Qualitative study of health system preparedness for traumatic incidents in a religious mass gathering Arezou Karampourian a , Zohreh Ghomian a , Davoud Khorasani-Zavareh a,b,c, * a Department of Health in Disasters and Emergencies, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran b Safety Promotion and Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran c Department of Neurobiology, Care Sciences and Society (NVS), H1, Division of Family Medicine and Primary Care, Alfred Nobels Allé 23 141 83 Huddinge, Sweden A R T I C L E I N F O Article history: Accepted 12 December 2018 Keywords: Arbaeen Health system Incident Pilgrim Preparedness Religious mass gathering Trauma A B S T R A C T Background and Objectives: Traumatic incidents may occur during religious mass gatherings. A lack of preparedness by the health system to respond to traumatic incidents may increase the mortality rate. This study investigated the factors that affect the preparedness of a health system to respond to traumatic incidents, and we provide appropriate suggestions for improving the response to such incidents during religious mass gatherings. Methods: A qualitative research method was used with a conventional content analysis approach. In total, 22 semi-structured interviews were conducted employing the content analysis method. The data were analyzed based on the means of the meaning units, condensed meaning units, sub-themes, themes, and codes. Results: Four main categories and nine sub-categories emerged from the data: factors that increased or decreased the occurrence of incidents (with three sub-categories comprising risk perception and fatalism, pilgrims’ responses to incidents, and health system response to traumatic events); medical infrastructure (with two sub-categories comprising medical infrastructure in the host country and medical structures in border cities); organizational resource category (with two sub-categories comprising manpower, and equipment and facilities); and coordination of responsible organizations (with two sub-categories comprising inter-organizational coordination and inter-agency collaboration). All of the data were extracted from the experiences of the participants. Conclusion: Similar to other mass gatherings, Arbaeen requires multi-sectoral and international planning, organizing, and management. The key factors that could improve the preparedness to respond to traumatic events in Arbaeen include training, increasing the perception of risk, changing the attitudes and behavior of pilgrims, developing a national strategic plan of the health system preparedness for policymakers, and implementing scenario-based exercises for executives. © 2018 Published by Elsevier Ltd. Introduction Mass gatherings of people are usually defined as involving a specified number of persons at a particular location for a specific purpose and a defined period of time (1). The number of people attending is sufficient to impose a strain on the planning and response resources of the community, state, or nation that hosts the event (1). The pilgrimage of Arbaeen is one of the largest annual religious gatherings throughout the world. During this ceremony, a large number of pilgrims gather on the 40 th day after the anniversary of the martyrdom of Imam Hussein, who was the third Imam of the Shiite Muslims, in Ashura near Karbala south of Baghdad (2). The number of Iranian pilgrims at the Arbaeen ceremony during 2016 was around 2.5 million (3). In general, several factors may contribute to the causes of traumatic incidents in mass gatherings, including the density and mood of the population, stampedes and terrorist incidents, and the lack of necessary infrastructure, where these factors can affect the amount and type of medical needs in mass gatherings (4–8). One negative consequence of these incidents may be a stampede by a crowd. Stampedes are severe human catastrophes (4) because they can occur repeatedly in gatherings with a high mortality rate, and they mainly happen at religious ceremonies (5). For example, the Mina stampede in Saudi Arabia during 2015 resulted in 4173 deaths (5). * Corresponding author. E-mail addresses: a.karampourian@sbmu.ac.ir (A. Karampourian), zghomian@gmail.com (Z. Ghomian), davoud.khorasani@sbmu.ac.ir (D. Khorasani-Zavareh). https://doi.org/10.1016/j.injury.2018.12.015 0020-1383/© 2018 Published by Elsevier Ltd. Injury, Int. J. Care Injured xxx (2018) xxx–xxx G Model JINJ 7977 No. of Pages 8 Please cite this article in press as: A. Karampourian, et al., Qualitative study of health system preparedness for traumatic incidents in a religious mass gathering, Injury (2018), https://doi.org/10.1016/j.injury.2018.12.015 Contents lists available at ScienceDirect Injury journal homepa ge: www.elsev ier.com/locate /injury