Operational Experiences and Challenges of the Iranian Red Crescent Operational Team in the Arbaeen Mass Gathering: A Qualitative Content Analysis

1.1. Literature Review

Various domestic and foreign studies have examined the challenges, opportunities, and solutions for improving health and relief services in exceptional circumstances such as the Arbaeen marches and other mass human gatherings. Molaei et al. studied health problems related to the Arbaeen pilgrimage, the factors that promote effective management of these problems, and measures to improve the health and safety of pilgrims during this large religious event. Their findings indicate that improving intersectoral coordination, strengthening health surveillance and health care systems, expanding public health infrastructure, educating pilgrims, and undertaking comprehensive planning can significantly improve pilgrim health and safety and improve the capacity of the health system to respond effectively during this large-scale event [3]. Karampourian et al. studied the challenges of health system preparedness for communicable disease control during the Arbaeen pilgrimage from the perspective of health stakeholders and managers. Major challenges included poor health infrastructure, weak control over factors contributing to the transmission of infectious diseases, low risk perception among the pilgrims, and low effectiveness of health education programmes. The authors concluded that improvements in risk management and the strengthening of health-promoting behaviours could play an important role in reducing threats to public health [14]. Yazdani et al., in their study titled Analysis of Barriers to Humanitarian Supply Chain Management in Tehran Red Crescent, concluded that cultural, managerial, and educational barriers are essential in supply chain management. This research emphasized the need to identify foreseeable disasters, requirements, and equipment needed, and define monitoring systems for policymakers [15].

Similar studies have been conducted internationally. Jahani et al., examining humanitarian aid chains, have identified challenges in coordination among the various actors in these chains. They believe that coordination mechanisms have not been implemented in humanitarian aid chains, despite their importance for effectively utilizing limited resources. The lack of effective mechanisms in this area has disrupted the efficiency of relief activities [16]. Sultan A. Alsaeed’s study examined factors affecting the performance of Red Crescent Society rescuers, including the expansion of the scope of activities, the competence of service providers, and their level of training. The findings indicate that the main challenges include a lack of public awareness, especially in critical situations, a lack of skills and information when contacting emergency medical services, and rescuers’ concerns about the crowd's reactions at the scene of the incident. This study proposes planning strategies to improve preparedness in managing MGs. The Saudi Arabian Red Crescent has also put forward a comprehensive plan to improve the quality of services, which aims to empower rescuers and support decision-makers in implementing the necessary reforms, ultimately leading to improved emergency response effectiveness and increased levels of security and public satisfaction [17].

Findings from studies conducted in Hajj contexts provide valuable insights but may be limited in their applicability to the Arbaeen pilgrimage due to differences in mobility patterns, infrastructure, and cross-border operational conditions. Previous studies have mostly concentrated on general public health and epidemiology, experience with mobile medical clinics, or humanitarian operations and emergency response systems. These studies provide valuable information, but the experiences and operational challenges of IRCS teams in the Arbaeen pilgrimage are unknown. In particular, the experiences and context-specific operational challenges of IRCS personnel, one of the main providers of emergency and healthcare services at border crossings and along the pilgrimage routes, have rarely been investigated independently through a qualitative content analysis approach.

1.2. Main Problem, Necessity and Objectives of the Study

Given the magnitude of the Arbaeen pilgrimage, the complexity of its operational environment, and the limited qualitative evidence regarding the experiences of frontline responders, a comprehensive understanding of the challenges faced by operational teams is needed. Qualitative approaches provide an opportunity to explore these experiences in depth, identify context-specific barriers, and generate practical recommendations to strengthen preparedness and response capacity [18]. To our knowledge, no qualitative study has comprehensively explored the operational challenges experienced by Iranian Red Crescent frontline teams during the Arbaeen mass gathering. This study aimed to identify and explore the challenges faced by IRCS operational teams during the Arbaeen pilgrimage and to help improve the effectiveness of relief operations. The findings may contribute to enhancing operational preparedness, strengthening organizational resilience, improving relief service delivery, and informing future managerial, educational, and policy interventions in mass gathering health management.

2.1. Study Design, Setting, and Participants

This research is a qualitative study using a conventional content analysis approach to identify and explore the challenges facing the IRCS operational teams during the Arbaeen gathering in 2025. Conventional content analysis was selected as the most appropriate method for the systematic description and classification of operational challenges in this context. This approach is widely used in qualitative research, particularly when theoretical evidence is limited, when a deeper understanding of understudied or poorly understood phenomena is required, or when the aim is to explore participants’ perspectives, experiences, and perceptions regarding a specific topic [19].

This study was conducted through semi-structured interviews with key informants, using purposive sampling and maximum variation, with 21 IRCS operational personnel who had rich experience in the field of Arbaeen deployment. Maximum variation was ensured across operational roles, professional backgrounds, organizational levels, years of experience, and deployment locations. The principal investigator contacted potential participants by telephone and provided information regarding the study objectives and procedures. All 32 eligible personnel were invited to participate; 21 agreed, while 11 declined due to time constraints.

2.2. Inclusion and Exclusion Criteria

The inclusion criteria were being employed by the Red Crescent, having at least one direct experience of attending the Arbaeen mass gathering, and being willing to participate in the study. Exclusion criteria included unwillingness to participate or inability to continue participating throughout the study.

2.3. Data Collection Instruments

An interview guide comprising three general questions was developed to address the study objectives and guide the discussion. This guide was developed by the research team to facilitate data collection and guide the interviews. It consisted of three open-ended questions designed to clarify the study objectives and encourage in-depth discussion. To assess the conceptual validity, clarity, and comprehensibility of the questions from the participants’ perspective, two pilot interviews were conducted with individuals outside the main study sample. Feedback from the pilot interviews, together with comments from the research team, informed the refinement of the final interview guide. Interviews began with broad, open-ended questions, followed by probing and exploratory questions as the conversation progressed to deepen understanding of participants’ experiences and perspectives. All interviews were conducted by the first author, who was formally trained in qualitative research methods and had prior experience conducting semi-structured interviews (Fig. 1).

The main interview questions included: Please describe your experience of participating in the Arbaeen MGs. Can you describe a typical day during your deployment in the Arbaeen operation?

What operational challenges did you experience while working during the Arbaeen MGs, and how did you manage them? The time for conducting the interviews was determined in advance with the participants. The approximate duration of the interviews was between 45 and 60 minutes. Interviews were conducted from 11/01/2025 to 21/05/2025 in a location agreed upon by the participants and where they felt comfortable.

In this study, data collection continued until data saturation was reached. Although no universally accepted definition or standardized approach to determining data saturation exists, it is generally described as an iterative process in which participants are continuously added until no new information, themes, or insights emerge from the collected data [20]. Saturation was achieved by the nineteenth interview. Nevertheless, two further confirmatory interviews were performed to ensure the adequacy of the data and to verify that no additional codes emerged.

2.4. Ethical Considerations

Ethical considerations in this study included explaining the importance, objectives, and methods; providing optional participation in the study; recording the interviews; maintaining data confidentiality at all stages; obtaining written consent; and mutually agreeing on the time and place of the interview. Individuals were assured that the obtained information would only be used for research purposes, and throughout the study, researchers took steps to anonymize data, protect participants' identities, and ensure that personal information was kept secure. In qualitative research, saturation is achieved when additional data no longer yield new insights and the findings become repetitive. The purpose of reaching saturation is to ensure the validity and completeness of the categories. Consequently, the number of participants is not predetermined, and sampling continues until saturation is attained.

In this study, saturation was reached after the nineteenth interview, and two additional interviews were conducted to confirm this, neither of which generated any new codes.

2.5. Data Analysis

Data analysis was conducted in five steps, following the Graneheim and Lundman approach [21].

First, the recorded interviews were transcribed verbatim and compared with the original file to ensure accuracy. The text was read several times in the second step to obtain a general impression. In the third step, meaning units for each interview were identified and coded. Meaning units consisted of words, sentences, or paragraphs that shared related aspects of content and context. In the fourth step, codes with similar meanings were categorized into more general subcategories. In the final step, by comparing the subcategories and reflecting deeply and carefully, the latent content of the data was identified and organized into main categories. Qualitative data analysis was performed using MAXQDA 20.

The quotations selected for this manuscript were translated into English by bilingual members of the research team. The translated excerpts were then independently reviewed by a bilingual researcher for conceptual accuracy and consistency with the original Persian text. Discrepancies were resolved by discussion and consensus.

2.6. Reliability and Validity

To ensure the trustworthiness of the findings, the criteria proposed by Guba and Lincoln were applied, including credibility, dependability, confirmability, and transferability [22]. Credibility was enhanced through prolonged engagement with the study field over a four-month period, continuous observation, and purposive maximum variation sampling to ensure diversity in participants’ educational background, job position, and workplace. Member checking was performed by sharing summaries of preliminary findings and category interpretations with five participants, who confirmed that the findings accurately reflected their experiences. In addition, regular peer debriefing sessions were conducted among three members of the research team to discuss coding decisions and category development.

Dependability and confirmability were strengthened by maintaining a clear and traceable record of data collection, coding, analysis, and interpretation processes, allowing the research process to be reviewed and evaluated by other team members. Efforts were also made to minimize the influence of researcher bias and preconceptions throughout the analysis. Transferability was supported by providing rich descriptions of the study context and participant characteristics, enabling readers to assess the applicability of the findings to other settings.

3.1. Demographic Information of Participants

Most of the participants in this study were male (17 people, 81%), had a bachelor's degree (14, 67%), and had attended Arbaeen MGs at least 5 times (16, 76%). The demographic information of the interview participants is presented in Table 1.

3.2. Main Results

After multiple rounds of data analysis and summarization, and after considering similarities and differences, 13 subcategories were organized into six main categories: (A) Resource limitations; (B) Weakness in planning; (C) Deficiencies in coordination and communication layers; (D) Weakness in the management system; (E) Deficiencies in ensuring the security and safety of personnel; and (F) Communication and sociocultural challenges. The findings suggest a multi-layered system in which structural constraints, operational deficiencies, and contextual factors interact to shape the effectiveness of disaster response during the Arbaeen mass gathering. A summary of the difficulties is given in Table 2. The findings are presented in categories and subcategories, but the analysis aimed to go beyond descriptive coding to identify latent patterns and interrelations among organizational, operational, and contextual factors impacting disaster response performance. The identified challenges occurred in three main operational settings: Iran, border crossing points, and Iraq. Some findings were context-specific, but there were several themes that reflected cross-cutting challenges that spanned multiple stages of the health response during the pilgrimage.

4.1. Category 1: Resource Limitations

One of the most critical challenges faced by the Red Crescent operational teams in the major Arbaeen operation is resource constraints, which reduce the effectiveness of relief and support services. A fundamental condition for the success of humanitarian systems in the response phase is the delivery of appropriate supplies in sufficient quantities and at the right time and place to people [23, 24]. The environment in which humanitarian organizations provide services is fraught with complexities and challenges, including time pressure and resource shortages, due to the unpredictability of demand and sudden events. At the same time, the effectiveness of any relief effort depends mainly on the speed of resource provision [25]. In the Arbaeen operation, budget constraints and delays in allocating financial resources are among the main challenges identified by the Red Crescent teams. When financial resources are allocated late or without careful planning, providing equipment, preparing bases, and attracting specialized human resources becomes difficult. MGs require sufficient resources for response before the incident occurs [26]. Research has shown that inefficient financial decision-making and limited budgets cause delays in response and reduce the effectiveness of the operation, which is more evident in the case of multi-hazards. Lack of proper planning for allocating resources severely undermines the performance of relief teams [27]. Similar resource-related challenges have been reported for Hajj operations, with adequate financial support, reliable supply chains, and coordinated logistics systems identified as critical components of preparedness for MGs [28]. Reforming the budget allocation system to implement a dynamic budgeting mechanism for timely resource transfers and proactive item provision before the Arbaeen ceremony can significantly reduce costs.

4.2. Category 2: Weakness in Planning

Planning and organizing for MGs and adequate staff training are essential. Neglecting them can cause irreparable damage. Comprehensive planning is a necessity for gatherings that have become recurring events [29]. Human capital includes health workers' knowledge, skills, and experience to do the right things. Various studies indicate that health workers’ knowledge and skills may be inadequate [30]. In the present study, the need for training of operational teams was also identified as an essential need, especially in new volunteer teams, which was consistent with the study by Lin et al., in which the improvement of the knowledge and skills of rescue teams for managing mass casualty incidents was also recognized as a necessity [31]. Various studies emphasize the necessity of planning and holding training courses and simulation exercises [32]. The feasibility of these approaches has been demonstrated [33, 34], and they can be implemented to adequately train rescue forces to respond appropriately to such events [35]. Furthermore, international frameworks and guidelines for mass gathering management emphasize the need to identify potential hazards associated with MGs. They also stress the importance of pre-planning, Mass Casualty Incident (MCI) protocols, structured triage systems, incident command systems, and routine multisectoral simulation exercises as key elements of preparedness for complex incidents involving large numbers of casualties. Operational challenges in implementing standardized patient prioritization in high-demand settings, such as Mass Casualty Incidents (MCI), are substantial. Effective triage is a cornerstone of mass casualty management and is essential for optimizing the use of limited resources during large-scale events [34]. In their study, Klassen et al. also stated that planning deficiencies can be identified through a regular training program [36]. Therefore, holding continuous exercises to improve teams' readiness for an appropriate response in emergencies and to review the correctness of implemented plans and policies has been considered essential [37, 38]. In the present study, planning deficiencies are a critical challenge affecting the readiness and optimal performance of the Crescent operational teams during the Arbaeen ceremony. The findings support the development of a comprehensive training system to be designed and implemented by the experience and expertise of operational teams, based on a training needs assessment. Holding discussion-based and debate-based exercises to test the programs, and specialized training continuously and throughout the year, adjusting the Arbaeen operational plan based on different scenarios, and using digital and modern technologies to reduce errors are suggested.

4.3. Category 3: Lack of Coordination and Communication Layers

Another challenge that most participants in the study reported was the lack of coordination and communication layers. An integrated communication system in border areas with weak infrastructure is necessary to improve the safety and efficiency of operations in MGs. The lack of supporting infrastructure, such as communication networks, leads to the inability to have a stable communication network and affects the coordination of operations [39]. Information management is of great importance in emergencies. On the other hand, the presence of people with different languages in health crises multiplies the challenges related to communication and information. Effective risk communication is essential for reducing disparities in access to, understanding of, and use of health information during MGs. Delays or disruptions in communication in MGs hinder the identification, recovery, and evacuation of patients and exacerbate emergencies [40]. Radio and mobile communications are disrupted during MGs. Disruptions in communication networks can hinder patient identification, recovery, and evacuation and exacerbate the crisis. Therefore, planning and coordination are essential to reduce the challenges responders face on the scene [41, 42]. The lack of a clearly defined incident command structure may lead to uncertainty among participants about team roles in potential emergencies. Incident Command System-based approaches enhance communication, coordination, and information management in emergency situations. They express leadership roles and allocation of resources; thus, they address critical challenges in high-stress incident management situations [43]. The communication challenges found in this study extend beyond the lack of equipment usually mentioned in cross-border MGs. Communication is crucial for disaster response. Communication systems for MGs that cross national borders must function within a range of legal, technical, and administrative frameworks. One of the key issues is the absence of roaming capability for Public Protection and Disaster Relief (PPDR) services. To overcome these barriers, investment in communication infrastructure is required, as well as the establishment of bilateral agreements, frequency licensing mechanisms, and interoperable communication protocols between the participating organizations and host country authorities [44]. Similar communication issues have been noted at large transnational MGs such as the Hajj and the Kumbh Mela, where interoperable communication technologies, emergency information-sharing platforms, and integrated command structures have been used to improve coordination [45]. The results show the need to use different communication layers, including traditional (wireless) and modern digital tools, to include interpreters in dispatch teams, to define primary and alternative communication processes, and to train operational teams in a second language to improve information management in MGs. These findings highlight the importance of bilateral coordination mechanisms with the Iraqi authorities.

4.4. Category 4: Weakness in the Management System

Another major category identified in the study was weakness in the management system. The impact of burnout in operational teams on the quality and effectiveness of operations is undeniable. Neglect and lack of psychological support for teams due to stressful and long-term working conditions lead to reduced motivation, operational accuracy, and decision-making errors [46]. Inadequate training reduces operational efficiency. Continuous training in the technical, psychological, and communication areas and holding exercises is essential for preparing forces [47]. A study by Petrudi et al. showed that the selection of managers without considering their field experience and expertise affects the different stages of risk management (prevention, preparedness, and response). Managers’ unfamiliarity with management principles confronts the organization with challenges such as a lack of financial resources and organizational coordination [48]. Failure to use previous experiences and lessons learned and employing non-specialists in large-scale operations such as Arbaeen causes neglect of vital system resources, including human resources. Lack of sleep among service providers negatively affects their personal lives and professional performance. Fatigue leads to decreased concentration, decreased motivation, and reduced performance and efficiency of personnel [42]. A study by Mason Harrell et al. showed that if psychological and safety aspects are addressed, one can expect optimal performance from the workforce. Developing resilience skills, specialized training, and organizational reforms, such as reducing workload and improving collaboration, can help mitigate these challenges and increase their well-being [49].

Addressing the mental health of the workforce and investing in continuous training are essential requirements for improving the efficiency of rescue and relief operations. Over time, burnout and demotivation of rescue workers will lead to job abandonment, reduced recruitment of volunteers, and ultimately damage the organization's sustainability. The well-being of rescuers should also be considered an operational resource. The comprehensive framework for protecting the health of rescuers includes pre-deployment health screening, fatigue management protocols, mental health support, access to rest and recovery facilities, occupational health monitoring, and post-deployment follow-up, which should be given due attention.

4.5. Category 5: Deficiencies in Ensuring Personnel Security and Safety

Attention to safety, the presence of a safety officer to assess and identify threats, and the use of personal protective equipment are essential for operational efficiency and should not be overlooked. Another challenge that the Red Crescent operational teams face is the deficiency in ensuring personnel security and safety. Ignoring the development of a detailed plan for the deployment of ambulances and access to medical centers threatens the safety and security of operations [50-52]. Given how the Arbaeen ceremony is held outdoors, the spread of respiratory infectious diseases threatens the operational teams' health. Personal Protective Equipment (PPE) is essential to protect human resources from threats [53]. During the Arbaeen ceremony, personnel are busy providing services for long hours. Prolonged exposure to large numbers of patients, lack of Personal Protective Equipment (PPE), work pressure, and insufficient rest indirectly increase the risk of infection of healthcare personnel [52]. Increased workload and multiple tasks assigned to personnel significantly increase their occupational health vulnerability [54]. Responder safety should be considered in a comprehensive occupational health framework. The main threats to responder health at MGs have been identified as fatigue, heat-related illness, psychological distress, responder injuries, transportation hazards, and crowd-related incidents [55, 56]. Therefore, protecting operational personnel requires integrated surveillance, risk assessment, preventive interventions, and ongoing monitoring [26].

Implementing infection prevention and control programs, risk assessment and control, and ambulance deployment location models in service environments is essential to protect human resources and logistics and increase operational resilience. Designing an intelligent network for deploying forces and ambulances, comprehensive practical training and continuous practice, and facilitating access to personal protective equipment during operations are recommended.

4.6. Category 6: Communication and Sociocultural Challenges

Attending the Arbaeen ceremony is a unique and challenging situation, given the large number of participants from different countries who speak different languages and have diverse cultural characteristics, health beliefs, and customs. Finding an interpreter to communicate with the participants during the operation is a significant challenge [57]. Communication barriers arising from language and cultural differences are well-recognized challenges in MGs. Designing multilingual training systems and employing bilingual or multilingual coordinators to reduce misunderstandings and improve communication has been recommended [58]. Religious beliefs about healing, non-adherence to medication during travel, and lack of essential medicines are other factors that increase the burden of emergency room visits and challenge response efforts for medical teams in MGs [59]. The availability of interpreters, multilingual communication tools, digital platforms and applications with offline capability, staff training on cultural and religious sensitivity to facilitate communication, engagement of trusted religious and community leaders, and implementation of participatory health education strategies are essential components of health communication management during MGs.

5.1. Practice and Policy Implications

This research, by identifying the key challenges of relief operations in the Arbaeen mass gathering, relies on field data to reform existing structures and move towards a resilient governance model to improve the efficiency of responsive relief systems, which comprises six principal axes. The first axis recommends developing a flexible and forward-looking resource allocation system tailored to operational needs and institutionalizing the definition of the “rapid response budget” process in national response structures. The second axis refers to developing a national roadmap for “health-oriented exercises” and designing and institutionalizing a comprehensive operational plan based on different scenarios at the macro level to improve the resilience of relief service providers. In the third axis, it is necessary to strengthen sustainable communication layers, including signing border agreements with the host country to ensure radio coverage and access to local networks, and establishing a mobile communication hub. The fourth axis considers it necessary to design a psychological support structure, hold continuous multidimensional training (technical, psychological, managerial) for effective human resource management, and define competency indicators for operational managers. The fifth axis states that at the policy level, there is a need to develop a plan to establish medical services based on scientific principles. Finally, the sixth axis suggests the need to define a cultural responsiveness framework and include it in cultural programs and design structures to attract multilingual volunteers using the capacity of immigrants and international students in the country.

5.2. Prioritization of Interventions and Feasibility

Based on the findings, prioritization should be based on the timeline for implementing the interventions needed to improve mass gathering management. Short-term priorities include improving the availability of Personal Protective Equipment (PPE), strengthening communication mechanisms, expanding multilingual support, and enhancing responder welfare services. Medium-term priorities include establishing integrated communication systems, institutionalizing responder health protection programs, and conducting multisectoral simulation exercises. Long-term priorities include developing cross-border agreements, establishing surveillance infrastructure, and reforming resource allocation mechanisms. This study identifies several recommendations that require evaluation for their political, legal, financial, and operational feasibility. The ability to communicate on the radio depends on bilateral agreements and frequency licensing mechanisms. Recruiting multilingual personnel, optimizing ambulance deployment, and establishing cross-border referral systems requires sustainable funding, a suitable workforce, and regulatory support. Further implementation research is needed to evaluate the feasibility and scalability of these interventions.