Knowledge, attitude and practice towards anabolic–androgenic steroids utilisation among gymnasium attendees in Al-Qassim Province, Saudi Arabia

Abstract

Despite the serious side effects associated with anabolic–androgenic steroids (AAS) being well-documented, their widespread misuse for bodybuilding and endurance enhancement continues to be a concern worldwide. A substantial number of studies have been conducted, both internationally and in Saudi Arabia, to investigate knowledge, attitudes, and practices with respect to AAS use among gym users. These studies have been conducted in various cities throughout Saudi Arabia and have focused primarily on male gym users; however, no local studies have been conducted in Al-Qassim province. Therefore, this study aimed to investigate the knowledge, attitudes, and practices around AAS use of both male and female gym users in Al-Qassim Province. This community-based, cross-sectional, questionnaire-based study was conducted from January 2022 to March 2022 and recruited 415 gym users from 24 gyms in Al-Qassim. In the results, 62.9% of the participants were men, and 37.1% were women. The participants demonstrated diverse levels of knowledge about AAS: 74% had heard about AAS, and 72.8% and 71.6% were aware of AAS's effects on muscle and body weight, respectively. However, only 13.3% knew that AAS could cause breast enlargement. Regarding participants’ attitudes towards AAS, the majority of the participants (83.6%) believed that using AAS harms health, and 52% and 52.8% of participants believed that there should be punishments for people who use or sell AAS, respectively, while 62.4% of participants felt sorry for AAS users. Our findings on participants' practices showed that 37.3% of participants knew someone who uses AAS, and most importantly, that 19.5% of the gym users (19.2% and 20.1% of male and female users, respectively) admitted that they have used AAS. 51.1% of the participants believed that these AAS are easy to obtain. The study also found a significant relationship between AAS use and sociodemographic variables, including marital status (p = 0.031), time spent in the gym (p = 0.016), chronic diseases (p = 0.028), and smoking (p = 0.031). In conclusion, despite the participants' relatively good knowledge, attitudes, and practices concerning AAS use, they lack knowledge on certain side effects. This could direct policymakers in managing and acting to increase awareness for bodybuilders and the public. In addition, the high prevalence of AAS users could alert the ministries of health and other related ministries to the need for strict rules, especially those stopping or at least minimising accessibility to these substances.

Introduction

The use of anabolic–androgenic steroids (AAS) in athletics has been widely recognised for several decades. Although clinicians prescribe those compounds for certain medical conditions—including cachexia, counteracting muscle loss associated with certain chronic diseases, and for boys with delayed puberty (Falqueto et al. 2021; Rogol 2005)—these steroids are commonly misused by athletes with illegal physician prescriptions or even without a prescription (Melnik et al. 2007). The misuse of such compounds leads to numerous side effects such as gynecomastia, impotence, menstrual disturbances, psychological disorders, hepatic disorders, acute myocardial infarction, and malignancies (Bond et al. 2022; Melnik et al. 2007; Nieschlag and Vorona 2015; Rahnema et al. 2014; Souza et al. 2017; Tentori and Graziani 2007; Turillazzi et al. 2011; Wysoczanski et al. 2008). Nevertheless, a wide variety of oral and injectable AAS compounds are illegally available, including testosterone, trenbolone, oxymetholone, methandrostenolone, nandrolone, stanozolol, boldenone, and oxandrolone. These AAS have been misused by bodybuilders to increase body mass, facilitate building muscle, and increase muscle strength (Fink et al. 2018; McCullough et al. 2021).

Previously, AAS were available in most countries without any regulation; however, in 1990, after the concerning side effects correlated with its misuse were revealed, the United States established the Anabolic Steroid Control Act to regulate AAS, which was modified and updated in 1994 (Denham 1997). In the United Kingdom, fines and imprisonment were introduced for possessing or selling anabolic steroids without a valid prescription (Iversen 2010). Thereafter, most countries commenced with AAS regulation—including Saudi Arabia, which established the Saudi National Anti-Doping Committee in 2004 (Al Ghobain 2017).

Still, AAS are commonly used worldwide, not only among bodybuilders but also within the public. A study conducted in the USA revealed that the prevalence of AAS use among men 18–26 years old was 2.7% (Nagata et al. 2022); however, the percentage increases remarkably among gym users and bodybuilders: 59.6% of gym users in the USA admitted using AAS (Parkinson and Evans 2006) In the United Kingdom, a study reported that 70% of gym users used AAS (Baker et al. 2006). In the Middle East and South America, several studies have been conducted to investigate AAS use among gym users. For example, the AAS use rates among gym users were 20.6% in Brazil (De Siqueira Nogueira et al. 2014), 39% in Iran (Fijan et al. 2018), 26% in Jordan (Tahtamouni et al. 2008), and 20% in Iraq (Mazin Hashim et al. 2021). In the Gulf region, AAS use in athletes was investigated in various countries, with rates of 35% in Kuwait (Khullar et al. 2016), 22% in the United Arab Emirates (Al-Falasi et al. 2009), and 14.6% in Bahrain (Alsamani et al. 2017).

A national study in the Kingdom of Saudi Arabia (KSA) showed that 9.8% of gym users use AAS (Althobiti et al. 2018). Other studies have explored AAS use in different areas of KSA and have found that the prevalence of AAS use among gym users was 20% in the western region (Almohammadi et al. 2021), 29.3% and 24.5% in Riyadh (Al Bishi and Afify 2017; Alharbi et al. 2019), 31.0% in Jazan (Bahri et al. 2017), 21.3% in the eastern province (Albaker et al. 2021), and 4.7% in Jeddah (Ahmed et al. 2019). As can be seen, different areas show different rates of AAS use. In addition, almost all of the studies yet conducted were limited to male gym users. As a result, our study is the first to explore AAS knowledge, attitudes, and practices among gym users in Qassim Province, Saudi Arabia; furthermore, our study investigated the prevalence of AAS use in gyms in Al-Qassim province for both men and women.

Methods

Sample size and sample selection

This cross-sectional study was devised to evaluate the knowledge, attitudes, and practices regarding AAS use among male and female gym-users in Qassim, Saudi Arabia. A random sampling method was implemented, drawing from a comprehensive list of fitness centres provided by Qassim's General Authority of Sports Welfare.The sample size was calculated using EPI Info™ statistical software. Since the exact number of gym users in Qassim Province is not known, a large population was assumed. Using a confidence level of 95%, an expected proportion (p) of 50% (due to the absence of prior estimates), and a margin of error of 5%, the sample size was calculated using the following formula:

n = [Z^2 × p × (1—p)]/d^2 z2.

n = (z^2 × p(1-p))/d^2.

n = required sample size.

Z = Z-score corresponding to the desired confidence level (1.96 for 95% confidence).

p = expected proportion (0.5).

d = margin of error (0.05).

Substituting the values:

n = (〖1.96〗^2 × 0.5(1–0.5))/〖(0.05)〗^2 = 384.16.

Therefore, the minimum required sample size was 385 participants.

To account for potential non-response or incomplete questionnaires, 10% was added to the calculated sample size:

Adjusted sample size = n + (n × 0.10) = 385 + (385 × 0.10) = 385 + 38.5 = 423.5

This resulted in a target sample size of 424 participants.

Participants were randomly selected using the cluster sampling technique from a comprehensive list of fitness centres provided by Qassim's General Authority of Sports Welfare.

Ultimately, the study included the valid and complete responses of 415 participants (261 males and 154 females) from 24 fitness centres, covering the four primary geographical regions of Qassim. This number is slightly below the target sample size of 424 participants due to non-responses and incomplete questionnaires. However, the achieved sample size exceeds the minimum required sample size of 385 participants, thus maintaining the study's statistical power and reliability.

Sources of data

Data was collected using a pre-prepared self-administered anonymous questionnaire. The questionnaire was developed by adapting the existing literature (Al Bishi and Afify 2017; Alharbi et al. 2019), after which it was evaluated and reviewed by bilingual (English and Arabic) speakers who were academic experts in the medical and health sciences. Afterwards, the questionnaire was translated into Arabic by a certified translator, and the translated version was subsequently reviewed by the same academic experts. This questionnaire utilised in this study assessed gym users'knowledge, attitudes, and practices regarding anabolic–androgenic steroids (AAS). The survey included 30 items across three domains: Knowledge (12 items), Attitudes (6 items), and Practices (6 items). The Knowledge Domain covered general knowledge (2 items), effects on physical attributes (2 items), and health risks (8 items). The Attitudes domain focused on perceptions of AAS users (2 items), beliefs about the harm and fairness of AAS use (3 items), and societal acceptance or disapproval of AAS use (1 item). The Practices domain included questions addressing AAS usage patterns (2 items), methods of obtaining AAS (2 items), and actions taken to prevent or discourage AAS use (2 items). Each item was a closed-ended question, using Likert scales or multiple-choice options for quantitative analysis. The validity and the reliability of the questionnaire were then tested in a pilot study involving 30 gym users, where the Cronbach's alpha coefficient for the questionnaire was 0.74.. This questionnaire was given to the male and female gym users who agreed to participate in the study, and it was re-collected after participants filled it out.

Ethics and human subjects issues

Given that this study is a questionnaire-based approach, participants were thoroughly briefed on the study's objectives and methodology prior to signing an informed consent form. Only those individuals who provided informed consent were admitted as participants and subsequently invited to complete the study questionnaire. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Confidentiality of the participants'information was maintained throughout the study. An ethical approval number (HAPO- 02-K- 012–2022 - 02–982) was obtained from the biomedical research ethics committee at Umm Al-Qura University prior to conducting the study.

Timeframe

The study lasted three months, from 1 January 2022 to 31 March 2022.

Data analysis strategies

Knowledge scores were calculated by assigning one point for each correct answer and zero for incorrect or"I don't know"responses. The total knowledge score for each participant was obtained by averaging these points.

Attitude and practice scores were calculated using a 4-point scale. For attitude questions, responses ranged from"strongly agree"to"strongly disagree". Proper responses, those reflecting a correct or positive attitude, were scored one point, while improper responses scored zero. For practice questions, responses indicating correct or desired practices were scored one point, while improper responses scored zero. Reverse scoring was applied where necessary to ensure that higher scores consistently indicated more positive attitudes or practices.

The total scores for attitudes and practices were also averaged for each participant. These averaged scores were then categorised into the same three groups as the knowledge scores: poor (less than 50%), fair (50% to less than 75%), and good (75% or more).

This scoring methodology ensured a consistent and quantifiable measure of participants'knowledge, attitudes, and practices regarding anabolic–androgenic steroids (AAS), facilitating reliable analysis and comparison across the study population. Collected data was imported into Microsoft Excel and analysed using the statistical package for social sciences (SPSS) version 25.0 software (IBM Inc, Chicago USA). Descriptive statistics (frequency and percentages) were used to describe the categorical study and the outcome variables. The chi-square test was used to assess the relationships between the sociodemographic variables and the categorical knowledge, attitude, and practice scores. A p-value of less than 0.05 was considered statistically significant. Additionally, graphs were constructed using Graph Pad Prism 10.0 software and the map was drawn using Adobe Illustrator.

Results

Sociodemographic characteristics of study participants

A total of 450 questionnaires were distributed to male and female gym users of 24 gyms across Qassim, of which 415 received responses from participants, making the participation rate of this study 92.2%. In our study, 261 (62.9%) participants were men, and 154 (37.1%) were women. The mean age of the male participants was 25.6 (± 6.2) years, and that of the female participants was 26.5 (± 5.7) years. Of the 415 participants, 243 (58.6%) were married, and 384 (92.5%) were Saudi citizens. Educational status showed that 188 (45.3%) held bachelor's degrees. In terms of work, 157 (37.8%) worked in the health sector, and 88 (21.2%) worked in the education sector (37.8%). Most of the participants (63.6%) had an average monthly income less or equal to 12000 SAR. More than one-third of the participants spent less than 1 h per session in the gym (39.0%). No chronic diseases were reported by the majority of the participants (64.1%), and most of them were non-smokers (75.2%). The sociodemographic characteristics of our study participants are shown in Table 1.

Table 1.

Sociodemographic characteristics of the study participants (N = 415)

Sociodemographic characteristics		No. (%)
Gender	Male	261 (62.9)
	Female	154 (37.1)
Marital status	Single	111 (26.7)
	Married	243 (58.6)
	Others	61 (14.7)
Age (years)	< 30	238 (57.7)
	≥ 30	177 (42.6)
Nationality	Saudi	384 (92.5)
	Non-Saudi	31 (7.5)
Education	High school or less	159 (38.3)
	Bachelor’s	188 (45.3)
	Post-graduate	68 (16.4)
Job Field	Health	157 (37.8)
	Education	88 (21.2)
	Others	170 (41.0)
Occupation	Employed	300 (72.3)
	Unemployed	115 (27.7)
Income (SAR)	≤ 12000	264 (63.6)
	> 12000	151 (36.4)
Time spent in the gym per session	Less than 1 h	162 (39.0)
	One hour or more	253 (61.0)
Chronic diseases	No chronic diseases	266 (64.1)
	Have chronic diseases	149 (35.9)
Smoking	Non-smoker	312 (75.2)
	Current smoker	103 (24.8)

Knowledge, attitude, and practice scores

As illustrated in Fig. 1, the highest number of good scores is found for practices, with good scores accounting for 58.6%, fair scores comprising 22.4%, and poor scores amounting to 19.0% of the sample. Closely behind, attitudes exhibit a similar pattern, with good scores constituting 56.1%, fair scores comprising 29.2%, and poor scores accounting for 14.7% of the sample. The knowledge results show the lowest good scores at 35.9%: the fair scores (40.5%) and the poor scores (23.6%) are higher compared to the fair and poor scores of both practices and attitudes.

Fig. 1.

Knowledge, attitude, and practice scores

Knowledge regarding AAS use and related factors

Table 2 reveals that 74% of participants have heard about AAS and 73% were aware of AAS use in bodybuilding. Additionally, 72.8% and 71.6% were cognisant of the fact that AAS use increased muscle and body weight, respectively. Moreover, 60% knew that AAS use decreased fertility and sexual function, 48.4% were aware that it could cause liver damage, 63.8% were aware that it could elevate blood pressure, 50.6% knew that it could increase the risk of cancer, 68.5% were aware that it could cause heart disease, and 58.8% knew that it could increase cholesterol levels. In addition, 46.5% of participants knew that AAS could impede growth. However, only 13.3% knew that AAS could cause breast enlargement, with 17.6% answering"No"and 69.1% answering"I don't know"to the question.

Table 2.

Knowledge regarding AAS use and related factors

Knowledge Level	No. (%)
1. Have you heard about anabolic steroids?
Yes	307 (74.0)
No	108 (26.0)
2. Do you think that anabolic steroids are used in bodybuilding?
Yes	303 (73.0)
No	46 (11.0)
I don't know	66 (16.0)
3. Do you think that anabolic steroid use can affect the size of your muscles?
Yes, it will increase muscle size	302 (72.8)
Yes, it will decrease muscle size	11 (2.6)
No, it will have no effect	32 (7.7)
I don't know	70 (16.9)
4. Do you think that anabolic steroid use can affect your body weight?
Yes, it will increase body weight	297 (71.6)
Yes, it will decrease body weight	10 (2.4)
No, it will have no effect	31 (7.5)
I don't know	77 (18.5)
5. Do you think that anabolic steroid use can affect your fertility and sexual function?
Yes, it will improve fertility and sexual function	35 (8.5)
Yes, it will decrease fertility and sexual function	249 (60.0)
No, it will have no effect	23 (5.5)
I don't know	108 (26.0)
6. Do you think that anabolic steroid use can affect your liver?
Yes, it will cause liver damage	201 (48.4)
Yes, it will improve liver function	9 (2.2)
No, it will have no effect	66 (15.9)
I don't know	139 (33.5)
7. Do you think that anabolic steroid use can affect your blood pressure?
Yes, it will increase blood pressure	265 (63.8)
Yes, it will decrease blood pressure	20 (4.8)
No, it will have no effect	70 (16.9)
I don't know	60 (14.5)
8. Do you think that anabolic steroids use can increase the risk of certain cancers?
Yes	210 (50.6)
No	93 (22.4)
I don't know	112 (27.0)
9. Do you think that anabolic steroid use can affect the heart?
Yes, it will cause heart diseases	284 (68.5)
Yes, it will improve heart function	23 (5.5)
No, it will have no effect	46 (11.0)
I don't know	62 (15.0)
10. Do you think that anabolic steroid use can affect your cholesterol level?
Yes, it will increase cholesterol level	244 (58.8)
Yes, it will decrease cholesterol level	32 (7.7)
No, it will have no effect	70 (16.9)
I don't know	69 (16.6)
11. Do you think that anabolic steroid use can cause breast enlargement?
Yes	55 (13.3)
No	73 (17.6)
I don't know	287 (69.1)
12. Do you think that anabolic steroid use can delay or impede growth?
Yes	193 (46.5)
No	99 (23.9)
I don't know	123 (29.6)

Relationship between the knowledge score and participants’ sociodemographic data

Table 3 indicates notable relationships between participants'knowledge scores and certain sociodemographic variables, including gender (p= 0.003), marital status (p= 0.005), job type (p= 0.034), occupation (p= 0.029), and income (p= 0.013). Males demonstrated higher knowledge scores, suggesting greater exposure to AAS information. Married participants showed higher knowledge scores, implying increased awareness of health-related information. Health sector workers exhibited higher scores, likely due to professional knowledge. Employed participants had better scores, possibly correlating with access to educational resources. Higher income participants also scored better, indicating better access to educational materials. However, variables such as age, nationality, education level, gym time, chronic diseases, and smoking status did not show significant relationships with knowledge scores

Table 3.

Relationship between the knowledge score and participants’ sociodemographic data

Sociodemographic variables * Knowledge score		Poor: n (%)	Fair: n (%)	Good: n (%)	P-value
Gender	Male n = 261	48 (18.4)	109 (41.8)	104 (39.8)	0.003
	Female n = 154	50 (32.5)	59 (38.3)	45 (29.2)
Marital status	Single n = 111	27(24.3)	51 (46.0)	33 (29.7)	0.005
	Married n = 243	55 (22.6)	84 (34.6)	104 (42.8)
	Others n = 61	16 (26.2)	33 (54.1)	12 (19.7)
Age (years)	< 30 n = 238	57 (23.9)	99 (41.6)	82 (34.5)	0.769
	≥ 30 n = 177	41 (23.1)	69 (39.0)	67 (37.9)
Nationality	Saudi n = 384	86 (22.4)	155 (40.4)	143 (37.2)	0.055
	Non-Saudi n = 31	12 (38.7)	13 (41.9)	6 (19.4)
Education	High school or less n = 159	37 (23.3)	74 (46.5)	48 (30.2)	0.136
	Bachelor n = 188	48 (25.5)	64 (34.1)	76 (40.4)
	Post-graduate n = 68	13(19.1)	30 (44.1)	25 (36.8)
Job Field	Health n = 157	36 (22.9)	51 (32.5)	70 (44.6)	0.034
	Education n = 88	23 (26.1)	36 (40.9)	29 (33.0)
	Others n = 170	39 (22.9)	81 (47.6)	50 (29.5)
Occupation	Employed n = 300	69 (23.0)	112 (37.3)	119 (39.7)	0.029
	Unemployed n = 115	29 (25.2)	56 (48.7)	30 (26.1)
Income	≤ 12000 n = 264	66 (25.0)	117 (44.3)	81 (30.7)	0.013
	> 12000 n = 151	32 (21.2)	51 (33.8)	68 (45.0)
Time in Gym per session	Less than 1 h n = 162	32 (19.8)	62 (38.2)	68 (42.0)	0.094
	One hour or more n = 253	66 (26.1)	106 (41.9)	81 (32.0)
Chronic diseases	No chronic diseases n = 266	55 (20.7)	107 (40.2)	104 (39.1)	0.090
	Have chronic disease n = 149	43 (28.9)	61 (40.9)	45 (30.2)
Smoking	Non-smokers n = 312	69 (22.1)	129 (41.3)	114 (36.6)	0.456
	Current smokers n = 103	29 (28.2)	39 (37.8)	35 (34.0)

Attitudes towards AAS use and related factors

Table 4 shows that 51.0% of the participants believed that using AAS can result in bigger and stronger muscles. An overwhelming majority (83.6%) of the participants believed that using AAS harms one’s health. In addition, 81.9% of the participants thought that people who use AAS feel guilty about it. The participants also believed that people who use and people who sell AAS should be punished (52% and 52.8%, respectively). Lastly, Table 4 reveals that 62.4% of participants felt sorry for AAS users.

Table 4.

Attitudes towards AAS use and related factors

Attitude level	No. (%)
1. Using steroids can make your muscles bigger and Stronger
Strongly agree	113 (27.2)
Agree	99 (23.8)
Disagree	116 (28)
Strongly disagree	87 (21.0)
2. Steroids are harmful to health
Strongly agree	165 (39.7)
Agree	182 (43.9)
Disagree	36 (8.7)
Strongly disagree	32 (7.7)
3. People who take steroids feel guilty
Strongly agree	151 (36.4)
Agree	189 (45.5)
Disagree	41 (9.9)
Strongly disagree	34 (8.2)
4. The person who uses steroids should be punished
Strongly agree	104 (25.0)
Agree	112 (27.0)
Disagree	111 (26.8)
Strongly disagree	88 (21.2)
5. The person who sells steroids should be punished
Strongly agree	120 (29.0)
Agree	99 (23.8)
Disagree	113 (27.2)
Strongly disagree	83 (20.0)
6. I feel sorry for anabolic steroid users
Strongly agree	126 (30.4)
Agree	133 (32.0)
Disagree	95 (22.9)
Strongly disagree	61 (14.7)

Relationship between the attitude score and participants’ sociodemographic data

Table 5 indicates significant relationships between participants'attitude scores and certain sociodemographic variables, including marital status (p = 0.012), nationality (p = 0.008), and occupation (p = 0.021). Married participants exhibited more positive attitudes towards AAS, suggesting greater health awareness and risk aversion. Saudi nationals showed higher good attitude scores compared to non-Saudis, reflecting potential cultural differences. Employed participants had more good attitude scores, possibly due to access to better health information and resources within their work environments. This suggests that marital status, nationality, and occupation can play crucial roles in shaping attitudes towards AAS. Other variables, such as gender, age, job field, income, gym time, chronic diseases, and smoking status, did not show significant relationships with attitude scores.

Table 5.

Relationship between the attitude score and participants’ sociodemographic data

Sociodemographic variables * Attitude score		Poor: n (%)	Fair: n (%)	Good: n (%)	P-value
Gender	Male n = 261	35 (13.4)	74 (28.4)	152 (58.2)	0.472
	Female n = 154	26 (16.9)	47 (30.5)	81 (52.6)
Marital status	Single n = 111	22 (19.8)	33 (29.7)	56 (50.5)	0.012
	Married n = 243	28 (11.5)	63 (25.9)	152 (62.6)
	Others n = 61	11 (18.0)	25 (41.0)	25 (41.0)
Age (years)	< 30 n = 238	34 (14.3)	79 (33.2)	125 (52.5)	0.106
	≥ 30 n = 177	27 (15.3)	42 (23.7)	108 (61.0)
Nationality	Saudi n = 384	51 (13.3)	111 (28.9)	222 (57.8)	0.008
	Non-Saudi n = 31	10 (32.3)	10 (32.3)	11 (35.4)
Education	High school or less n = 159	18 (11.3)	50 (31.5)	91 (57.2)	0.062
	Bachelor n = 188	33 (17.6)	44 (23.4)	111 (59.0)
	Post-graduate n = 68	10 (14.7)	27 (39.7)	31 (45.6)
Job Field	Health n = 157	24 (15.3)	36 (22.9)	97 (61.8)	0.274
	Education n = 88	14 (15.9)	29 (33.0)	45 (51.1)
	Others n = 170	23 (13.5)	56 (33.0)	91 (53.5)
Occupation	Employed n = 300	47 (15.7)	76 (25.3)	177 (59.0)	0.021
	Unemployed n = 115	14 (12.2)	45 (39.1)	56 (48.7)
Income	≤ 12000 n = 264	42 (15.9)	84 (31.8)	138 (52.3)	0.110
	> 12000 n = 151	19 (12.6)	37 (24.5)	95 (62.9)
Time in Gym per session	Less than 1 h n = 162	16 (9.9)	50 (30.9)	96 (59.2)	0.085
	One hour or more n = 253	45 (17.8)	71 (28.0)	137 (54.2)
Chronic Diseases	No chronic diseases n = 266	36 (13.5)	80 (30.1)	150 (56.4)	0.636
	Have chronic disease n = 149	25 (16.8)	41 (27.5)	83 (55.7)
Smoking	Non-smokers n = 312	46 (14.7)	94 (30.1)	172 (55.2)	0.726
	Current smokers n = 103	15 (14.6)	27 (26.2)	61 (59.2)

Practice around AAS use and related factors

As seen in Table 6, it was found that 37.3% of the participants knew someone who uses AAS; of these participants, 28.2% have been offered AAS themselves. More than half of the participants (51.1%) believed that obtaining these substances is easy. In addition, 19.5% of the participants admitted to using AAS. Furthermore, 22.7% of the participants reported using narcotics or psychiatric drugs. Lastly, 14.5% of the participants admitted they had offered or introduced AAS to others.

Table 6.

Practice towards anabolic steroid use and related factors

Practice level	No. (%)
1. Do you know anyone who uses anabolic steroids?
Yes	155 (37.3)
No	260 (62.7)
2. Have you ever been offered anabolic steroids?
Yes	117 (28.2)
No	298 (71.8)
3. Do you think it is easy to get these steroids?
Yes	212 (51.1)
No	203 (48.9)
4. Have you ever used steroids or any muscle-building medication?
Yes	81 (19.5)
No	334 (80.5)
5. Have you ever used narcotics or psychiatric drugs?
Yes	94 (22.7)
No	321 (77.3)
6. Have you ever offered/introduced anabolic drugs to others?
Yes	60 (14.5)
No	355 (85.5)

Relationship between the practice score and participants’ sociodemographic data

Table 7 indicates significant relationships between participants'practice scores and certain sociodemographic variables, including marital status (p = 0.014), job field (p = 0.018), gym time per session (p = 0.002), chronic diseases (p = 0.007), and smoking status (p = 0.025). Married participants had higher good practice scores compared to singles, suggesting greater health awareness and better practices. Participants in the education field also had higher good practice scores compared to those in health and other fields, possibly due to their regular exposure to educational content that emphasises the consequences of drug misuse. Those who spent less than one hour per gym session had higher good practice scores, indicating a more effective use of gym time and highlighting that those who spend more time may have lower practice scores as they could be eager to increase their muscle size and might be overtraining or focusing more on appearance than overall health. Participants without chronic diseases had higher good practice scores, reflecting better overall health practices. Non-smokers also had higher good practice scores compared to current smokers, highlighting the negative impact of smoking on health practices. Other variables, such as gender, age, nationality, education, occupation, and income, did not show significant relationships with practice scores.

Table 7.

Relationship between the practice score and participants’ sociodemographic data

Sociodemographic variables * Practice score		Poor: n (%)	Fair: n (%)	Good: n (%)	P-value
Gender	Male n = 261	48 (18.4)	66 (25.3)	147 (56.3)	0.187
	Female n = 154	31 (20.2)	27 (17.5)	96 (62.3)
Marital status	Single n = 111	29 (26.1)	23 (20.7)	59 (53.2)	0.014
	Married n = 243	38 (15.6)	49 (20.2)	156 (64.2)
	Others n = 61	12 (19.7)	21 (34.4)	28 (45.9)
Age (years)	< 30 n = 238	48 (20.2)	58 (24.4)	132 (55.4)	0.326
	≥ 30 n = 177	31 (17.5)	35 (19.8)	111 (62.7)
Nationality	Saudi n = 384	73 (19.0)	81 (21.1)	230 (59.9)	0.062
	Non-Saudi n = 31	6 (19.4)	12 (38.7)	13 (41.9)
Education	High school or less n = 159	36 (22.6)	31 (19.5)	92 (57.9)	0.097
	Bachelor n = 188	32 (17.1)	39 (20.7)	117 (62.2)
	Post-graduate n = 68	11 (16.2)	23 (33.8)	34 (50.0)
Job Field	Health n = 157	31 (19.7)	45 (28.7)	81 (51.6)	0.018
	Education n = 88	18 (20.5)	9 (10.2)	61(69.3)
	Others n = 170	30 (17.6)	39 (22.9)	101 (59.5)
Occupation	Employed n = 300	55 (18.3)	68 (22.7)	177 (59.0)	0.840
	Unemployed n = 115	24 (20.9)	25 (21.7)	66 (57.4)
Income	≤ 12000 n = 264	58 (22.0)	54 (20.5)	152 (57.5)	0.098
	> 12000 n = 151	21 (13.9)	39 (25.8)	91 (60.3)
Time in Gym per session	Less than 1 h n = 162	21 (13.0)	29 (17.9)	112 (69.1)	0.002
	One hour or more n = 253	58 (22.9)	64 (25.3)	131 (51.8)
Chronic Diseases	No chronic diseases n = 266	43 (16.2)	52 (19.5)	171 (64.3)	0.007
	Have chronic disease n = 149	36 (24.2)	41 (27.5)	72 (48.3)
Smoking	Non-smokers n = 312	50 (16.0)	72 (23.1)	190 (60.9)	0.025
	Current smokers n = 103	29 (28.2)	21 (20.4)	53 (51.4)

Correlation between AAS use and sociodemographic variables

Table 8 indicates that there are significant relationships between AAS use and several sociodemographic variables, including: marital status, with single participants tending to use AAS (27.9%) more than married participants (16%) and others (18.1%); time spent in gym per session, with a higher percentage of AAS users among those who spend one hour or more (23.3%) than among those who spent less than 1 h (13.6%%); chronic diseases, with participants who have chronic diseases tending to use AAS (26.2%) more than participants who don’t have chronic diseases (25.5%); and smoking, with current smokers using AAS (27.2%) more than non-smokers (17%). No significant relationships were found between other sociodemographic variables and AAS use. 19.5% of the gym users (19.2% and 20.1% of male and female users, respectively) admitted that they have used AAS. The relationship between AAS use and gender is not significant.

Table 8.

Relationship between AAS use and sociodemographic variables

Sociodemographic variables * AAS use		AAS User n (%)	Non-user n (%)	P-value
Gender	Male n = 261	50 (19.2)	211 (80.8)	0.799
	Female n = 154	31 (20.1)	123 (79.9)
Marital status	Single n = 111	31 (27.9)	80 (72.1)	0.031
	Married n = 243	39 (16.0)	204 (84.0)
	Others n = 61	11 (18.1)	50 (81.9)
Age (years)	< 30 n = 238	49 (20.6)	189 (79.4)	0.535
	≥ 30 n = 177	32 (18.1)	145 (81.9)
Nationality	Saudi n = 384	75 (19.5)	309 (80.5)	0.599
	Non-Saudi n = 31	6 (19.4)	25 (80.6)
Education	High school or less n = 159	35 (22.0)	124 (78.0)	0.490
	Bachelor n = 188	32 (17.0)	156 (83.0)
	Post-graduate n = 68	14 (20.6)	54 (79.4)
Job Field	Health n = 157	34 (21.7)	123 (78.3)	0.560
	Education n = 88	18 (20.5)	70 (79.5)
	Others n = 170	29 (17.1)	141 (82.9)
Occupation	Employed n = 300	58 (19.3)	242 (80.7)	0.489
	Unemployed n = 115	23 (20.0)	92 (80.0)
Income	$\le$ 12000 n = 264	56 (21.2)	208 (78.8)	0.303
	> 12000 n = 151	25 (16.6)	126 (83.4)
Time in Gym per session	Less than 1 h n = 162	22(13.6)	140 (86.4)	0.016
	One hour or more n = 253	59 (23.3)	194 (76.7)
Chronic diseases	No chronic diseases n = 266	43 (16.2)	223 (83.8)	0.028
	Have chronic disease n = 149	38 (25.5)	111 (74.5)
Smoking	Non-smokers n = 312	53 (17.0)	259 (83.0)	0.031
	Current smokers n = 103	28 (27.2)	75 (72.8)

Discussion

This study investigated the knowledge, attitudes, and practices regarding AAS use among male and female gym members in Qassim Province, Saudi Arabia.

Our findings showed that the participants are very familiar with the effects of AAS, including bodybuilding, increased muscle size, decreased fertility and sexual function, increased blood pressure, increased risk of certain cancers, increased risk of heart diseases, increased cholesterol level and increased body weight. However, a considerable percentage of participants showed inadequate knowledge about certain adverse effects of AAS, with a lack of knowledge predominant in how AAS affects the liver, breast enlargement, and growth delay. These findings reflect gym members'lack of knowledge about certain unwanted health effects of AAS use. Similarly, several studies in different Saudi cities have shown a significant lack of knowledge among participants regarding the specific side effects of AAS, ranging from 43% to over 80% (Ahmed et al. 2019; Al Bishi and Afify 2017; Aldarweesh and Alhajjaj 2020; Alharbi et al. 2019; Almohammadi et al. 2021). This lack of certain knowledge detected in our study and these other studies could be highly beneficial in directing efforts and modifying policies around AAS misuse in Saudi Arabia.

Our study showed significantly greater knowledge regarding AAS use among male, married, Saudi, and employed participants. In contrast, other sociodemographic categories did not show any relationships with knowledge on AAS use. The greater knowledge among men could be explained by their body ideals, wherein men prefer to be more muscular than women do. This desire could encourage them to gain more knowledge about AAS use; it could also be explained by the fact that personality traits and individual characteristics (perfectionism, holding to traditional masculine norms) along with sociocultural influences (media, verbal commentary) could be linked to a male drive for muscularity (Lennon and Johnson 2021). In addition, married participants showed greater knowledge compared to single participants; this could be explained by the fact that married individuals are concerned about their body image as a part of marital satisfaction (Azra Shaheen et al. 2016). Moreover, married individuals often have better access to health-related information through communication with their spouses and shared resources. They may also engage more in community and social activities, which increases their exposure to health education and awareness programs. These factors together contribute to their higher knowledge levels. Furthermore, our findings showed significantly greater knowledge among employed compared to unemployed participants; this could be explained by the fact that employed people might be more concerned about their body and also that they are in an economically better position than unemployed people. This conjecture can be supported by a study conducted in South Korea which concluded that employment is associated with greater weight management and bodybuilding (Han et al. 2018).

In addition, the ‘good’ attitude score was significantly more common among participants than the ‘fair’ and ‘poor’ scores. A remarkable percentage of the participants believe that AAS are harmful to one’s health and that the people who use AAS feel guilty. These results are higher than the results of a previous study conducted in Riyadh, where 69.9% of the participants agreed that steroids are bad and 54.5% of them believed that steroid users feel guilty (Alharbi et al. 2019). In addition, our participants believed that those who use and those sell steroids should be punished, which was quite similar to the participants in the above-mentioned study (Alharbi et al. 2019). Again, Saudi, married, and employed participants showed significantly higher attitude scores compared to non-Saudi, single, and unemployed participants, Saudi individual's higher attitude scores could be due to better access to health-related information, a greater sense of responsibility towards their health, and more opportunities to engage in community activities that promote health awareness. Married individuals may place a higher value on maintaining a healthy body image as part of marital satisfaction and have better access to health information through communication with their spouses. Additionally, employed participants may have greater exposure to workplace wellness programs and a more structured environment that fosters health awareness, leading to their higher attitude scores.

In terms of AAS practice, our participants showed remarkably more ‘good’ scores compared to ‘fair’ and ‘poor’ scores (58.6%, 22.2%, and 19%, respectively). Our findings also showed a significant relationship between AAS use and spending one hour or more in the gym; this could be justified by the fact that participants who spend more time per session in the gym have a greater desire to build their muscles, which also motivates them to use AAS. Additionally, there were significant relationships between AAS use and participants being chronic disease patients and being current smokers. Patients with chronic diseases and smokers might not be very concerned about their health, and this could explain their higher use of AAS.

An unexpected and interesting finding in our research was that there is no significant relationship between AAS use and gender: male users represent 19.2% of the total male sample, and female users represent 20.1% of the total female sample. This contradicts a study conducted in Sweden, where AAS use among men was significantly higher than AAS use among women (3.9% and 0.2%, respectively) (Leifman et al. 2011). Another study conducted with 1519 gym users showed that 506 men and 12 women used AAS (Ip et al. 2010). The high prevalence of AAS use among women in our study could be explained by the misinformation about AAS spread through social media, especially given the evidence in the literature that women are more manipulated by social media (Garaus and Wolfsteiner 2023). In addition, the global surge—which has specifically spread to Saudi Arabia in recent years—of women being empowered to participate in all types of sport may encourage them to use AAS to enhance their physical appearance (Rizvi and Hussain 2022). Another possible explanation for the high prevalence of AAS use among women in our study is peer influence and gym culture. As more women engage in fitness activities and frequent gyms, they may be exposed to environments where the use of anabolic–androgenic steroids is normalised or even encouraged. Trainers, peers, or experienced gym users might promote AAS as an effective means to enhance performance or achieve aesthetic goals rapidly, creating pressure to conform without fully understanding the associated health risks. For instance, a study conducted in the United Kingdom found that social environments within gyms can significantly influence individuals to use performance-enhancing drugs (Boardley and Grix 2014).

Psychological factors may also contribute to this phenomenon. Body image dissatisfaction and low self-esteem, exacerbated by societal pressures and media images of idealised physiques, might drive women to seek quick solutions such as AAS use. Conditions like body dysmorphic disorder may further influence these decisions, as women strive to meet unrealistic beauty standards. A study by Hildebrandt et al. (2010) indicated that body dissatisfaction is a significant predictor of AAS use among women. The desire for rapid physical transformation can make AAS use appealing despite potential health risks.

Furthermore, cultural attitudes towards substance use may play a role. If steroid use is not widely regarded as harmful within certain communities, or if its dangers are underestimated compared to other substances, women may be more inclined to use AAS without fully consideration of the potential health consequences. A lack of awareness and inadequate education on AAS could further normalise their use, highlighting the need for public health initiatives to inform and protect vulnerable populations. In the same line as our study, a recent study in Iran showed a high prevalence of AAS use (41.99%) among female resistance-training practitioners during the Covid- 19 pandemic (Hoseini and Hoseini 2024). Another study showed that 22% of Brazilian women use AAS (Santos e Santos et al. 2023). However, A recent study in Jeddah found lower AAS usage rates (8.6% of males and 1.2% of females) compared to our research (Abumunaser et al. 2024). To the best of our knowledge, this is the only study that investigates AAS use among both males and females in Saudi Arabia, similar to our study in Al-Qassim. The discrepancy may be due to differences in sampling methods, regional sociocultural dynamics, and the perceived ease of obtaining AAS. These findings highlight the need for further investigations to understand regional variations and develop targeted interventions.

The average (across women and men) proportion of participants in this study who admitted to using AAS was 19.5%. This is similar to other local and international studies, where the proportion of gym users who were AAS users was 29.3% of the participants in Riyadh (Alharbi et al. 2019), 24.5% in the western province of Riyadh, Saudi Arabia (Al Bishi and Afify 2017), 17.69% in the Eastern province of Saudi Arabia (Aldarweesh and Alhajjaj 2020), and 22% in the United Arab Emirates (Al-Falasi et al. 2009). What’s more, the results of our study are lower than in other regional and local studies—such as Kuwait, where the percentage of anabolic steroids users was 35% (Khullar et al. 2016), and Jazan, Saudi Arabia, where the percentage was 31% (Bahri et al. 2017). Although the percentages of AAS users seem to be low, given the serious side effects of misusing such compounds, this amount of users is nevertheless alarming; in addition, these rates are still considerably high compared to other international results, such as 3.9% in Stockholm, Sweden (Leifman et al. 2011) and 10.7% in Lebanon (Mufarrij 2020). In contradiction to the current findings, a local study conducted in 2017 investigating AAS use among 4860 male gym users in Saudi Arabia found that the AAS users were 9.8% of the sample (Althobiti et al. 2018) which could be justified by the variation in sampling and demographics.

Regardless, the prevalence of AAS use in our study and most of the studies in Saudi Arabia are alarming. The easy accessibility of AAS in Saudi Arabia might facilitate its use. Our study highlights the easy accessibility of AAS, with a significant portion of participants believing they are easy to obtain. This trend is similar to other studies, such as one conducted in Riyadh, where a high percentage of gym users confirmed the ease of obtaining AAS (Alharbi et al. 2019). Thus, even though AAS are illegal in Saudi Arabia for recreational and performance-enhancing purposes, its access is available under the counter, and investigations focus more on use in sports competitions than on use among the public and gym users.

Figure 2 displays the prevalence of AAS use in our study and other studies in local Saudi cities found in the literature.

Fig. 2.

The prevalence of AAS use in Saudi Arabia

Conclusion and future work

This research highlights the widespread use of anabolic–androgenic steroids (AAS) among both men and women, which may be a cause for concern for local authorities. It is crucial that policymakers take action to raise awareness about the harmful effects of these substances. Additionally, strict regulations should be implemented, to hinder the easy accessibility of steroids and prevent their widespread misuse.

Our findings revealed a higher-than-expected prevalence of AAS use among women. The reasons behind this phenomenon should be further investigated, and future studies could explore the prevalence of AAS use among women in other Saudi cities.

Limitation

This study involved a self-administered questionnaire, which could be subjected to self-reporting bias. Participants might underreport AAS use due to social desirability or legal concerns. Anonymity was emphasised to reduce these biases. A lab-based study—for example, taking samples of participants’ blood—would give accurate results on AAS use. In addition, this study is limited to one city; exploring the use of AAS all over the country—especially by women—would provide a more accurate depiction of this subject. Furthermore, this study is cross-sectional, providing a snapshot of AAS use at a specific point in time. As such, it cannot establish causality or track trends and long-term effects. The smaller sample size of female participants compared to male participants may limit the generalisability of findings related to female AAS use. Efforts were made to recruit a balanced sample; however, achieving gender parity in this type of research can be challenging.

Author contribution

The author was solely responsible for the conception, design, analysis, interpretation of data, drafting, and revising of the manuscript.

Funding

The author confirms that there is no conflict of interest in this study and that he did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors to conduct this research.

Data availability

The data supporting the findings of this study are available within the article.

Declarations

Ethics declaration

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval (HAPO- 02-K- 012–2022 - 02–982) was obtained from the Biomedical Research Ethics Committee at Umm Al-Qura University prior to commencing the study.

Competing interests

The authors declare that they have no competing interests.