Objectives: Doping-related knowledge, beliefs and attitude influence adolescent athletes' susceptibility to prohibited performance-enhancing substances. They might be modified by different cultural backgrounds. This study's aim was to analyse the geographical heterogeneity of doping-related knowledge, beliefs and attitude among adolescent elite athletes. Design: Cross-sectional study. Methods: A questionnaire was distributed to athletes participating in the Winter Youth Olympic Games 2020 in Switzerland. Main outcomes (`subjective and actual knowledge`, `beliefs` and `attitude`) were stratified for athletes' region of origin. Geographical heterogeneity was tested with a two-way analysis of variance, and two multiple regression analyses were conducted to assess independent associations of knowledge, age and athletes' geographical region with doping-related beliefs and attitude. Results: 533 athletes (54% females, mean age: 16.0 ± 1.0 years), completed the questionnaire (response rate: 33%). Actual knowledge was moderate-to-good (9.2 ± 2.9 correct answers out of 13), and scores of attitude and beliefs showed favourable patterns. Considerable geographical heterogeneity was found for knowledge (p < 0.001), beliefs (p = 0.004) and attitude (p < 0.001). Higher subjective knowledge and actual knowledge were favourably associated with attitude (ß = -0.096, p = 0.049; ß = -0.316, p < 0.001) and beliefs (ß = 0.120, p = 0.016; ß = 0.212, p < 0.001), independent of age and geographical region. Conclusions: This study demonstrates considerable geographical heterogeneity of doping-related knowledge, beliefs and attitude, which are three essential target factors of doping prevention in adolescent elite athletes. This evidence should encourage medical doctors and other professionals to change their educative anti-doping approach from teaching knowledge about negative consequences into investigating and forming a young athlete's mind-set.
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