Engaging community pharmacists to eliminate inadvertent doping in sports: A study of their knowledge on doping.

This study aimed to evaluate the community pharmacists' knowledge of tackling the issue of inadvertent doping in Malaysia. A cross-sectional survey was conducted among 384 community pharmacists working in Malaysia using a self-administered questionnaire. All the respondents were pharmacists fully registered with the Pharmacy Board of Malaysia and had been working in the community setting for at least one year. Of the 426 community pharmacists approached, 384 community pharmacists participated in this study, giving a response rate of 90.14%. The majority of the respondents were females (63.5%), graduated from local universities (74.9%), with median years of practising as a community pharmacist of six years (interquartile range, IQR = 9 years). The respondents were found to have moderate levels of doping-related knowledge (median score of 52 out of 100). Anabolic steroids (95.8%), stimulants (78.6%) and growth factors (65.6%) were recognised as prohibited substances by most of the respondents. Around 65.9% did not recognise that inadvertent doping is also considered a doping violation. Most of them (90%) also have poor levels of knowledge of doping scenarios in the country. Community pharmacists in Malaysia have limited knowledge in the field of doping. More programmes and activities related to doping and drugs in sports should be held to enhance the community pharmacists' knowledge on the issue of inadvertent doping.

Introduction

Inadvertent doping is an issue where an athlete records a positive drug test after having unintentionally and unknowingly taken a banned substance [1]. Athletes may become ill or injured, or suffer from chronic medical conditions [2], which may necessitate the use of medications that are banned in sports. For instance, in Japan, many over-the-counter medications contain prohibited substances; this explains the high rate of unintentional doping in the country [3]. A well-known case of inadvertent doping caused by using over-the- counter medications was at the 2000 Olympic Games. Pseudoephedrine, a banned substance, was mistakenly given to a Romanian gymnast by her team physician to treat her cold symptoms. This resulted in her being stripped of the gold medal that she won, and the team physician was expelled from the Games [4]. Some successful Malaysian badminton players, weightlifters, and wushu athletes were also caught in doping scandals, believed to be caused by inadvertent use of banned substances [5].

Inadvertent doping also involves the use of nutritional supplements among athletes. In past studies in Malaysia, 70% of the elite athletes and 40% of the youth athletes were reported to be consuming nutritional supplements [6, 7]. Inadvertent doping results when supplement labels contain misinformation that misleads athletes to falsely believe that prohibited products are allowed in sports [8].

The key to addressing the issue of inadvertent doping by athletes is prevention [9]. Pharmacist, as a healthcare professional that is specifically trained in medication use, can play an important role in combating doping in sports. Athletes may attend to the community pharmacy as a customer or a patient, to purchase medications, over-the-counter medications, or health supplements. For examples, prescribed medication such as salbutamol inhaler is a common medication used for asthma but excessive use without knowing the upper dose limit could violate the doping rules. Some over-the-counter medications may be sold with different active ingredients in different countries. A British skier had his Olympics bronze medal stripped due to unaware of the presence of banned substance in the formulation of the nasal inhaler he bought overseas during competition [10]. Previous literatures also reported that some athletes obtained drug products from pharmacies [11] while others would seek pharmacists’ advice on the use of medications or supplements for various conditions, including the management of sports injuries [12]. The International Pharmaceutical Federation (FIP) also recognises pharmacists’ roles in preventing doping in sports by updating themselves on the World Anti-Doping Code and help athletes to identify prohibited substances in sports [13].

Although pharmacists are generally well-equipped with knowledge on medications, their abilities and readiness to counsel the athletes are yet to be known. The additional knowledge on the Prohibited List published by World Anti-Doping Agency (WADA) annually is the minimum requirement for the pharmacists to provide correct information to the athletes. Nevertheless, previous studies have reported that most of the pharmacists did not have sufficient knowledge on the prohibited substances in sports [14, 15]. However, the current levels of knowledge among Malaysian community pharmacists about doping in sports are not well studied. This study expands on the survey conducted by Chiang et al in the capital city of Malaysia, Kuala Lumpur [16]. In our study, we have expanded the data collection to other states in Malaysia and assessed other aspects that were not investigated.

Thus, this study aims to offer important insights into the factors that could influence community pharmacists’ levels of doping-related knowledge and provides overview of Malaysian community pharmacists’ knowledge of doping in sports especially with respect to their readiness to take part in anti-doping initiatives. Assessing their knowledge helps to identify new avenues for future studies and also areas of deficiency that would require interventions to improve pharmacists’ current roles in assisting athletes with medication use and avoiding unintentional intake of banned substances.

Methods

Study design and sampling

This is a cross-sectional survey conducted online and via distribution of hard copies of questionnaires to community pharmacists in Malaysia. A list of registered community pharmacists was obtained from the Malaysian Pharmaceutical Society’s website, and a simple randomised list was generated. The respondents included in this study were pharmacists fully registered with the Pharmacy Board of Malaysia and had been working in the community pharmacy setting for at least one year.

Data collection

A pilot study was carried out to test the reliability and validity of the questionnaire. The pilot study was done on 31 community pharmacists prior to data collection. Minor improvement was made based on their feedback. Questionnaires were distributed to selected community pharmacists from May 2019 until November 2019. They were briefed about the objectives of the study before consenting to take part. We have included an explanatory statement at the beginning of the questionnaire that advises the respondents not to refer to any resources when answering the knowledge-based questions. This study was approved by the Research Ethics Committee, the National University of Malaysia (UKM PPI/111/8/JEP-2018-215).

Sample size calculation

To ensure that the study findings generalizable to the whole community pharmacist population in Malaysia, we used the Krejcie and Morgan formula was used to calculate the required sample size [17]. The calculation was based on the total number of community pharmacists in Malaysia, determined to be 3094 [18]. The minimum sample size was calculated at 384.

Study instruments

The demographic section contained 13 questions about socio-demographic characteristics, namely gender, age, race, place of practice, type of place of practice, practice premises, profession, academic qualification, experience of practising abroad, postgraduate qualification, professional membership, number of years in practice, and understanding of the term ‘doping’. We took into accounts of the experience of practicing abroad as improved knowledge on pharmacy practice and patient care is associated with exposure of international experiences [19].

The knowledge section included questions that were adapted from a previous survey that assessed the readiness of community pharmacists as counsellors for athletes [16]. The questions can be classified into five main domains: 1) Prohibited substances in sports; 2) The roles of WADA; 3) Anti-doping rule violations; 4) General knowledge of doping; 5) Doping cases in Malaysia. We wrote several additional questions about the roles of WADA, types of doping violations, athlete biological passport (ABP), and the doping situation in Malaysia, based on The Prohibited List 2019 and World Anti-Doping Code 2019 [20-22]. Overall, this section consists of 10 multiple-choice and true or false questions.

Assessment of the knowledge is done based on the marks that the respondents obtain. A score of 2 was given to each correct answer; 1 for ‘not sure’; and 0 for each wrong answer. The total score was 68. The respondents were then grouped into three categories based on their knowledge levels. Respondents who scored 41 or less (60% or less of 68) were classified as having poor levels of knowledge; 42–56 (61%-83% of 68) as having moderate levels of knowledge; and 57 or more (84% or more of 68) as having good levels of knowledge [16, 20].

Data analysis

The data were analysed using the Statistical Package of Science Analysis (SPSS) version 25. Continuous data was presented as medians alongside values for the interquartile range. The Mann-Whitney U and Kruskal-Wallis tests were used to determine the association between the respondents’ demographic characteristics and knowledge scores. A p-value of <0.05 was used to mark statistical significance.

Results

Pilot study

The reliability and validity of the questionnaire was assessed (Npilot = 31) prior to data collection. The value of Cronbach’s alpha obtained for the knowledge section was 0.780, which indicated good reliability.

Response rate

Over a period of seven months, 426 questionnaires were distributed, and 384 questionnaires were completed and returned, giving a response rate of 90.14%. Overall, the missing value calculated from the valid responses was 0.61%.

Demographic characteristics

The demographic characteristics of the respondents (N = 384) are shown in Table 1. Most of the respondents were women (N = 244, 63.5%), aged between 23 and 30 (N = 182, 47.4%), and worked in cities or urban areas (N = 297, 78.0%), particularly the Federal Territory of Kuala Lumpur (N = 160, 41.8%).

Table 1

The respondents’ demographic characteristics (n = 384).

Demographic variables	Number (n = 384)	Percentage (%)
Gender
Male	140	36.5%
Female	244	63.5%
Age
23–30 years	182	47.4%
31–40 years	135	35.2%
41–50 years	48	12.5%
>50 years	19	4.9%
Race
Malay	76	19.8%
Chinese	279	72.7%
Indian	22	5.7%
Others	7	1.8%
Place of practice
Northern Peninsular
• (Perlis, Kedah, Penang, Perak)     Eastern Peninsular	79	20.6%
• (Kelantan, Terengganu, Pahang) Central Peninsular	24	6.3%
• (Selangor, Negeri Sembilan) Southern Peninsular	80	20.9%
• (Melaka, Johor) East Malaysia	36	9.4%
• (Sabah, Sarawak) Federal Territories	4	1.0%
• (Labuan, Kuala Lumpur, Putrajaya)	160	41.8%
Type of place of practice
City or urban	297	78.0%
Town or suburban	84	22.0%
Academic qualification
Local (Bachelor’s degree or equivalent)	284	74.9%
Foreign (Bachelor’s degree or equivalent)	87	23.0%
Local & Foreign (Bachelor’s degree or equivalent)	8	2.1%
Experience of practising overseas
Yes	50	13.1%
≤1 year (out of 50)	25	50.0%
1–5 years (out of 50)	18	36.0%
>5years (out of 50)	3	6.0%
Not stated (out of 50)	4	8.0%
No	332	86.9%
Presence of postgraduate degree (PhD or Master’s degree)
Yes	16	4.2%
No	365	95.8%
Involvement as member of professional bodies
Yes	248	65.6%
Malaysian Pharmaceutical Society (MPS)	241	62.8%
General Pharmaceutical Council (GPhC)	6	1.6%
Royal Pharmaceutical Society of Great Britain (RPSGB)	6	1.6%
Malaysian Community Pharmacy Guild (MCPG)	3	0.8%
Malaysia Pharmacy Board	3	0.8%
No	130	34.4%
Years of practice (median = 6, IQR = 9)
<2 years	34	9.1%
2–5 years	147	39.2%
6–10 years	84	22.4%
11–20 years	83	22.1%
>20 years	27	7.2%
Have you heard about the term ‘doping’?
Yes	307	80.6%
No	74	19.4%

The majority of the respondents (N = 284, 74.9%) obtained their pharmacy degrees from local universities. Only 13.1% (N = 50) of the respondents had worked abroad, and most of them did so for less than one year (N = 25, 6.5%). A small number (4.2%, N = 16) of the respondents had postgraduate degrees (PhD or master’s). Most of the respondents (N = 248, 65.6%) were members of professional bodies, the main one being the Malaysian Pharmaceutical Society (MPS) (N = 241, 62.8%). In terms of their professional experience measured by years in practice, most of the respondents had been practising in various settings for a total of two to five years (N = 147, 39.2%). The median number of years of working as a community pharmacist was six years with the interquartile range (IQR) being nine years.

The respondents’ familiarity of the term ‘doping’

More than three-quarters of the respondents (N = 307, 80.6%) had heard of the term ‘doping’.

The respondents’ knowledge of doping in sports

Table 2 shows a descriptive analysis of the five domains of the respondents’ knowledge of doping in sports.

Table 2

The respondents’ knowledge of doping in sports (N = 384).

Domains	Variables	Correct answer	Number of respondents with correct answer, N (%)	Number of respondents with the wrong answer / not sure answer, N (%)
Knowledge on prohibited substances in sports	The substances classified by the World Anti-Doping Agency (WADA) as prohibited in sports include:(i) Anabolic-androgenic steroids (AASs)(ii) Peptide hormones(iii) Growth factors(iv) Beta-2 agonists(v) Insulin(vi) Stimulants(vii) Diuretics(viii) Nicotine(ix) Non-steroidal anti-inflammatory drugs (NSAIDs)(x) Beta-blockers(xi) Caffeine(xii) AlcoholAthletes use diuretics as masking agents to hide the presence of other banned substances in their urine.Which of the following drugs can be used by an athlete in competition only?(i) Salbutamol(ii) Salmeterol(iii) Inhaled corticosteroids(iv) Oral corticosteroids(v) Injected corticosteroids	TrueTrueTrueTrueTrueTrueTrueFalseFalseTrueFalseFalseTrueTrueTrueTrueFalseFalse	368 (95.8)174 (45.3)252 (65.6)132 (34.4)31 (8.1)302 (78.6)213 (55.5)326 (84.9)351 (91.4)98 (25.5)316 (82.3)306 (79.7)275 (71.6)272 (70.8)172 (44.8)175 (45.6)338 (88.0)349 (90.9)	16 (4.2)210 (54.7)132 (34.4)252 (65.6)353 (91.9)82 (21.4)171 (44.5)58 (15.1)33 (8.6)286 (74.5)68 (17.7)78 (20.3)109 (28.4)112 (29.2)212 (55.2)209 (54.4)46 (12.0)35 (9.1)
	(vi) Dihydrocodeine	False	366 (95.3)	18 (4.7)
Knowledge on the roles of World Anti-Doping Agency (WADA)	The roles of the World Anti-Doping Agency (WADA) include:(i) To coordinate anti-doping activities worldwide.(ii) To establish the World Anti-Doping Code.(iii) To establish a list of prohibited substances in sports.(iv) To conduct tests for prohibited substances in blood or urine samples.(v) To prosecute doping offenders in sports.
		True	314 (81.8)	70 (18.2)
		True	251 (65.4)	133 (34.6)
		True	293 (76.3)	91 (23.7)
		False	138 (35.9)	246 (64.1)
		False	254 (66.1)	130 (33.9)
Knowledge on doping violations	Doping violations include:(i) Presence of a prohibited substance in blood or urine.(ii) Helping in trafficking prohibited substances to athletes.(iii) Refusing to undergo a doping test requested by authorized personnel.(iv) Administering a prohibited substance to an athlete.(v) Unintentional intake of a prohibited substance.
		True	352 (91.7)	32 (8.3)
		True	196 (51.0)	188 (49.0)
		True	276 (71.9)	108 (28.1)
		True	286 (74.5)	98 (25.5)
		True	131 (34.1)	253 (65.9)
General knowledge of doping scenarios	Therapeutic Use Exemption (TUE) allows athletes to use prohibited substances for medical reasons in or out of competition.	True	243 (63.3)	141 (36.7)
	The Athlete Biological Passport (ABP) is a program that monitors selected biological variables over time to indirectly reveal the effects of doping rather than attempting to detect the doping substance or method itself.	True	100 (26.0)	284 (74.0)
Knowledge on doping in Malaysia	Do you know whether your professional body (e.g Malaysian Medical Council, Malaysian Pharmaceutical Society, etc.) has a guideline on the use of prohibited substances in sports?	False	20 (5.2)	364 (94.8)
	Universiti Sains Malaysia, Penang (USM) Analytical Biochemistry Research Centre (ABrC), formerly known as Doping Control Centre (DCC), has WADA accreditation to carry out anti-doping drug testing.	False	8 (2.1)	376 (97.9)
	The National Sports Institute in Malaysia is the official anti- doping agency in Malaysia.	False	42 (10.9)	342 (89.1)

Knowledge of prohibited substances in sports

Most of the respondents knew that anabolic-androgenic steroids (N = 368, 95.8%), stimulants (N = 302, 78.6%), and growth factors (N = 252, 65.6%) are prohibited in sports. These drugs are prohibited at all times in sports. Insulin (N = 31, 8.1%) and beta-blockers (N = 98, 25.5%) were, however, lesser known among the respondents. Alcohol (N = 78, 20.3%) was most frequently mistaken by the respondents as a prohibited substance, followed by caffeine (N = 68, 17.7%), nicotine (N = 58, 15.1%) and NSAIDs (N = 33, 8.6%). We found that 71.6% of the respondents (N = 275) were aware that diuretics can be used by athletes as masking agents; however, only 55.5% (N = 213) knew diuretics are prohibited in sports.

This section also contains questions about the use of drugs in competition. Most of the respondents (N = 272, 70.8%) were able to identify salbutamol as being allowed in competition, but less than half of the respondents were able to do so for salmeterol (N = 172, 44.8%) and inhaled corticosteroids (N = 175, 45.6%). Less than a quarter of the respondents misidentified oral corticosteroids (N = 46, 12.0%), injected corticosteroids (N = 35, 9.1%), and dihydrocodeine (N = 18, 4.7%) as substances allowed in competition.

Knowledge of the roles of the World Anti-Doping Agency (WADA)

The role of WADA in coordinating anti-doping initiatives worldwide was correctly identified by most of the respondents (N = 314, 81.8%), and this is followed by the other functions the agency serves in publishing updated lists of prohibited substances in sports (N = 293, 76.3%) and establishing the World Anti-Doping Code (N = 251, 65.4%). Most of the respondents (N = 254, 66.1%) knew that WADA does not prosecute athletes who violate anti- doping rules. However, many of them (N = 246, 64.1%) did not know that the tests for detecting prohibited substances in blood or urine samples are not conducted by WADA but WADA- accredited laboratories.

Knowledge of doping violations

Most of the respondents were aware that doping violations include the presence of a prohibited substance in a blood or urine sample (N = 352, 91.7%), refusal to undergo a doping test requested by authorised personnel (N = 286, 74.5%), and administration of a prohibited substance to an athlete (N = 276, 71.9%). Slightly over half of the respondents (N = 196, 51.0%) were aware that being complicit in the trafficking of prohibited substances to athletes is also a doping violation. Only a minority of the respondents knew that unintentional intake of prohibited substances by athletes is a doping offense (N = 131, 34.1%).

General knowledge of doping

More than half of the respondents (N = 243, 63.3%) knew that the Therapeutic Use Exemption (TUE) allows athletes to use prohibited substances for medical reasons in or out of competition. We found that only 26.0% (N = 100) correctly identified ABP as a programme that monitors selected biological variables over time to indirectly reveal the effects of doping.

Knowledge of the anti-doping initiatives in Malaysia

Most of the respondents (N = 364, 94.8%) mistakenly assumed or were unsure whether the professional bodies in Malaysia provided guidelines on the use of prohibited substances in sports. Many of the respondents (N = 376, 97.9%) were still unaware that the Analytical Biochemistry Research Centre, Universiti Sains Malaysia had been removed from WADA’s list of accredited laboratories that carry out anti-doping drug testing. Also, a small number of respondents (N = 42, 10.9%) knew that the National Sports Institute in Malaysia is not the official anti-doping agency in Malaysia.

Total scores of the respondents’ doping-related knowledge

Based on their total knowledge scores, the respondents were classified as having poor, moderate, or good levels of knowledge of doping in sports (Table 3).

Table 3

The respondents’ levels of knowledge of doping (N = 384).

Total score	Number (N = 384)	Percentage (%)
(median = 52, IQR = 6)
≤41 (Poor)	10	2.6%
42–56 (Moderate)	333	86.7%
≥57 (Good)	41	10.7%

Only 1.8% (N = 7) of the respondents scored 41 or less (poor levels of knowledge). More than three-quarters of the respondents (N = 317, 82.6%) scored between 42 to 56 (moderate levels of knowledge). A quarter of the respondents (N = 60, 15.6%) scored 57 or more (good levels of knowledge). The median score was 52 with an IQR of 6.

Statistical studies

Table 4 shows the relationship between the respondents’ demographic characteristics and knowledge scores.

Table 4

Association between demographic variables and the respondents’ knowledge scores.

p-value (p<0.05)
	Gender	Race	Place of practice	Academic qualifications	Experienc e of practicing overseas	Presence of postgraduat e degree	Involvemen t as a member of professional bodies	Years of practice	Familiarit y with term ‘doping’
Total score on knowledge	0.559a	0.821b	0.987b	0.971b	0.435a	0.047a	0.001a	0.045b	0.000a

a Mann-Whitney U test.

b Kruskal-Wallis test.

The respondents were grouped based on their demographic characteristics. The Mann- Whitney U test (U value) was used when the comparison of mean ranks (knowledge scores) involved only two groups of respondents, while the Kruskal-Wallis test (H value) was used to compare mean ranks between more than two groups of respondents. Through these statistical analyses, we found the knowledge scores to be significantly affected by the respondents’ postgraduate qualifications (or lack thereof) (p = 0.047), professional membership (p = 0.001), amount of professional experience measured in years (p = 0.045), and understanding of the term ‘doping’ (p<0.0001).

As shown in Table 5, those who with postgraduate degrees (N = 16) had a significantly larger mean rank than those without any postgraduate qualifications (N = 365; 244.50 vs 188.65, U = 2064, p = 0.047). The respondents who were members of professional bodies (N = 248) had a significantly larger mean rank than those without any professional membership (N = 130; 203.26 vs 163.25, U = 12707, p = 0.001). The respondents who had been practicing for ≥6 years i.e., 6–10 years (N = 84), 11–20 years (N = 83), and >20 years (N = 83) had significantly higher mean ranks than those with less experience i.e., <2 years (N = 34) and 2–5 years in practice (N = 147; 210.54, 194.09, and 211.30 vs 179.28 and 169.42, H = 9.735, p = 0.045). The respondents who understood the term ‘doping’ well (N = 307) had a larger mean rank than those who did not (N = 74; 210.08 vs 111.85, U = 5502, p<0.0001).

Table 5

Comparison of mean rank between associated demographic variables and total score of community pharmacists’ knowledge.

Associated demographic variables	Statistical tests result (p<0.05)	Components of associated demographic variables	Mean rank
Presence of postgraduate degree	U = 2064, p = 0.047	With postgraduate degree (N = 16)	244.50
		Without a postgraduate degree (N = 365)	188.65
Involvement as member of professional bodies	U = 12707, p = 0.001	Member (N = 248)	203.26
		Non-member (N = 130)	163.25
Years of practice	H = 9.735, p = 0.045	<2 years (N = 34)	179.28
		2–5 years (N = 147)	169.42
		6–10 years (N = 84)	210.54
		11–20 years (N = 83)	194.09
		>20 years (N = 27)	211.30
Familiarity with term ‘doping’	U = 5502, p = 0.000	Familiar (N = 307)	210.08
		Unfamiliar (N = 74)	111.85

U = Mann-Whitney U test; H = Kruskal-Wallis test

Discussion

The current study evaluated the Malaysian community pharmacists’ knowledge related to drugs in sports. In general, most of the respondents had heard of the term ‘doping’ and were able to describe it adequately as the use or misuse of drugs by athletes to enhance their performance in sports. Most of them were able to identify anabolic-androgenic steroids (AAS), stimulants, and growth factors as prohibited substances in sports. This is consistent with previous studies, which reported that pharmacists were able to identify anabolic-androgenic steroids and stimulants as prohibited substances in sports [23, 24]. We also found that most of the respondents knew that diuretics could be used as masking agents, a finding similarly reported by Chiang et al [16]. The pharmacists’ familiarity with these substances could be associated with the popularity of the substances in doping cases and they were the most abused substances in sports as proven by the reports by WADA in 2017 stating that up to 58% of all adverse analytical findings in doping tests came from AAS and stimulants [25].

However, most of the respondents failed to identify insulin and beta-blockers as prohibited substances. This is because beta blockers are prohibited in-competition for certain sports only [21]. So, the respondents might have lesser awareness on these unpopular doping substances. Additionally, WADA reported in 2017 that only 0.3% of doping tests were positive for beta-blockers, suggesting that the drugs were infrequently misused by athletes [25]. This may explain why these substances were less recognised by the respondents as prohibited substances. Meanwhile, the respondents might not be aware of the mechanism and the reason of insulin being used as a doping agent. Insulin is normally used by diabetic patients for treating high sugar level, but it could be misused by bodybuilders and weightlifters to suppress proteolysis and increase protein synthesis for faster muscle gain [26].

Besides, the study extends our knowledge on the familiarity of the Malaysian community pharmacists on the definition of doping violations. Most of the respondents in this study were unaware that helping in trafficking prohibited substances to athletes and unintentional intake of a prohibited substance are also considered doping violations. The results show the lack of awareness of the community pharmacists on the doping definition published by WADA which clearly states that athletes should be responsible for everything they ingest, and even accidental intake of banned substance would violate the doping rules [22]. Therefore, pharmacists need to step up in expanding their knowledge so that in the future they could advise the athletes and become their support personnel in building a healthy and sustainable sports career for them.

Only 63.3% of the respondents in this study knew that TUEs are required for the use of drugs by athletes, and the proportion is lower than the 75.9% reported by Chiang et al [16]. In comparison, 45.2% of the South African pharmacists who responded to a survey scored poorly on the knowledge regarding TUEs [27]. These findings indicate that there is still a need for educating pharmacists on the importance of TUEs as a mechanism that enables the use of prohibited substances or methods in the treatments of illnesses, injuries, or chronic medical conditions experienced by athletes [28]. Most of the respondents in this study were also unaware that ABP is a newly introduced doping detection method. ABP is relatively simple and can be potentially adopted by many countries as an effective measure against doping [29]. A full understanding of the harmonised modules employed in ABP, including the haematological and steroidal modules, is the first step towards establishing proper ABP testing facilities. The ABP Operating Guidelines [30], published by WADA, harmonize both modules and are a good resource for establishing proper ABP testing facilities.

Furthermore, almost 90% of the respondents in our study did not know the doping initiatives and official bodies in Malaysia. Malaysia once had an accredited laboratory at Universiti Sains Malaysia, which was suspended due to non-compliance with the International Standard for Laboratories [31]. Besides, most of the community pharmacists did not know that the official anti-doping agency in Malaysia that is tasked with fighting doping is Anti-Doping Agency of Malaysia (ADAMAS) despite its existence since 2007 [32]. The percentage is substantially lower than that reported in another study i.e., 54.9% of Slovenian pharmacists knew their national anti-doping agency [20]. Failure to recognize the proper source of information to refer to when meeting athletes in their working environment may make pharmacists unable to provide correct recommendations and advice to the athletes. The Irish College General Practitioners (ICGP) published guidelines to educate general practitioners on doping-related regulations and their roles and involvement in the prevention of doping in sports. The guidelines are reviewed periodically, with the latest edition being published in 2015 [33]. In contrast, no professional bodies in Malaysia have published guidelines on the use of prohibited substances in sports; but most of the respondents in our study were unaware of this. Professional bodies in every country, including Malaysia, should adopt a similar practice to ICGP and publish guidelines for engaging healthcare professionals in the prevention of doping in sports.

Overall, our study demonstrated that the average knowledge score of Malaysian community pharmacist on doping was moderate. This is in line with previous literatures by Lemettilä et al (2021) and Gebregers et al (2021) [15, 34]. These findings pointed out the needs to improve pharmacists’ knowledge in drugs in sports which could be done by establishing courses on drugs in sports during university study or special courses on drugs in sports for the working pharmacists. In Malaysia, subjects related to doping in sports are incorporated in curriculum in pharmacy programmes either as a core subject with three credit hours or elective subject with two credit hours. However, some universities in Malaysia did not offer the subjects to their students [35]. The lack of exposure and training provided during university may then cause the pharmacists to have low confidence when they are dealing with issues related to prohibited substances in sports.

The correlation analysis showed that the respondents with six or more years of professional experience had better knowledge and could potentially be trained to become drug advisors or counsellors for athletes. A good understanding of the term ‘doping’ predicted better knowledge scores. Thus, pharmacists should be encouraged to learn more about doping-related issues. We found that the respondents who were members of professional bodies obtained significantly better knowledge scores. Most of the respondents in this study were members of Malaysian Pharmaceutical Society. This national association for pharmacists periodically organises courses and seminars for professional development, averaging ~15 programmes per month in the past three years [36]. Thus, pharmacists that are interested in getting more information on drugs in sports should take self-initiative to attend relevant courses offered by anti-doping agency to keep themselves up to date.

Sports pharmacy is considered a relatively new and emerging fields especially in South-East Asia. Pharmacists are traditionally perceived by the public as specialists in medication dispensing and counselling. However, their role of pharmacist in healthcare has expanded over the years towards primary prevention through health education. Athletes are a special population with generally good health status but may still consume a relatively large number of medications and supplements compared to the ordinary healthy individuals. Thus, it is important for pharmacists to engage and provide their professional service to athletes in the future to eliminate inadvertent doping.

Limitations

The first limitation of the study relates to the use of self-administered questionnaires. Although the explanatory statement clearly indicates that the respondents should answer the knowledge-based questions honestly without referring to any resources, some might not have followed the guidelines. This may have led to inaccuracy in the assessment of the respondents’ knowledge. Second, the respondents were recruited through convenience sampling, and the questionnaires were not evenly distributed to community pharmacists in the different states of Malaysia. Thus, the results of this study may not be generalised to the entire population of community pharmacists across Malaysia.

Conclusion

We found that community pharmacists in Malaysia had moderate levels of doping- related knowledge. They were able to identify prohibited substances commonly misused by athletes. Most were still unaware that inadvertent doping constitutes a doping violation, despite its being the primary contributor to the prevalence of doping in sports. Most were also ill- informed about the doping situation in Malaysia. Hence, more doping-related programmes and activities should be organised to enhance community pharmacists’ knowledge of inadvertent doping and transform them into proactive participants in contemporary anti-doping initiatives.

Supporting information for respondents’ demographic characteristics.

(XLSX)

Click here for additional data file.

Supporting information for respondents’ levels of knowledge in doping.

(XLSX)

Click here for additional data file.

Supporting information for demographic variables and the respondents’ knowledge scores.

(XLSX)

Click here for additional data file.

1 Sep 2021

PONE-D-21-01079

Engaging Community Pharmacists to eliminate Inadvertent Doping in Sports: A Study of their Knowledge on Doping

PLOS ONE

Dear Dr. Ali,

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Reviewer #1: The article is interesting and relevant. However, it lacks of rational and the results are very descriptive while they could be linked to hypothesizes. Another weakness is the unbalanced sampling regarding for example age, gender or academic levels. Indeed it’s unclear if this sample is representative of the Malaysian pharmacists.

The introduction is too short and the research question is the question is insufficiently problematized: It is not clear why pharmacists are in the first line regarding doping ? The examples provided in the beginning of the MS did not indicate that the pharmacists were involved in inadvertent doping. Another key point is the cultural definition of the pharmacists wok in Malaysian that is not defined. Indeed, it is expected the potential role of the pharmacists could change between countries: from physician collaboration, patient counselling to commercial benefits… Please explain how pharmacists work in Malaysian: are there able to sell drugs without physicians order? Is there durgs that are free to sell even they are prohibited in the WADA list? Is there a commercial activity linked to the price of drugs that offers potential differential benefits between pharmacists’ office? There is no review of research and most of the references are only proposed in the discussion. In addition, the question of assessment of the knowledge is not considered: what types of knowledge? How they could be assessed ? In the result section, the sample has been split and comparisons using different variables such academic level, year of practice and so on. The reason why these comparisons have been done and are relevant should be explain in the introduction. Are there Hypothesizes for that regarding previous research? In addition in the introduction, it will be also interesting to indicate their potential role for doping violation rule regarding trafficking of prohibited substances to athletes and unintentional intake of a prohibited substances.

To resume, this article did not provide a sufficient report of what you know now and what we need to know that justify this study.

The results are however interesting and the discussion and conclusion clear. Please see if you can also adjust the sample or justify its representativeness.

Reviewer #2: Introduction: Written well.

Methods:

Data Collection: How authors ensured that participants have not referred internet while giving knowledge based questions?

Discussion: Subheading may not requires under discussion.

Conclusion: Please remove the limitations which are mentioned under the heading of conclusion. Make separate heading for limitation.

References: Internet based references please make sure are active and referenced in appropriate manner, if reader would like to visit internet based links. these internet based references should be accessible.

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Submitted filename: review-PLOS_ Pharmacists.pdf

Click here for additional data file.

1 Feb 2022

Dear Editor,

Manuscript: Engaging Community Pharmacists to Eliminate Inadvertent Doping in Sports: A Study on their Knowledge on Doping

We thank the reviewers for their constructive comments. We have revised and proofread the manuscript accordingly. Important changes are annotated with ‘comments’ in the manuscript. Additions are highlighted in yellow; other types of edits are marked with ‘Track Changes’.

Reviewer #1:

1. The article is interesting and relevant. However, it lacks of rational and the results are very descriptive while they could be linked to hypothesizes.

Response to reviewer: The main aim of the study is to gauge the current level of knowledge of doping among community pharmacists. This will in turn inform the design of future studies involving specific interventions among pharmacists based on proven hypotheses. Thus, the descriptive nature of the study is inevitable, as there is a lack of baseline data to form a hypothesis.

2. In the result section, the sample has been split and comparisons using different variables such academic level, year of practice and so on. The reason why these comparisons have been done and are relevant should be explain in the introduction. Are there Hypothesizes for that regarding previous research?

Response to reviewer: We have expanded the introduction and added studies describing the effects of prior training on doping-related knowledge levels: “Previous studies reported that specific training, such as university courses and workshops, significantly influenced respondents’ levels of doping-related knowledge [1,2,3].”

The findings of these studies suggest that academic qualifications or years of experience may affect one’s level of doping-related knowledge. We have also included the findings of these studies in the discussion.

3. Another weakness is the unbalanced sampling regarding for example age, gender or academic levels. Indeed it’s unclear if this sample is representative of the Malaysian pharmacists.

Response to reviewer: We have expanded the description of the methods to include the study design and the sampling procedure. Also, we have added descriptions of the findings of other studies showing that the demographic characteristics reported by those studies are similar to ours.

“In terms of the demographic characteristics, we found that the majority of the respondents were young Chinese women with professional degrees in pharmacy. This is in line with the characteristics of the participants enrolled in other studies involving community pharmacists in Malaysia [4,5,6].”

4. The introduction is too short and the research question is insufficiently problematized: It is not clear why pharmacists are in the first line regarding doping? The examples provided in the beginning of the MS did not indicate that the pharmacists were involved in inadvertent doping.

Response to reviewer: We have added descriptions of the roles of community pharmacists in tackling issues related to doping in sport:

“According to Tsarouhas et al., 15% of athletes obtained drug products from pharmacies [7]. Athletes may also ask pharmacists for advice on the use of medications or supplements for various conditions, including the management of sports injuries [8]. The International Pharmaceutical Federation (FIP) recognises pharmacists’ roles in preventing doping in sports. It is recommended that pharmacists should update themselves on the World Anti-Doping Code and help athletes to identify products containing substances prohibited by the World Anti-Doping Agency (WADA) [9].”

5. Another key point is the cultural definition of the pharmacists work in Malaysian that is not defined. Indeed, it is expected the potential role of the pharmacists could change between countries: from physician collaboration, patient counselling to commercial benefits… Please explain how pharmacists work in Malaysian: are there able to sell drugs without physicians order? Is there drugs that are free to sell even they are prohibited in the WADA list?

Response to reviewer: In Malaysia, there are different categories of medications that can be dispensed by community pharmacists i.e.:

● Group A Can only be sold by a licensed wholesaler to a pharmacist or to another licensed wholesaler or by a licensed wholesaler to be immediately exported to a purchaser outside Malaysia.

● Group B Can be dispensed only against prescription of a Registered Medical Practitioner, Dentist, or Veterinary Surgeon, as the case may be and with the prescription in the correct form as required by the law.

● Group C Can only be sold as a dispensed medicine with entry in the Prescription Book.

● Group D Can only be sold as a dispensed medicine with an entry in the Poisons Book.

● Part II Poisons Retail sale restricted to Poison Licence Holder. Labelling requirements only.

● NP- Non-scheduled Poisons Non-scheduled poisons or over the counter products for retail sale.

Source: MIMS Malaysia (https://www.mims.com/malaysia/viewer/html/poisoncls.htm)

It depends on:

● Whether the drugs have legitimate medical uses.

● The potential of the drugs to be misused by athletes to gain unfair advantages in sports.

Note: This information is not included in the manuscript because it is not directly related to the study findings.

In the original version of the manuscript, we have already highlighted in the discussion the misuse of different classes of drugs that could be prevented by interventions by community pharmacists:

However, it is worth pointing out that many of the WADA-prohibited drugs are commonly used in medical treatments and are therefore not banned in these settings e.g., insulin is not well known for its performance-enhancing properties, while beta-blockers are prohibited in-competition for only certain sports such as archery and shooting, which may explain why these substances were less recognised by pharmacists as prohibited substances.

6. Is there a commercial activity linked to the price of drugs that offers potential differential benefits between pharmacists’ office? There is no review of research and most of the references are only proposed in the discussion.

Response to reviewer: This is an interesting point. However, the commercial activity linked to the price is irrelevant to this study.

7. In addition, the question of assessment of the knowledge is not considered: what types of knowledge? How they could be assessed?

Response to reviewer: We have expanded the description of how we adapted the questionnaire from previous studies:

“The knowledge section included questions that were adapted from a previous survey that assessed the readiness of community pharmacists as counsellors for athletes [10]. The questions can be classified into five main domains [1,11,12]: 1) Prohibited substances in sports; 2) The roles of WADA; 3) Doping violations; 4) General knowledge of doping; 5) Doping cases in Malaysia.”

8. In addition in the introduction, it will be also interesting to indicate their potential role for doping violation rule regarding trafficking of prohibited substances to athletes and unintentional intake of a prohibited substances.

Response to reviewer: This is an interesting point. However, community pharmacists play no roles in handling anti-doping rule violations. So, this is irrelevant to this study.

In regard to unintentional intake of prohibited substances, we have added the following into our introduction:

“Athletes may become ill or injured, or suffer from chronic medical conditions [13], which may necessitate the use of medications that are banned in sports. For instance, in Japan, many over-the-counter medications contain prohibited substances; this explains the high rate of unintentional doping in the country [14].”

“Inadvertent doping also involves the use of nutritional supplements among athletes. In prior studies, 55% to 98% of athletes were reported to be consuming nutritional supplements [15,16]. Inadvertent doping results when supplement labels contain misinformation that misleads athletes to falsely believe that prohibited products are allowed in sports [17].

9. To resume, this article did not provide a sufficient report of what you know now and what we need to know that justify this study.

Response to reviewer: Referring to our first response, the aim of the study is to obtain baseline findings that will inform the design of future studies involving specific interventions among pharmacists.

Reviewer #2:

10. Introduction: Written well.

Response to reviewer: Noted with thanks.

11. Methods:

Data Collection: How authors ensured that participants have not referred internet while giving knowledge-based questions?

Response to reviewer: In the respondent explanatory statement, we remind the respondents that their honesty in answering the questionnaire is crucial to ensuring the validity of the study findings. We conducted the study based on ‘trust’ and have faith in pharmacists’ professionalism and ethical integrity.

Nevertheless, this is an important point. We have briefly discussed it under ‘Limitations’.

“The first limitation of the study relates to the use of self-administered questionnaires. Although the explanatory statement clearly indicates that the respondents should answer the knowledge-based questions honestly without referring to any resources, some might not have followed the guidelines. This may have led to inaccuracy in the assessment of the respondents’ knowledge.”

12. Reviewer #2: Discussion: Subheading may not requires under discussion.

Response to reviewer: All the subheadings were removed.

13. Reviewer #2: Conclusion: Please remove the limitations which are mentioned under the heading of conclusion. Make separate heading for limitation.

Response to reviewer: We have created a separate subsection for the study limitations.

14. Reviewer #2: References: Internet based references please make sure are active and referenced in appropriate manner, if reader would like to visit internet based links. these internet based references should be accessible.

Response to reviewer: The references have been amended accordingly.

References cited in this letter:

1. Auersperger I, Topic MD, Maver P, Pusnik VK, Osredkar J, Lainscak M. Doping awareness, views, and experience: a comparison between general practitioners and pharmacists. Wien Klin Wochenschr. 2012;124(1-2):32-8.

2. Howard MS, DiDonato KL, Janovick DL, Schroeder MN, Powers MF, Azzi AG, Lengel AJ. Perspectives of athletes and pharmacists on pharmacist-provided sports supplement counseling: An exploratory study. Journal of the American Pharmacists Association. 2018 Jul 1;58(4):S30-6.

3. Starzak, D., Derman, W., Mckune, A. & Semple, S. 2016. Anti-Doping Knowledge and Opinions of South African Pharmacists and General Practitioners. Journal of Sports Medicine and Doping Studies 6: 1-7.

4. Teong WW, Ng YK, Paraidathathu T, Chong WW. Job satisfaction and stress levels among community pharmacists in Malaysia. Journal of Pharmacy Practice and Research. 2019 Feb;49(1):9-17.

5. Selvaraj A, Redzuan AM, Hatah E. Community pharmacists’ perceptions, attitudes and barriers towards pharmacist-led minor ailment services in Malaysia. International journal of clinical pharmacy. 2020 Apr;42(2):777-85.

6. Francis J, Toh LS, Sellappans R, Loo JS. Awareness of osteoporosis risk assessment tools and screening recommendations among community pharmacists in Malaysia. International journal of clinical pharmacy. 2021 Jan 28:1-9.

7.Tsarouhas K, Kioukia–Fougia N, Papalexis P, Tsatsakis A, Kouretas D, Bacopoulou F, Tsitsimpikou C. Use of nutritional supplements contaminated with banned doping substances by recreational adolescent athletes in Athens, Greece. Food and chemical toxicology. 2018 May 1;115:447-50.

8. Howard, M. S., Didonato, K. L., Janovick, D. L., Schroeder, M. N., Powers, M. F., Azzi, A. G. & Lengel, A. J. 2018. Perspectives of Athletes and Pharmacists on Pharmacist-Provided Sports Supplement Counseling: An Exploratory Study. J Am Pharm Assoc (2003) 58(4s): S30-S36.e32.

9. Awaisu, A., Mottram, D., Rahhal, A., Alemrayat, B., Ahmed, A., Stuart, M. & Khalifa, S. 2015. Research Knowledge and Perceptions of Pharmacy Students in Qatar on Anti-Doping in Sports and on Sports Pharmacy in Undergraduate Curricula. 79.

10. Chiang LM, Hatah E, Shamsuddin AF. The readiness of community pharmacists as counsellors for athletes in addressing issues of the use and misuse of drugs in sports. Lat. Am. J. Pharm. 2018 Jan 1;37(5):1049-55.

11. The World Anti Doping Code: The 2019 Prohibited List, (2019).

12. WORLD ANTI-DOPING CODE 2015 with 2019 amendments, (2019).

13. Overbye, M. & Wagner, U. 2013. Between Medical Treatment and Performance Enhancement: An Investigation of How Elite Athletes Experience Therapeutic Use Exemptions. 24.

14. Shibata, K., Ichikawa, K. & Kurata, N. 2017. Knowledge of Pharmacy Students About Doping, and the Need for Doping Education: A Questionnaire Survey. BMC Res Notes 10(1): 396.

15. Balaravi, B., Mei Qi, C., Wen Jin, C., Quah Lw, S., Ramadas, A. & Karppaya, H. 2017. Knowledge and Attitude Related to Nutritional Supplements and Risk of Doping among National Elite Athletes in Malaysia. 23.

16. Somerville, S. J., Lewis, M. & Kuipers, H. 2005. Accidental Breaches of the Doping Regulations in Sport: Is There a Need to Improve the Education of Sportspeople? Br J Sports Med 39(8): 512-516; discussion 516.

17. Davar, V. 2012. Nutritional Knowledge and Attitudes Towards Healthy Eating of College-Going Women Hockey Players. 37.

Thank you.

Sincerely,

Adliah Mhd Ali

Submitted filename: Cover Letter_Response for Resubmission.docx

Click here for additional data file.

7 Mar 2022

20 Apr 2022

Response to Reviewers

Reviewer #3:

The manuscript describes the doping problem at hand in Malaysia and the reason why community pharmacist engagement is crucial in combating the problem. The reviewer queries have been adequately addressed. The only fault I found was with a sentence in the abstract which needs correction. Please fix this at line 9 of the abstract. "With median years of practising as a community pharmacist for six years". The "for" in this phrase must be replaced with "of".

Author’s feedback:

The phrase was replaced as suggested (page 3 line 52).

Reviewer #4:

1. The introduction was significantly improved. However, I believe the background, significance, and rationale of the study can be even more improved. I would suggest that the authors discuss specifically medications that are often associated with inadvertent doping to give some context. This should be categorized into over-the-county versus prescription drugs.

Author’s feedback:

Some examples of the medications that are associated with inadvertent doping was added (page 4 line 91-94).

2. I also believe that a clear description of the roles of community pharmacists should be clearly mentioned, potentially in a section under Setting to provide some contextual understanding about how medications are dispensed (with or without a prescription), etc. In essence, response to Review #1, question 5, should be inserted into the text.

Author’s feedback:

In the response to Review #1, question 5, we explained on the categories of medications that are dispensed by the community pharmacists which are Group A, B, C, D, and non-poison medications (as listed below). However, this information is not included in the manuscript as it not directly relevant to the study findings. We have also pointed out that the study involved pharmacists working in the community setting (Lines 144-146).

Malaysia Regulatory Classification

Regulatory Classification for Malaysia

A - Group A

Can only be sold by a licensed wholesaler to a pharmacist or to another licensed wholesaler or by a licensed wholesaler to be immediately exported to a purchaser outside Malaysia.

B - Group B

Can be dispensed only against prescription of a Registered Medical Practitioner, Dentist, or Veterinary Surgeon, as the case may be and with the prescription in the correct form as required by the law.

C - Group C

Can only be sold as a dispensed medicine with entry in the Prescription Book.

D - Group D

Can only be sold as a dispensed medicine with an entry in the Poisons Book.

P2 - Part II Poisons

Retail sale restricted to Poison Licence Holder. Labelling requirements only.

NP- Non-scheduled Poisons

Non-scheduled poisons or over the counter products for retail sale.

3. It is still quite unclear to me how community pharmacists will be directly involved to eliminate inadvertent doping based on the data presented. While you have pointed out that more education can be provided, what practical tasks are you recommending that pharmacists do? For example, if someone comes into the pharmacy, are there standardized questionnaire to identify that (1) this is an athlete, and (2) they may be using drugs that lead to intentional or inadvertent doping. What interventions exist in the community pharmacy literature that have been shown to have impact? This is still very unclear to me... If you are to keep the study title as is: "Engaging Community Pharmacists to Eliminate Inadvertent Doping in Sports: A Study of their Knowledge on Doping", the "engaging" component will need additional justification and literature support.

Author’s feedback:

We have extended the introduction to explain how the community pharmacists may take part in preventing inadvertent doping (page 4 line 87-91). We have also added a short paragraph at the discussion to highlight on the potential roles of pharmacist in prevention of doping in sports (page 33 line 599-608).

Reviewer #5:

Introduction

1. The rationale of this study. You already mentioned that Chiang et al. had surveyed on this particular subject. What is the difference between the previous survey and yours? If you emphasize this point, it will make the gap or rationale of your study much more transparent.

Author’s feedback:

In the current study, we wrote a more comprehensive set of questions for measuring the knowledge level. Chiang et al. assessed respondents’ knowledge of prohibited substances, WADA, NADO, and TUEs in Kuala Lumpur leaving out the roles of WADA, doping violations, ABP, and the doping situation in Malaysia. We had also expanded the research to all the other states in Malaysia (page 6 line 119-121).

2. You state that your study highlights community pharmacists’ roles in advising athletes and making them not inadvertently consume prohibited substances. In my opinion, I am reluctant to say that because health behavior has components more than knowledge. They can understand correctly but still misuse it because of their attitude. More specifically, your research surveys only community pharmacists and does not include any athletes. So, the study results cannot infer the behavior of athletes.

Author’s feedback:

The aim of the study is to measure the level of knowledge and readiness of community pharmacists to engage with athletes. We take note of the suggestion regarding health-related behaviour and the appropriate preventive measures to curb drug abuse among athletes can be investigated in another study.

Methodology

3. In the data collection subsection. The required characteristics of participants, i.e., registered pharmacists and working in the community pharmacy for at least one year, might be more appropriate to present in the study design and sampling subsection as eligibility criteria after the sampling method.

Author’s feedback:

We have moved the characteristics of the participants as suggested to study design and sampling (page 8 line 144-146).

4. In the data collection subsection. You already answered another reviewer about the respondent explanatory statement about their honesty in answering the questionnaire. Suppose you include this detail in this section. In that case, it will help readers to understand the circumstance when respondents answer the questionnaire.

Author’s feedback:

We have added the explanatory statement in the “Methods” section as suggested (page 8 line 157-159). This was also mentioned in the “Limitation” section (page 33 line 614-620).

5. Why do you calculate the sample size? What is the rationale or parameters you include in this calculation? It might be easier to understand if you describe the purpose of the calculation. For example, to test a hypothesis, etc.

Author’s feedback:

Calculating the sample size is to ensure we recruited sufficient numbers of participants to generalize the study findings to the whole population (page 8 and 9 line 167-168).

6. I think some of the demographic characters, i.e., the experience of practicing abroad and professional membership, are irrelevant to the doping knowledge. You should explain the rationale to include these characters in the introduction. Otherwise, it might be significant by chance alone without real association.

Author’s feedback:

We explained the rationale to include some of the demographic information as suggested (page 10 line 179-181). We proposed that experience of practising abroad can provide the pharmacists opportunity to be exposed to different experiences with athletes. Meanwhile, pharmacist in Malaysia would need to fulfil the Continuous Professional Development (CPD) credit points in order to renew the license. Thus, we propose that pharmacists with professional membership would receive more information on the courses provided by the society and thus may have better knowledge in various topics. The association of these demographic characteristics with knowledge levels were presented in Table 4.

7. I puzzle about the way you scored this questionnaire’s answers. Is “not sure the answer” not equivalent to “the wrong answer”? Also, the cut point. Is this the standard way of using this questionnaire?

Author’s feedback:

The reason of awarding 1 mark for "not sure" is we think the participants had a certain degree of knowledge on the topic but is "unsure" of the answer. Even if the participants answered "not sure" for all the questions, they would only score 34 (which is classified as poor level as well). The cutting point is based on previous literatures as cited (page 10 line 199-204).

8. Why do you determine the association between the score and the demographic characteristics? It is not present in your study objective. Also, some characters look irrelevant, as I mention above. I saw you discuss these associations in the discussion section, but it does not make sense to me. Professional organizations in your study do not have a purpose for anti-doping. If it is an anti-doping organization, this might explain why?

Author’s feedback:

Our hypothesis is that members of professional organisations may in general be more motivated to learn new things to increase their knowledge because of requirements for continuous professional development. Please also refer to our response to comment no 6.

Results

9. You have a pilot study. So, you have to mention it in the methodology section.

Author’s feedback:

We have added on the explanation on the pilot study as suggested (page 8 line 151-154).

10. According to the response rate, we already know that the way respondents respond to the questionnaire affects the generalizability of the results, and you use both hardcopy and online forms. So, you should report the overall response rate and the response rate of hardcopy and online.

Author’s feedback:

We distributed the questionnaire through a variety of social media platforms and WhatsApp groups. We used the snowballing and convenience sampling methods to distribute online and physical copies of the questionnaire. This makes it impossible to accurately calculate the response rate.

11. Subsection the respondents’ understanding of the term ‘doping.’ In your study. You use the question, “Have you heard about the term doping?”. You cannot conclude that the respondent who says yes understands what doping is. Heard is not equivalent to understanding, am I right? So, it would be best if you changed understanding to familiar or anything similar.

Author’s feedback:

We have reworded ‘understanding’ to ‘familiarity’ as suggested (page 13 line 248).

12. I found many typos or discordant results. For example, the percentage of respondents who knew about anabolic-androgenic steroids in the text (98.5%) is inconsistent with the table (95.8%). As well as your box-plot, IQR in the picture is approximately 17, but IQR in the table is 6. You should double-check your results again.

Author’s feedback

We have checked the manuscript and corrected the inconsistencies. The percentage of respondents who knew about AAS is corrected to 95.8% (page 15 line 267). Figure 1 is removed.

13. What is the meaning of U and H from statistic tests? If you can interpret it, you should do so. But if it is only raw statistical results like degree of freedom, you can omit it.

Author’s feedback:

U is the symbol used in Mann-Whitney U test while H is the symbol used in Kruskal-Wallis test; legends were inserted at the bottom of the table 5.

Discussion

14. I think reference number 26 should move to the end of the sentence, “Anabolic-androgenic steroids, diuretics, and stimulants were the three most commonly detected classes of drugs in doping tests according to WADA.” Rather than, “This probably explains why these drugs were readily identified by most of the respondents as prohibited substances in sports” because the latter sentence is your speculation.

Author’s feedback:

We have moved the reference as suggested and rewrite some part of the discussion to make it more concise and relevant to the study findings.

15. Some of your claims are not supported by the results. For example, this explains why nicotine, NSAID, caffeine, and alcohol were sometimes mistaken as prohibited substances, considering their negative or enhancing effects on athletes’ sports performance. We do not know that because the athletes do not participate in this study. So, you cannot explain by using the results. It is only speculation.

Author’s feedback:

We have removed this paragraph and refine the discussion. In the original version of the discussion, what we intended to point out was that those substances were sometimes mistaken by pharmacists (not athletes) as being prohibited in sports. So, whether athletes took part in the study is irrelevant.

16. The discussion part can be more concise. The way it is right now is like the key answer for grading the exam. I think some of the information in the discussion part is irrelevant to this study. For example, you state that inhaled glucocorticoids are underused in treating asthma in athletes. What is the connection? Does athlete think the inhaled glucocorticoids are prohibited, making them underused? However, it has nothing to do with this study.

Author’s feedback:

We have removed this paragraph and refined the discussion.

17. You should discuss the anti-doping content in your bachelor’s degree curriculum. This might shed light on the readers as the anti-doping content is not required in many countries for a PharmD degree.

Author’s feedback:

We have added a short explanation on the anti-doping course as offered by the university in Malaysia. The course is commonly known as “Drugs in Sports” in most of the university (page 32 line 573-576).

18. Limitation comes before the conclusion.

Author’s feedback:

We have moved the limitation as suggested.

Reference

19. Lastly, you should cite each of them in the same format.

Author’s feedback:

All the references were cited as Vancouver format and any new references added were cited in the desired format.

Submitted filename: Cover Letter_Response for Resubmission.docx

Click here for additional data file.

11 May 2022

Engaging Community Pharmacists to Eliminate Inadvertent Doping in Sports: A Study of their Knowledge on Doping

PONE-D-21-01079R2

Dear,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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PLOS ONE

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Reviewer #5: All comments have been addressed

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Reviewer #5: Yes

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Reviewer #5: Yes

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Reviewer #5: Yes

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Reviewer #5: I really appreciate your modifications and explanations. This version is easier to understand. I think your work can inspire community pharmacists around the world to expand their roles.

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2 Jun 2022

PONE-D-21-01079R2

Engaging Community Pharmacists to Eliminate Inadvertent Doping in Sports: A Study of their Knowledge on Doping

Dear Dr. Mhd Ali:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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