Exploring challenges of health system preparedness for communicable diseases in Arbaeen mass gathering: a qualitative study

Approach

We collected data from June 2017 to March 2018. Since the study attempted to explore preparedness challenges of health systems, a qualitative research method with the approach of conventional content analysis was used¹⁸. The health system's challenge in Arbaeen is multidimensional, Owing to the cultural difference between Iran and Iraq, the challenges faced by the health system during the Arbaeen pilgrimage should be investigated in both countries. Indeed, the cultural practices of the participants, especially those surrounding health, differs during the Arbaeen ceremony. Therefore, a qualitative research method, with the aim of describing phenomena, providing new knowledge, insight and a practical health guide, is the method used in this study^18,19.

Setting

The study was conducted using in-depth interviews, based on stakeholder’s experiences in Iraq-Iran land terminals (Mehran, Shalamche, and Chazaba) and also in health care posts in Iraq. The interviews were conducted with health care providers and policy makers, as well as pilgrims in the Arbaeen ceremony.

Participant selection

Participants were chosen among executive managers and policymakers of the Ministry of Health and Medical Education, medical training and treatment and other related organizations, including the Red Crescent organization, Mobilizing the Medical Society, the Hajj and Pilgrimage Organization, medical universities in the border cities and the Social Security Organization. In total, 17 participants, consisting of 13 executive managers and 4 health policymakers, were selected in this study through purposeful sampling with the aim of exploring challenges of health system preparedness for communicable diseases in the Arbaeen ceremony. The existence of practical experience in planning or participate in Arbaeen ceremony and the ability to communicate and willingness to participate were inclusion criteria in the research. We recruited participants either by phone call or by approaching them in person.

"Maximum variety sampling" was used to explore the experiences of the participants in those selected so that they were chosen from the Ministry of Health and Medical Education, medical training and treatment and other related organizations, including the Red Crescent organization, Mobilizing the Medical Society, the Hajj and Pilgrimage Organization, medical universities in the border cities and the Social Security Organization, with different experiences of work, education and gender. Inclusion criteria included the existence of practical experience in planning or participate in Arbaeen ceremony, the ability to communicate and willingness to participate in the research (Table 1).

Data gathering

The study was done through face-to-face interviews followed by telephone interviews for concept saturation. The data was collected using audio recorders with permission from the participants. AK conducted the interviews, AK and DKZ transcribed the data. AK and DKZ and ZGH coded the data. DKZ and ZGH performed rigor. Initially the first two interviews were conducted in a non-structured format, with the following 15 interviews being semi-structured. Open questions used to generate the data were developed by experienced and/or knowledgeable policy makers and health care providers. The individual’s experiences and beliefs were used without considering their specialty²⁰. Interviews were continued until data and concept saturation were reached²¹. The interview duration was between 35 and 95 minutes, based on the tolerance, amount of information and desire of the participants. Interviews were performed individually and based on participants' willingness in terms of time and site.

Firstly, interview questions began with the following general questions based on the participants' level and the main questions of the research: "How was your organization preparedness plan to deal with infectious diseases in Arbaeen ceremony?"; "Please express your experiences of related challenges in infectious diseases in Arbaeen ceremony"; "What problems were in your preparedness plan?"; “What problems did you face in the vaccination program of the health team and pilgrims in Arbaeen ceremony?”; and “What is your offer to pilgrims for a safe pilgrimage?" Following this, exploratory questions were gradually used to clarify the concept and deepen the interview process: e.g. “Please explain further what you mean?” and “Why?” At first, the interviews were transcribed verbatim and then typed up using Microsoft Word Office.

Data analysis

The data were analyzed through a conventional content analysis method¹⁸. First, the main researcher converted the interviews to written texts. The digital files were listened to several times and the texts were read repeatedly. Next, the meaning units were determined based on the aim and the question of the research. Meaning units were a collection of words and sentences that were related to each other in terms of content and were grouped together. Meaning units reached the level of abstraction and conceptualization and were coded considering the research question. The key points and subjects were extracted as open codes. These codes have been put under the broader headings based on the present similarities and differences; in other words, the data were reduced in order to describe the phenomenon and gain a better understanding, and this abstraction process continued until concept extraction¹⁸. Data first emerged as meaning units, then condensed meaning units, codes, sub-themes and finally themes.

Ethical considerations

The study was approved by Ethics Committee of Shahid Beheshti University of Medical Sciences on 10/08/2017, No. IR.SBMU.RETECH.REC.1396.349. The interviews were conducted and recorded with participants' consent. Written or verbal consent was taken from participants to participate in the study. Verbal consent was only taken for telephone interviews; this was due to the distance between interviewer and interviewee. Anonymity, confidentiality and the right of resignation were informed to participants and considered during the study. The interview time was set according to participants' willingness.

Rigor

The researchers used the trustworthiness criteria recommended by Guba and Lincoln to establish rigor²². All authors were engaged in the environment and field of research. In addition, the principle investigator always had suitable involvement with the participants for in-depth interviews. Credibility was established by the prolonged engagement of researchers with participants. Researcher triangulation was also used to verify the accuracy of the coding process. The research team also retained raw data, codes, and themes for control of the reliability. At the same time, sampling was carried out with maximum diversity in order to provide triangulation by means of credibility and confirmability. A detailed description of the method was used to establish transferability. Engaging participants in the research increases the interaction between researchers and participants and then the credibility²². The research supervisor monitored the data collection and data analysis process. It is necessary to mention that the research team participated in the Arbaeen ceremony as pilgrim and conducted field notes. Also, member- and peer-checking were used to ensure credibility. Therefore, many interviews with related topics were sent to some external expert reviewers and participants (policymakers of the Ministry of Health and Medical Education, medical training and treatment and the Red Crescent organization) to be checked, and they were requested to assess the degree of relevance between the findings and raw data. Moreover, transferability was established by sampling with maximum variation from various centers, including the Ministry of Health and Medical Education and other peer organizations including the Red Cross organization, the Medical Community Mobilization, the Hajj and Pilgrimage Organization, the country's medical universities in the border cities and the Social Security Organization with different experiences of work, education and gender. A completed SRQR checklist is available in Supplementary File 1.

Themes and sub-themes

The mean age of participants was 43 and the mean time of work experience was 18 years (Table 1). Overall, 1125 original codes were extracted and after integration using conventional concept analysis, four original themes consisting of 11 sub-themes were identified. The theme of “health infrastructure defection in Iraq” had three sub-themes: “health abandonment in Iraq”, “the weakness of health culture” and “problems related to health system”. The theme of “poor control of factors effective in infectious diseases” had three sub-themes: the “underlying factors in prevalence of contagious diseases”, “health system response to communicable diseases” and “ignoring the risks of the Arbaeen ceremony”. The theme of “low perception of risk in pilgrims” had three sub-themes: “lack of awareness in pilgrims”, “fatalism in pilgrims” and “unhygienic belief in pilgrims”. The theme of “ineffectiveness of health education” had two sub-themes: “training shortage in the targeted group” and “educational content problems” (Table 2).

According to the findings of this study, the main theme is pilgrim-based education. It seems that the biggest issue with the prevention of communicable diseases in the Arbaeen ceremony is pilgrim-based education. Educating pilgrims can directly help people to create or reform health infrastructures in Iraq. Education can also help to identify health risks and respond to them by identifying effective factors in combating infectious diseases. The training of health instructors and guidelines from people who are trusted and accepted by pilgrims, such as missionaries and religious leaders, can have a positive impact on their beliefs. The main point of training is to determine the targeted group both at the level of pilgrims and health directors and consider the training needs of each group in preparing training guidelines.

Health infrastructure defection in Iraq

Health abandonment in Iraq. Most of the participants believed that the Iraqi health system has been abandoned because foodstuff distribution is not under the supervision of a special organization and does not have a special trustee in the execution and monitoring of health rules or, if there is one, he is inconspicuous. The existence of a trustee or supervisor in the health system can prevent the delivery and distribution of unsafe food and reduce the prevalence of infectious diseases. Unhealthy foodstuff preparation, production and distribution, and a lack of food evaluation and supervision system can lead to gastroenteric disease. Based on the participants’ experiences, the lack of a health system trustee means system weakness.

The following quotation is an example of the above: "Sometimes donations are prepared in an unhealthy manner and so lead to acute digestive problems… The health system is weak in Iraq because health rules are not enforced and there is no supervision for these centers…" (Executive manager, male, 30–40 years, 11–20 years job experience).

The weakness of health culture. According to the participants' point of views, observation of unhealthy behaviors, such as neglect of the individual and public health standards, and the existence of cultural differences between Iran and Iraq, are considered by pilgrims to bring about an unsafe culture. Policy makers and executives should be familiar with the kind of health culture in Iraq so that they can develop a program to prevent contagious diseases. In Iranian culture, the non-use of spoons and forks is considered as lack of health belief and neglect of health, whereas in Iraq, eating food with the hands is part of the food culture. Iran's health system can help train the Iraqi people in sanitary practices alongside Iranian pilgrims.

The following quotation is an example of the above: "Some food providers don’t meet health … The culture of using spoons and forks for food serving is different in Iran and Iraq… one of the cultural works which we can do in Iraq is health education…" (Executive manager, male, 41–50 years, 11–20 years job experience).

Problems related to health system. Most participants acknowledged that despite annual health care improvements in Iraq, there are also some shortages in this field due to the lack of a long history of a health service system. Health system weakness, incomplete health service implementation and insufficient supervision of environment health are indicative of the weakness of the health infrastructure; this has made it impossible to provide environmental health, sanitation and waste disposal.

The following quotation is an example of the above: “Health background in Iraq was poor… There were no waste bins and waste sanitation there… failure to implement health services has led to failure in meeting health conditions … there was no health system supervision and waste collection system… of course every year its gets better than the previous year … " (Executive manager, female, 41–50 years, 21–30 years job experience).

Poor control of the effective factors on infectious diseases

The underlying factors in prevalence of contagious diseases. Most participants have identified underlying factors of infectious diseases as one of the challenges affecting the preparedness of the health system in dealing with infectious diseases. Various factors, such as population density and diversity, not paying attention to the principles of personal and general health, for example through a lack of health facilities, weather conditions during the trip and changes in nutrition can cause the spread of infectious diseases. Identifying these factors helps pilgrims and planners to prevent infectious diseases.

The following quotation is an example of the above: "There were few toilets or no healthy facilities. Somehow, pilgrims would have to sleep in the desert or in a limited space with a lot of people… Congestion of pilgrims from different countries increases the risk of spreading infectious diseases…” (Executive manager, male, 51–60 years, Over 30 year job experience).

Health system response to communicable diseases. On the basis of the view of participants, mass population movements from different countries and their gathering with different population diversity can transfer and spread endemic diseases and also emerging diseases such as plague and anthrax. There is also the possibility of bioterrorism events occurring during the Arbaeen ceremony. The health system needs facilities such as equipped laboratories to diagnose and treat infectious diseases in a timely manner. The inaccessibility or lack of experimental equipment for disease identification leads to the failure of timely diagnosis of diseases, a lack of disease control and finally the incidence of epidemics. Syndromic surveillance system can be used to diagnose infectious diseases. There is a need to correctly pass the treatment period of infectious diseases in order to prevent epidemics, although drug shortages can affect treatment completion and is one of the causes of epidemics. Vaccination also helps to prevent infectious diseases, but the requirement of pilgrims to vaccinate is always up to the host country and since vaccination is not one of Iraq's priorities, the Ministry of Health and Medical Education can only advise pilgrims to vaccinate.

The following quotation is an example of the above: "There is the probability of spread of local and new-appeared diseases and even bioterrorism due to the gathering of pilgrims from different countries… some diseases can't be diagnosed due to lack of facilities but syndromic surveillance system can be used. …the large number of pilgrims and lack of medication have led to not having complete course of antibiotic treatment… The need for vaccination is one of the requirements of the host country". (Policy makers, male, 41–50 years, 21–30 years job experience).

Ignoring the risks of the Arbaeen ceremony. The Arbaeen pilgrimage has special features that distinguish it from other mass gatherings. Participation of different peoples with a diverse range of socio-demographic statuses, cultures and nationalities makes this distinction. The Arbaeen pilgrimage has some specific hazards like other trips that are sometimes neglected. The population of Arbaeen pilgrims and its time of year are changeable. Financial management of travel expenses at the ceremony is carried out by volunteers. Considering these features is essential for the readiness program. In the opinion of the majority of participants, one of the challenges of the health system is the lack of attention to the risks of Arbaeen ceremony and the lack of planning based on these features.

The following quotation is an example of the above: "Arbaeen is a new phenomenon that children and adults, men and women with different cultures and ethnicities take part in the ceremony … Even with the knowledge of the dangers of the route, people attend Arbaeen ceremony… Arbaeen is a spontaneous and popular event and doesn’t cost much … the population is moving and the time of the ceremony changes every year …" (Executive manager, male, 30–40 years, 21–30 years job experience).

Low perception of risk in pilgrims

Lack of awareness in pilgrims. One of the challenges in the view of the participants, especially executives, is the pilgrims' low awareness of health hazards, such as not using personal hygiene products and non-compliance with health standards. Unhealthy and dangerous practices, such as unsanitary food consumption, are not understood by pilgrims, and this low awareness and inadequate knowledge of the risks are the causes of infectious diseases in the pilgrims. Respect for personal and public health, such as hand washing, providing food from health food centers and avoiding overeating, is effective in preventing digestive diseases.

The following quotation is an example of the above: "Some pilgrims do not wash their hands or do not use personal hygiene products …Or they do not get foods from healthy centers … overeating and then digestive problems are one of the pilgrims' problems … the other problem is not being familiar with Arabic language …" (Executive manager, female, 30–40 years, less than 10 years job experience).

Fatalism in pilgrims. Participants believed that one of the health challenges is belief in destiny and fatalism; so that most pilgrims who participate in the Arbaeen walking ceremony, based on their belief in destiny, have a relatively low understanding of the dangers and diseases, and begin their trip merely confident in Allah and without any plan for dealing with infectious diseases, such as vaccination, and continue the way using food and drinks that are often unhealthy.

The following quotation is an example of the above: "It's enough to decide to travel and you do not need to have a special plan … If you think openly, you won’t get sick, and nothing bad will happen…" (Policy makers, male, 41–50 years, 21–30 year job experience).

Unhygienic beliefs in pilgrims. Based on the participants’ experiences, low perception of danger in pilgrims is sometimes seen as insanitary beliefs in preventing medication consumption and disregarding hygiene recommendations. Believing in the use of medication during illness, preventing self-curing and trying to abide by hygiene recommendations prevents infectious diseases.

The following quotation is an example of the above: "Sometimes we see pilgrims using traditional treatments instead of antibiotics consumption… they don’t pay attention to hygiene recommendations such as masking and not using suspicious food…" (Executive manager, male, 30–40 years, 11–20 year job experience).

Ineffectiveness of health education

Training shortage in the targeted group. Based on stakeholders' views, one of the present challenges is the quantitative and qualitative shortage in the stakeholder’s training level. This means that providing a personal and public health plan should cover all stakeholders, including executives, policymakers and volunteers in the Arbaeen ceremony, and be considered with respect to each participant. Furthermore, the timing of training is also important and should be before the days of Arbaeen ceremony in order to have a greater effect on the individuals' knowledge. Indeed, training courses should be held separately for each of the groups, pilgrims, executive managers, and policymakers, and at a proper time before Arbaeen.

The following quotation is an example of the above: “Training should not exactly be in the days of Arbaeen. Personal and public health training must be held several months before Arbaeen… the training is not only for pilgrims, but also anyone involved in Arbaeen ceremony. Everyone should be trained from pilgrims to policymakers…" (Policy maker, male, 41–50 years, 21–30 year job experience).

Educational content problems. Another problem was the provision of educational content. Most of the participants believed that training should be fitted with pilgrims' needs and respond to the problems of pilgrims. Pilgrims should be divided into different groups based on the level of education, their problems and illnesses, and individual and general education should be planned accordingly. Participants also believed that training in the area of personal, general and nutritional health should be provided more comprehensively.

The following quotation is an example of the above: "We should divide pilgrims to diverse groups and send targeted training messages to each group, not the same training for everyone…the benefactors should be trained…pilgrims should have more training…" (Policy maker, male, 41–50 years, 21–30 year job experience).