested the effectiveness of a TPB-based intervention, among male young adults. The intervention was designed to supply refusal skills opposed to doping use, and provided educational content concerning the side effects of doping use and proper nutrition, aiming to enhance gym practices, without doping use. Resistance skills against doping use were improved; intention and knowledge about the side effects of doping use reduced the rates of AAS usage in the intervention group. Participants’ beliefs against doping use were modified, but the subjective norm and perceived behavioural control did not improve.
Anti–doping education interventions targeting adolescents.
Although the prevalence of doping use is presented because of a lack of knowledge about the health consequences of this behaviour (Masala et al., 2019), health education is not part of the Greek school’s curriculum, not to say anti-doping education. WADA (2019) emphasizes education initiatives, highlighting them as the target purpose of the WADA code (WADA, 2021). Recommended education regarding the validity of anti-doping organizations has been proven effective in improving athletes’ perceptions of their legitimacy (Henning & Dimeo, 2018; Woolway et al., 2020). Álvarez et al. (2019) assessed the effectiveness of a doping prevention school program, targeting adolescents which consisted of six sessions with results proving its effectiveness for doping prevention, by increasing students’ knowledge, attitudes, and beliefs.
Literature suggests the application of theory-based educational interventions including new technologies for non-athletic adolescent groups (Daher et al., 2021). For example, Lucidi et al. (2017) tested the effectiveness of a cognitive theory-based, media literacy school intervention, educating students on how the media may diminish the moral consequences of doping to achieve greater control over media exposure (Potter, 2004). The program lasted six months and the results showed a decrease in students’ attitudes concerning doping use. Similarly, Mallia et al. (2020) examined the effectiveness of a media literacy intervention, with effects on positive attitudes toward doping use, but a significant increase in students’ self-efficacy in dealing with media influence.
Virtue ethics and overall wellness are crucial doping preventative milestones among adolescents. In a study of Barkoukis et al. (2016), students attended classroom sessions emphasizing learning about prohibited substances and their side effects. Attitudes toward the use of legal substances were significantly negative in the intervention group, with no changes in attitudes toward doping use. In a recent study by Kavussanu et al. (2021) young athletes’ doping susceptibility and doping likelihood were tested on a basis of two interventions, a “moral” intervention, and an education intervention. Both reduced the risk of doping, with results suggesting the addition of moral variables in an effective anti-doping educational intervention.
Doping behaviour and life skills education
Life skills are defined by the abilities which enable individuals to successfully handle daily demands and pressures (WHO, 1997) and they are classified as physical, cognitive, and behavioural (Danish & Donahue, 1995). Those abilities can be learned, interactively, through teaching and practicing (Goudas, 2010), thus, interactive programs have been proven more effective than information-driven ones (Tobler & Stratton, 1997). Reinforcing healthy habits and preventing harmful behaviours are two main purposes of life skills education (Fallace et al., 2019), and particularly in adolescence, life skills education fosters health-related, self-regulation (Kirchhoff & Keller, 2021). Literature research highlights the effectiveness of life skills education through different contexts, such as sports (Papacharisis et al., 2005) and schools (Kirchhoff & Keller, 2021; Tiwari et. al., 2020). According to Kirchhoff and Keller’s (2021) recent review, most life skills programs, among adolescents, were targeting substance use prevention, with most of them indicating positive effects in the long term (Spoth et al., 2017). More precisely, the most effective were refusal, problem-solving and critical thinking skills, leading to self-efficacy resistance (Kirchhoff & Keller, 2021). For example, Botvin et al. (1990) applied a cognitive-behavioural intervention, among high school students. The conditions were distributed in peer-led and teacher-led interventions, with and without booster sessions and a control group. Results indicated that this type of substance abuse prevention strategy, proved effective, especially when life skills teaching was implemented by peer leaders with booster sessions. Relevant reviews (Fallace et al., 2019; Hale et al., 2014), demonstrated that behavioural interventions, assisting with life skills education, have been proven effective in improving social, knowledge and competence skills.
Backhouse et al. (2014) classified the main successful doping prevention approaches: the knowledge-based approach, which emphasizes the side effects of doping use, life skills teaching (practicing social skills, refusal skills, decision making, improving self-efficacy, etc.), emotionally based (focusing on feelings of self-worth and self-esteem) and moral values approach. Similarly, Barkoukis et al. (2014) argued that anti-doping interventions should not focus only on promoting the risk factors of engaging in doping behaviour but should include preventive approaches such as life skills teaching, emotion regulation techniques, and communication technologies. To the best of our knowledge, there is a lack of life skills school education programs targeting doping use prevention, exclusively.
Aim of the Study
The current study aims to evaluate the effectiveness of an antidoping school education program, based on the principles of the TPB with the assistance of life skills education. The program is based on the idea that students will require a broader knowledge of doping and its health consequences and would enable healthier lifestyle choices. The program includes the promotion of exercise behaviour, values, and personal development skills acquisition (Pöppel, 2021). The hypothesis is that the students’ post-intervention measure will reflect an increase in their knowledge about doping and improve students’ average responses for TPB variables. This study examined the effectiveness of the implementation of a school-based health education program designed to educate and prevent doping use in Greek secondary school students. The education program was named “Doping destroys health and sports” (DOSPO). It was based on the principles of TPB, life skills education, and the use of digital components aiming to improve their knowledge about doping use. The program consisted of 10 one-hour sessions which included behaviour modification techniques, goal-setting, problem-solving, and cognitive restructuring methods.
Method
Participants
Participants of the DOSPO program were 65 students from five Greek secondary schools
(Mage: 15.07 ± 1.17 years, 27 boys and 38 girls;). Students and teachers participated voluntarily. Participants were recruited using the snowball sampling method (Leighton et al., 2021). The DOSPO program was promoted through advertisements on social media and emails. PE teachers who were interested in implementing the program filled in fulfilled a form of participation, indicating their willingness to use the program’s material in weekly class sessions, assisted by researcher’s guidance. Teachers informed students about the program.
Eligibility criteria were being a secondary student, 12-16 years old, willing to participate in the study, having parents’ consent form, and being able to read and complete the questionnaires on their own. The exclusion criteria were the inability to complete program sessions, and an incomplete questionnaire. It is important to mention here that at the beginning of this intervention program, participants were 68 high school students, but for personal reasons, three of them (two boys and one girl) did not manage to participate in all sessions and dropped out from the post-intervention measurement (dropout rate: 4.41%).
Instruments
The TPB scales were developed, by Ajzen’s (2002) recommendations, to capture students’ attitudes toward doping, attitudes toward the program, intention to learn about doping, subjective norm, and PBC. All the instruments of the present study have previously been utilized in relevant school-based interventions with Greek participants (e.g., Angeli et al., 2022; Hassandra et al., 2009; Kolovelonis et al., 2016).
Attitudes towards doping
Attitudes toward doping behaviour were assessed by five items (e.g., “For me doping is…”). The responses ranged on a 7-point bipolar Likert scale (e.g., good-bad, healthy-unhealthy, useful-useless, and pleasant-unpleasant).
Intention to learn about doping
Two items incorporated the assessment of the intention to learn about doping (e.g., “I intend to learn about doping”, “I will try to learn about doping”). Participants’ responses were given on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).
Subjective norm
It was assessed with two items (e.g., “Important people to me believe that I will learn about doping”, “Key people in my life would like to be informed about doping”). Answers were offered on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).
Perceived behavioural control
Participants’ competence to control themselves regarding what extent they will learn about doping use was captured with two items (e.g., “It depends on me if I learn about doping”, “It is my responsibility whether I am informed about doping”). They answered on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).
Attitudes toward the application of the program
Under the following phrase “For me the program is…”, participants provided their answers on a 7-point Likert scale with bipolar words (e.g., good-bad, pleasant-unpleasant, attractive-unattractive, and useful- useless).
Satisfaction with the program
It was assessed with six items (e.g., “This online program was easy to use”), upon the completion of the intervention. Students answered on a 7-point Likert scale from 1 (totally disagree) to 7 (totally agree).
Knowledge about doping use
A 20-item questionnaire was created to assess general knowledge of doping use (e.g., “Doping control is conducted by testing blood, urine and exhaled air” or “The use of some pharmaceutical substances that dope athletes can cause some forms of cancer in the long term”) based on previous school-based health intervention programs (e.g., Angeli et al., 2022; Hassandra et al., 2009; Kolovelonis et al., 2016). Participants’ answers were given on a 3-point Likert scale (0 = no, 1 = I am not sure, 2 = yes), and their scores ranged between 0-60.
Procedure
Initially, the present study was approved by the Bioethics Committee of the Department of Physical Education and Sport Science, University of Thessaly, Greece (Ref. Number: 653; Date: 12 December 2012). Also, at the start of the intervention, all students and their parents/guardians gave their consent to participate in it. The program’s material and the measures were administrated through the website http://research.pe.uth.gr/health/. Teachers who were interested in implementing the program fulfilled a form of participation. They were given access to the program’s materials, with the presumption that students would complete the pre-intervention questionnaires, using the usernames given. Upon the completion of the sessions, students reuse their usernames and re-evaluate the program by responding to the post-intervention questionnaires. A certificate of attendance was given to the teachers who implemented all the sessions and motivated their students to complete the post-intervention measurement, along with the results of the evaluation. The program consisted of downloadable material, containing application instructions, relevant bibliography, PowerPoint presentations, tasks, ideas for experiential activities, games, appropriate teaching strategies and techniques, topics for project work, relevant websites, and more. The program comprised 10 one-hour sessions, which are described below (Table 1).
Table 1. Description of the DOSPO program (sessions and activities).
| Sessions | Contents | Activities |
| 1st | Introduction – Doping scandals – Side effects of doping – Doping control process – The importance of fair play | “Why do we participate in sports?”
Anti-doping images – “How an athlete feels when is caught doping?” – Anti-doping messages |
| 2nd | Initial evaluation – Purpose of the program – General knowledge about doping – Comprehend the existence of rules in sport
|
Discussion about cases of athletes who used Performance Enhancing drugs – “Organize a match with and without rules” – Discuss our feelings about doping – Familiarize significant others (family) with the rules in sports. |
| 3rd | Ethics and values in sports – moral reward
|
Discuss the prize of the Olympic Games- definition significance of the victory – Create a message communicating values in sports – Teamwork: “gather information and create a poster about values in sports” |
| 4th | Assessment of doping knowledge | Knowledge test: “How is doping defined?” –
“Discuss anti-doping images and create a story using some of them” |
| 5th | Assessment of knowledge towards side effects of doping – Teaching life skills through drama
|
“Write down the term of doping” – Discuss pictures of acne caused by anabolic steroid use” – Drama play: “How does an athlete with side effects of doping behave? How do family, friends, and teammates treat him/her?” – Search for information: “What happens when children use illegal substances?” |
| 6th | Information about doping control process and regulations | “Interview an elite athlete: do athletes have the necessary knowledge about doping use? Which are their attitudes?”- Create a knowledge test about doping using online information – Create a poster with a message promoting healthy sports |
| 7th | What causes athletes to dope – social, economic, and psychological drives in doping – increased awareness- information
|
Discussion: “Is it certain for a doped athlete that he/she reaches the peak performance – does the risk outweigh the reward” – Find interviews of athletes who were doped. |
| 8th | How athletes feel when they are caught using PEDs – Practice the empathic process for a doped athlete (doping behaviour)
|
How a doped athlete may feel? – Role-play: interviewing students acting out
athletes who dope and athletes who they are “clean” – discuss and compare the answers |
| 9th | Body Dysmorphia – causes of body image disorders and gender differences – media, culture, and body dissatisfaction | Body image definition – social norms and body image – discuss pathological behaviours related to body image – discuss the evolution of body image through history by gathering evidence |
| 10th | Introduce the goal-setting technique – Learn how to set individual goals – Practice problem-solving skills on exercise behaviour | Define goal-setting technique – Overcoming obstacles to health (exercise behaviour) – Interpret problem-solving technique |
Statistical analysis
The data analysis was conducted with IBM SPSS v 26.0. (IBM Corp, Armonk, NY, USA), while the level of significance was set at p ≤ .05. Descriptive statistics (means, standard deviations) and Cronbach’s α reliability index were calculated for both measurements. Additionally, separate paired samples t-tests were conducted, and Cohen’s d effect size was calculated to capture possible differences in the examined variables (intention, attitudes, subjective norm, PBC towards doping use and learning about doping, knowledge about doping, attitudes and satisfaction towards the DOSPO program implementation) between pre- and post-intervention measurements.
Results
Descriptive statistics (means, standard deviations) and Cronbach’s α reliability index are presented in Table 2. All scales had acceptable reliability except PBC (α = .29) and knowledge about doping (α = .58) on pre-intervention measurement. However, despite these low reliability values, we decided to keep them for further statistical analyses. Tenenbaum et al. (2012) claim that a scale can display potentially low reliability due to a variety of internal (e.g., participants’ personality characteristics, stress) and external factors, such as measurement conditions (e.g., time, place of completion, weather) and supervision that is provided by the researcher or the teaching staff. Field (2009) adds that due to the complexity and diversity that these scales display, researchers should also anticipate reliability values lower than .70 when using psychological variables in their study.
The results for the DOSPO health intervention program showed significant differences in students’ intention to learn about doping (t64 = -1.991, p = .05, d = .24), attitudes toward the program’s implementation (t64 = -2.856, p < .01, d = .35), and knowledge about doping (t64 = -6.232, p < .001, d = .76) between pre- and post-intervention measurements. More specifically, after the implementation of the DOSPO health education program, students reported higher scores on intention to learn about doping, attitudes toward the program’s implementation, and knowledge about doping compared to their pre-intervention measure (Table 2, Figures 1-3). Regarding students’ satisfaction with the implementation of the DOSPO health education program, they also reported very high rates of satisfaction (Table 2). On the other hand, there were no significant differences in students’ attitudes towards doping (t64 = -.343, p = .733), subjective norm (t64 = -.674, p = .502), PBC (t64 = -1.217, p = .228), doping behaviour (t64 = .441, p = .682), and exercise behaviour (t67 = -1.725, p = .09).
Table 2. Descriptive statistics, reliability index, and significant differences between pre and post-intervention measures on DOSPO health education program.
| Pre-intervention | Post-intervention | ||||||
| Variables | M | SD | α | M | SD | Α | |
| Attitudes towards doping | 1.62 | .79 | .84 | 1.65 | .89 | .80 | |
| Intention to learn about doping | *5.59 | 1.57 | .97 | 5.96 | 1.13 | .78 | |
| Subjective norm | 5.36 | 1.56 | .90 | 5.52 | 1.52 | .96 | |
| PBC | 5.67 | 1.40 | .29 | 5.92 | 1.21 | .79 | |
| Attitudes toward the program’s implementation | **5.21 | 1.48 | .84 | 5.73 | 1.26 | .86 | |
| Knowledge about doping | ***34.71 | 7.22 | .58 | 43.22 | 9.28 | .76 | |
| Doping behaviour | 1.58 | 1.02 | .87 | 1.52 | .98 | .66 | |
| Satisfaction with the program | – | – | – | 5.91 | .82 | .79 | |
| Notes. M: Mean; SD: Standard Deviation; α: Cronbach’s α reliability index; PBC: Perceived Behavioural Control; *p < .05; **p < .01; ***p < .001. | |||||||
Discussion
The objective of the study was to assess the effectiveness of a school education program named “DOSPO”, targeted to improve knowledge, attitudes, and beliefs about doping. The recipients of the program were students and non-athletes from different Greek secondary schools. The results showed that the program highly influenced students’ knowledge about doping, and intentions to learn about doping use, and had a significant positive effect on students’ attitudes toward the program implementation. The significant improvement of this doping prevention education program in knowledge is consistent with previous health promotion studies in the school context (e.g., Angeli et al., 2022; Codella et al., 2019; Nicholls et al., 2020; Sagoe et al., 2016). Besides, research reveals that a lack of awareness about doping information, or knowledge obtained from unreliable sources affects adolescents’ doping behaviour (Duncan et al., 2018; Kim & Kim, 2017). Doping-related knowledge constitutes an important factor in preventing doping behaviour as it has been proven to foster the development of protective traits such as healthier attitudes and beliefs (Königstein et al., 2021).
The knowledge effect holds great importance, as existing literature reveals that athletes have acknowledged the impact of insufficient doping education on their doping behaviour (Backhouse et al., 2016; Hauw & Mohamed, 2015). Thus, an appropriate educational school program may build their resistance and refusal skills (Backhouse et al., 2016). However, Álvarez et al. (2019) demonstrate the impact of anti-doping intervention on participants’ knowledge but showed that certain information requires a longer period to be processed, questioning the feasibility of short time interventions. To conclude, knowledge acquisition through an educational intervention is important as it has been found to improve resistance and prevent doping behaviour among adolescents
(Allahverdipour et al., 2009; Chan et al., 2016).
Regarding their attitudes toward the program implementation, students appreciated and greatly welcomed the educational program. Indeed, they reported very high scores in satisfaction from their participation in the DOSPO program. These results confirm research findings that adolescents prefer more engaging and interactive programs which contain drama and role-playing more than merely informational content (Backhouse et al., 2012; Hallward & Duncan, 2019). The effectiveness of such interventions is increased when online training is combined with real-life interaction, offering adolescents the chance to acquire knowledge and skills independently (Elbe & Brand, 2016). Besides, the use of technology and the development of internet-based educational programs, with the addition of life skills and communication technologies, have been proven effective support strategies (Barkoukis et al., 2014; Champion et al., 2013).
In respect of students’ intentions to learn about doping, results showed a significant increase (d = .24) in post-test results. Taking into account that intention predicts behaviour, and stability demonstrates an important mechanism that regulates the intention-behaviour relationship (Conner & Norman, 2022), students’ intention to learn indicates that the intervention and the components of the program proved their effectiveness. Besides, according to relative metanalysis, effective interventions typically have an impact on intentions (Webb & Sheeran, 2006). Regarding attitudes, one potential explanation may be that they were already negative pre-test (mean score 1.62 in baseline, pre-intervention assessment). Consequently, the impact of the intervention was not a significant and observable improvement. However, attitudes are proven to be the proximal factor to doping behaviour among studies that excluded intentions (Jalleh et al., 2014). Yet, it is interesting to note that, in the study of Elbe and Brand, 2016, attitudes toward doping use increased in post-test results. The authors stated that participants had already developed opinions concerning doping use and realized that doping use is a complex result of cognitive processes and environmental conditions, and not a simple dilemma, based on ethical decision-making.
Despite the conceptual framework of TPB where attitudes, PBC, and subjective norms influence intentions, our data demonstrated that the DOSPO program could not improve students’ PBC, subjective norms, and attitudes. We may attribute this to the lack of fidelity of implementation (FOI) (Li et al., 2021). Students’ behavioural responses, such as motivation, engagement with the program’s material, and satisfaction, are highly influenced by the teacher’s role (Valero-Valenzuela et al., 2019). It is important to note that teachers who implemented the DOSPO program, did not have any specific training on how to apply the program’s skills and strategies. Thus, the program’s effectiveness may have been affected by students’ insufficient responsiveness to intervention, or by a disparity between students’ expectations and teachers’ approach (McKenna et al., 2014). Fidelity assessment (Mowbray et al., 2003) enables a comprehensive evaluation of the degree to which students acquired the essential components of the program’s material.
Regarding subjective norm appears to be the weakest predictor of intentions (e.g., Armitage & Conner, 2001; Lucidi et al., 2004; Mann & Lohrmann, 2019). Furthermore, the subjective norm is related to the injunctive norm (Fishbein & Ajzen, 2011), and strongly correlated to intention among adolescents (Rivis & Sheeran, 2003). In light of these, future studies should consider fidelity measurements, in order to validate the intervention’s effectiveness and peer modelling, given that peer influence may facilitate the prevention of doping use (Barkoukis et al., 2019). Results, regarding subjective norm and PBC respectively, agree with the findings of Jalilian et al. (2011) who found that the intervention did not have an impact on those variables. The authors attributed this null effect, to the lack of studies to improve the predictability of these variables.
In relation to doping behaviour, there were no statistically significant changes. It is important to note that, sports motivation is proven to be a significant factor in doping behaviour (Mudrak et al., 2018). Doping behaviour is defined as the outcome of interactions between individuals and situations and not merely cognitive-based actions (Hauw & Mc Namee, 2015), this floor effect may be attributed to the fact that participants were high school students and non-athletes, consequently, were inexperienced with doping use, thus the intervention could not produce a behavioural change.
Conclusions
Concluding, the educational program improved students’ knowledge, intentions to learn about doping, and attitudes toward the program’s implementation. Importantly, the evaluation highlighted the students’ willingness to be educated on this issue. Notwithstanding these important findings, some study limitations should be considered. Firstly, the collected data came from students’ self-reported measures, which means that their answers might be affected by recall bias. The relatively small sample of participants, the absence of a control group, and the low reliability showed by a small number of instruments (PBC, knowledge) used in the present study should also be acknowledged. Furthermore, the lack of fidelity implementation may have an impact on program’s effectiveness.
Due to the above-mentioned limitations, the findings of the present study should be interpreted with caution by future researchers. Future studies should consider fidelity measurements, to validate educational intervention effectiveness.
Conflicts of Interest
The authors declare no conflict of interest.
Funding
The present study is a part of a doctoral thesis, which was co-financed by Greece and the European Union (European Social Fund-ESF) through the Operational Programme «Human Re-sources Development, Education and Lifelong Learning» in the context of the Act “Enhancing Human Resources Research Potential by undertaking a Doctoral Research” Sub-action 2: IKY Scholarship Programme for PhD candidates in the Greek Universities» (MIS 5113934).
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